Radiation burns of the ear and auditory canal: treatment and care

Radiation burn of the auricle and skin of the external auditory canal is a variant of radiodermatitis in the irradiated area during treatment of tumors of the head and neck, ear skin, or parotid gland. Acute changes begin with erythema and dry scaling, progressing to areas of moist maceration and painful erosions with continued irradiation; late changes include epithelial atrophy, telangiectasia, fibrosis, hyperpigmentation, and a tendency toward secondary infections. Edema, luminal dermatitis, granulation, and the risk of stenosis are also observed in NSP. [1]

The ear area is vulnerable because the skin is thin, the cartilage is poorly vascularized, and there are skin-cartilage junctions and a narrow canal nearby, where moisture and maceration promote inflammation. In later stages, perichondritis/chondritis and the extremely rare but severe osteoradionecrosis of the temporal bone are possible. These complications may appear years after treatment. [2]

It's important to understand the scale of the problem. Overall, radiodermatitis develops in the majority of patients undergoing radiation therapy (up to 95%, according to combined data from various sites), and with head and neck irradiation, the rate of reactions of grade ≥2 is high; the addition of targeted or platinum regimens increases skin toxicity. Proper skin care and prevention of complications reduce the severity and shorten interruptions in radiation therapy. [3]

This article provides a systematic analysis of ICD-10/ICD-11 codes, epidemiology, causes and risk factors, pathogenesis, symptoms, classifications (CTCAE/RTOG), complications, "when to see a doctor", diagnosis (step-by-step), differential diagnosis, treatment (including modern methods), prevention, prognosis and FAQ.

Code according to ICD-10 and ICD-11

In ICD-10, radiation injuries of the skin of the ear and NSP are coded in block L58 "Radiodermatitis" with clarifications: L58.0 - acute radiodermatitis; L58.1 - chronic radiodermatitis; L58.9 - unspecified. For complications involving the ear, codes are added by organ/condition: for example, H61.3* "Acquired stenosis of the external auditory canal" (with details on lateralization), for osteonecrosis of the temporal bone - section M87.* ("Osteonecrosis", with selection of a specific subcategory by localization/cause according to local rules). [4]

In ICD-11, radiation dermatoses are classified under sections EJ71-EJ7Z ("Dermatoses due to ionizing radiation"), which indicate the chronic effects of ionizing radiation on the skin and may post-coordinate "harmful effects of ionizing radiation" as an external cause. For treatment sequelae, a composite entry with the underlying diagnosis plus modifiers is permitted (e.g., "sequence of radiation therapy"), and for stenosis of the esophagus and other otologic outcomes, the affected organ and type of complication are coded. [5]

Table 1. Examples of coding (for reference, local rules specify specifics)

Clinical situation	ICD-10 (example)	ICD-11 (example)
Acute radiodermatitis of the auricle	L58.0	EJ71 (skin due to ionizing radiation) + external cause XE5PJ
Chronic radiodermatitis NSP	L58.1	EJ71 + clarification of chronic course
Acquired stenosis of the anterior ventricle after RT	H61.303/323 (by party/cause)	Ear damage code + "consequence of treatment effect"
Osteoradionecrosis of the temporal bone	M87.* (selection of subcategory)	Osteonecrosis code + clarification of post-radiation nature

Sources of classifications: official reference books ICD-10-CM/ICD-11 and WHO guidelines. [6]

Epidemiology

Acute radiodermatitis is the most common toxicity of radiation therapy: according to consolidated oncology guidelines, up to 95% of patients experience skin reactions of varying severity; in the head and neck group, the proportion of grade ≥2 reactions is significantly higher due to the proximity of folds, cartilage, and thin skin. The inclusion of targeted therapy (e.g., cetuximab) may increase the incidence of severe skin reactions. [7]

Lesions of the external auditory canal are less common but clinically significant: in a retrospective series of patients exposed to high doses of external irradiation, stenosis of the external auditory canal developed in 8.7% of patients; concomitant parotidectomy increased the risk. Mild and moderate complications of the external auditory canal (otitis, granulation tissue) are described more frequently, but standardized frequencies are fewer. [8]

Osteoradionecrosis of the temporal bone is a rare late toxicity that can appear >10 years after treatment. In one study in patients after irradiation of the parotid region, the estimated incidence was as high as 8.5% (confidence interval 3.6-13.4%), but these are selective data; other series report significantly lower values (about 0.5% for extramaxillary locations in general). [9]

The ear's susceptibility to complications increases with a humid canal environment, the use of hearing aids/earplugs during radiation therapy, concurrent chemotherapy, diabetes, and smoking. These factors shift the spectrum of complications toward persistent dermatitis and infections. [10]

Table 2. Orders of magnitude for key outcomes

Indicator	Grade
Any radiodermatitis on RT (different zones)	up to 95% of patients
Stenosis of the anterior ventricle after high-dose RT	≈ 8.7%
Osteoradionecrosis of the temporal bone	~0.5-8.5% (by series)
Onset of late complications	months - decades after RT

Reasons

The main reason is ionizing radiation in therapeutic doses (photon RT, sometimes protons/stereotaxics) for tumors of the skin of the ear, parotid gland, external auditory canal, nasopharynx, etc. Additional triggers: humidity and maceration of the NSP, mechanical friction (masks, fixation), local irritants (alcohol solutions), wearing earplugs. [11]

High total doses and large daily fractions increase the risk and depth of damage; when the temporal bone is involved, the risks of bone complications and sensorineural hearing loss (via the dose to the cochlea) increase. [12]

The combination of RT with chemotherapy (platinum) or targeted therapy increases epithelial toxicity and the risk of severe desquamation. [13]

Rare iatrogenic scenarios include excessive fixation/compression of skin immobilization devices and improper skin care in radiation fields.[14]

Risk factors

Classic: high doses to the skin of the ear/NSP, high volume V>20-30 Gy, short treatment periods without interruptions once moist desquamation has already begun, and additional systemic therapy. The average dose to the cochlea is important for the risk of hearing loss, traditionally a benchmark of ≤45 Gy (according to QUANTEC and subsequent consensus reports). [15]

Local: canal moisture, wearing hearing aids/earplugs, contact irritants, failure to follow care recommendations, occlusion with rollers/bandages, chronic otitis externa before LT. [16]

Patient-specific: smoking, diabetes mellitus, old age, nutritional/protein deficiency, concomitant skin diseases (atopy, psoriasis). [17]

Rare but significant predictors of late osteochondral complications: previous surgery in the parotid/temporal region, high point doses to the cortical bone of the temporal bone, post-radiation infections. [18]

Table 3. What increases the risk of ear complications during RT

Factor	Why is it dangerous?
Humidity, occlusion in NSP	Maceration, biofilm support
Total dose/fraction	Depth of necrosis, late fibrosis
Average dose to a snail >35-45 Gy	Risk of sensorineural hearing loss
Hearing aid during sessions	Microtrauma and moisture retention
Smoking, diabetes	Microcirculation/repair disorders

Pathogenesis

Acute radiodermatitis is caused by the death of basal keratinocytes, cytokine-mediated inflammation, and barrier disruption; clinically, it presents as erythema → dry/wet desquamation → erosions. Edema, hypersecretion, granulation, and skin roughening with lumen narrowing are also present in NSP. [19]

Chronic changes include atrophy, telangiectasia, subcutaneous tissue fibrosis, hypo-/hyperpigmentation. Due to poor vascularization, perichondritis/chondritis develops in the cartilage; with bone involvement and impaired trophism, osteoradionecrosis with chronic infection occurs. [20]

Hearing is impaired through two mechanisms: conductive disturbances (stenosis of the auditory canal, thickening of the eardrum, otitis media, fibrosis) and sensorineural disturbances (dose to the cochlea and auditory nerve trunk). [21]

Slow late vascular-fibrotic changes explain why severe ear and temporal bone complications appear years/decades after completion of RT. [22]

Symptoms

Acute: localized pain, burning, erythema, dry/wet desquamation of the auricle, maceration and oozing of the entrance to the esophagus, itching and pain when touched. If the canal is involved, there is a feeling of congestion, hearing loss, and serous-purulent discharge. [23]

Subacute: granulation, crusting, persistent soreness in the LES, thickening of the skin, short-term improvements followed by relapses with moisture/manipulation. [24]

Late: scarring and stenosis of the ACE (progressive conductive hearing loss), chronic otitis externa, painful deformity of the auricle due to perichondritis/chondritis, rare signs of osteoradionecrosis (persistent pain, exposed bone, chronic discharge, recurrent infections). [25]

Red flags: rapidly increasing pain/edema with fever, foci of necrosis, foul odor, facial nerve paresis, fistulas - a reason for urgent evaluation for severe infection/osteoradionecrosis. [26]

Classification, forms and stages

For acute radiodermatitis, the CTCAE v5.0 (grade 1-5) and/or the RTOG/EORTC scale are used; they agree on key features (erythema, dry/moist desquamation, ulceration, limitation of daily activities). For the ear, the same criteria are used, supplemented by a description of the degree of edema and patency of the NSP. [27]

The stages of the process include the acute period (during RT and up to 4-6 weeks afterward), early-late (months), and late-late (years). For NSP, the "inflammatory" and "cicatricial" phases of stenosis are described separately. [28]

Forms: isolated cutaneous radiodermatitis of the turbinate; radiodermatitis of the entrance and walls of the esophagus; dermatitis + otitis externa; stenosis of the esophagus; osteoradionecrosis of the temporal bone. [29]

Table 4. Radiodermatitis of the skin of the ear according to CTCAE v5.0 (simplified)

Degree	Skin signs	Functional consequences
1	Mild erythema/dry desquamation	No/minimal
2	Moderate/bright erythema, moist desquamation in folds, moderate pain	Limiting self-care to episodes
3	Moist desquamation outside the folds, ulceration, severe pain	Marked limitation of daily activities
4	Necrosis/bleeding ulcers, hospitalization	Threat to vital functions
5	Fatal outcome	-

Complications and consequences

External auditory canal: chronic otitis externa, granulation tissue, stenosis of the external auditory canal (≈8.7% in high-dose regimens with parotidectomy), ear plugs/crusts, recurrent pain, conductive hearing loss. [30]

Cartilage/soft tissue: perichondritis/chondritis of the auricle, deformity of the auricle, chronic pain, cosmetic defect and social stigma. [31]

Bone and ear cavity: osteoradionecrosis of the temporal bone with bone exposure, chronic infection, and fistulas; sometimes extensive surgical treatment is required (measures up to subtotal petrosectomy). Conservative therapy often alleviates symptoms but does not eliminate areas of exposed bone. [32]

Hearing: conductive hearing loss (stenosis of the esophagus, otitis media, thickening of the tympanic membrane) and sensorineural (dose to the cochlea; protection guidelines - average dose ≤35-45 Gy according to QUANTEC/European consensus). [33]

When to see a doctor

1. Any moist, painful, or bleeding areas of the ear skin during or in the first weeks after RT; 2) persistent pain/congestion/purulent discharge from the ear; 3) rapid narrowing of the ear canal, hearing loss; 4) signs of severe infection (fever, throbbing pain, foul odor); 5) symptoms of facial nerve damage. These are reasons for urgent examination by an otolaryngologist and the treating radiation oncologist. [34]

If you use hearing aids/earplugs and are receiving head and neck RT, report discomfort promptly: it may be necessary to temporarily discontinue the NSP occlusion during irradiation and treatment of radiodermatitis. [35]

In cases of long-standing chronic pain, non-healing scabs, and suspected exposed bone, early imaging for osteoradionecrosis is indicated. [36]

Diagnostics

Step 1. Clinical assessment. Examination of the turbinate and tympanic membrane under good lighting; microotoscopy/endoscopy of the tympanic membrane, recording the area of moist desquamation, ulcer depth, and granulation; assessment of the patency of the canal and tympanic membrane. Photographic recording is for dynamics. [37]

Step 2. Severity stratification. Grading according to CTCAE v5.0 and/or RTOG (grades 1-4), separate assessment of the patency of the auditory canal and hearing function (Rinne/Weber at the bedside, then pure tone audiometry in case of complaints of hearing loss). [38]

Step 3. Laboratory and smears. For wet, diseased, or foul-smelling lesions, perform a smear/culture from the urinary tract (look for Pseudomonas and mixed flora); if the infection persists, rule out fungal colonization. Blood tests as indicated. [39]

Step 4. Visualization. If osteoradionecrosis is suspected, CT of the temporal bones (bone mode) to assess cortical bone, air cells, and fistulas; if there is spread to soft tissues/neurological symptoms, MRI. [40]

Step 5. Consultation. Radiotherapist + ENT +, if necessary, maxillofacial surgeon, audiologist; discussion of the transition to reconstructive tactics in case of persistent stenosis of the ESP or progressive ORN. [41]

Table 5. Mini-algorithm for assessing a patient with radiation injury to the ear

Stage	What are we doing?	For what
Examination/endoscopy of the NSP	Map of defeats	Starting point and control of dynamics
CTCAE grading	A unified language of gravity	Connection with tactics
Sowing in damp areas	Identify the bacterial/fungal component	Acupressure therapy
Audiometry	Assess the contribution of the conductive/sensorineural component	Rehabilitation plan
CT/MRI for suspected ORN	Search for bone/fistula/spread	Determine the scope of the operation

Differential diagnosis

We distinguish acute radiodermatitis from contact dermatitis (adhesives, cosmetics), thermal burns, frostbite, and herpes zoster of the auricle (viral crusts and pain along the dermatome). A clue is the temporal association with RT and the typical location in the fields. [42]

In the NSP, we separate radiation-induced otitis externa from bacterial/fungal primary otitis externa and from malignant otitis externa (necrotizing form in diabetics) - the latter causes severe pain, granulation at the osteochondral border, and systemic symptoms. [43]

Late ear ulcers/NSP should be distinguished from tumor recurrence and new skin lesions (squamous cell carcinoma in a chronic setting). Long-standing ulcers require a biopsy. [44]

Treatment

Basic care for mild radiodermatitis (grades 1-2): daily gentle washing (water/non-harsh cleanser), moisturizing with alcohol-free creams twice daily, and gentle drying without rubbing. Avoid alcohol-based solutions, irritants, tight masks/bandages, and any occlusive hearing aids (earplugs, earplugs) during the active phase. It is essential to teach the patient self-monitoring of moisture and pain. [45]

Topical corticosteroids (momatasone, betamethasone) can reduce the severity and delay the transition to moist desquamation if there is a risk or significant reaction. They are applied in a thin layer according to a regimen agreed upon with the radiation therapist; excessive or prolonged use is undesirable. Film-forming silicone coatings (Mepitel Film, Hydrofilm) are acceptable for prophylaxis and in the early stages; they have been shown to reduce the incidence and severity of dermatitis in breast cancer and, to some extent, in the head and neck region. [46]

Photobiomodulation (low-energy laser/light) is a method with a growing evidence base for the prevention of acute radiodermatitis: in the MASCC guidelines, it is listed among the options for preventing/mitigating the reaction with the right parameters; use only in centers with protocols. Specific randomized studies for the ear area are scarce, so the decision is individual. [47]

For moist desquamation (grade 2-3): atraumatic hydrogel/silicone dressings (e.g., Mepilex Lite) for protection, pain control, and gentle cleaning. If signs of secondary infection are present, topical combination medications (antibiotic + moderate steroid) should be administered in short courses; if NSP is involved, antibiotic/steroid ear drops, microsanitation, and, if necessary, a Vic turunda. Silver sulfadiazine is not routinely recommended for the prevention of radiodermatitis. [48]

Specifically regarding the external auditory canal: avoid occlusion (earplugs, devices) during an active reaction, regularly undergo atraumatic sanitation with an ENT specialist, use antibiotic/steroid drops for otitis externa; maintain dryness (dry ear regimen). In case of granulation, gentle chemical/instrumental coagulation by a specialist. [49]

If cicatricial stenosis of the esophagus develops, conservative dilation (gentle dilation, silicone stents/spacers, topical steroids) is the initial treatment. In cases of recurrence or severe narrowing, canaloplasty/meatoplasty with skin grafting is performed; this improves ventilation, facilitates care, and facilitates hearing. Timely surgery prevents chronic infections and permanent conductive hearing loss. [50]

Suspected osteoradionecrosis is the basis for a staged plan: long-term debridement, infection control (systemic and topical antibiotics), pain management, and nutritional support. Conservative measures often relieve symptoms but rarely eliminate exposed bone; persistent pain/infection/fistulas require surgery (ranging from limited debridement to canal-wall-down/subtotal petrosectomy). Several series report high cure rates after subtotal petrosectomy. [51]

Hyperbaric oxygenation and drug regimens such as PENTO (pentoxifylline + tocopherol ± clodronate) are actively discussed for jaw ORN; for temporal bone ORN, there is less evidence, they are not routinely recommended, and are considered on a case-by-case basis in multidisciplinary centers. The decision is individualized after weighing the risks and benefits. [52]

Hearing protection and rehabilitation. In cases of severe stenosis and/or otitis, early audiology and a correction plan are recommended: sanitation of the cochlea, surgery as indicated, and, after stabilization, hardware or implantable systems (including bone conduction). To reduce the risk of sensorineural hearing loss, the ALARA principle to the cochlea is followed during the RT planning stage (target Dmean ≤35-45 Gy or lower, if possible). [53]

And finally, regarding RT interruptions: severe radiodermatitis sometimes requires pauses, but this can worsen tumor control. Modern care regimens (steroids, films, dressings, pain relief) and early ENT support allow for more frequent treatment without unplanned interruptions. This is a strategic goal. [54]

Table 6. Quick selection of tactics by degree (guideline for the physician)

Situation	What to do
Degree 1	Wash, moisturize, train, avoid occlusion of NSP
Degree 2	Add topical steroid; film/soft dressing; NSP debridement
Degree 3	Combined topical agents (AB + steroid), dressings; removal of occlusion; pain relief
Degree 4	Hospitalization, intensive care, discussion of surgery/regime change

Prevention

Before and during RT: instruct the patient on gentle washing and regular moisturizing; consider prophylactic topical steroids if high risk and/or film coatings in the friction area; avoid alcohols/fragrances. For NSP - do not wear earplugs/devices during sessions and the active reaction phase. [55]

Planning of radiation therapy: spare the skin of the auricle and the entrance of the cochlea whenever possible; control the dose to the cochlea (Dmean ≤35-45 Gy, lower if possible), and ensure uniformity of dose distribution in the ear area. The ALARA principle for the hearing organs. [56]

NSP hygiene: dry regimen, avoid cotton swabs and aggressive solutions, and schedule regular sanitation with an ENT specialist. If you're prone to ear infections, schedule preventive visits. [57]

Comorbidity: glucose optimization, smoking cessation, protein-calorie support - this really reduces the risk of severe skin and infectious outcomes. [58]

Table 7. Dos and Don'ts

Action	Allowed?	Comment
Wash with warm water and a mild detergent	Yes	No rubbing/scrubbing
Daily moisturizing cream	Yes	No alcohol/fragrances
Silicone films (Hydrofilm/Mepitel)	Yes	According to indications/risk
Earplugs/devices during RT	No	Enhance maceration
Alcohol solutions, iodine	No	They worsen dermatitis

Forecast

Most mild to moderate radiation injuries to the ear heal within a few weeks with proper care and without lasting consequences. The key to success is preventing maceration in the ear canal and prompt debridement. [59]

Stenosis of the anterior spinal cord is often amenable to conservative correction and minimally invasive surgery with good functional results, especially with early intervention. Delayed treatment leads to recurrent infections and persistent conductive hearing loss. [60]

Osteoradionecrosis of the temporal bone requires long-term observation: conservative measures control symptoms, but permanent cure is more often achieved by surgery (up to subtotal petrosectomy), after which quality of life usually improves. [61]

Hearing is best preserved when dose restrictions are observed at the planning stage; if a sensorineural component does develop, modern rehabilitation devices (including implantable ones) provide decent hearing in a stable ear. [62]

FAQ

Can "strongly cauterizing" antiseptics be used on the skin of the ear during RT? No. Alcohol/iodine solutions aggravate dermatitis; gentle washing and moisturizing are preferred, and, if indicated, a topical steroid and/or film should be used. [63]

Are dressings necessary for moist desquamation? Yes, atraumatic silicone/hydrogel dressings reduce pain and protect the skin; in case of infection, topical combination agents are added. [64]

What should you do with your hearing aid during RT and active dermatitis? Temporarily avoid use or minimize wearing time; discuss alternatives (loop system, amplifying headset) until skin and NSP stabilize. [65]

When to suspect osteoradionecrosis? If chronic pain, foul-smelling discharge, exposed bone, fistulas, recurrent infections, or facial nerve paralysis are present, perform a CT/MRI and refer to a specialized center. [66]

Is there a "magic pill" for preventing dermatitis? No. The best proven measures are proper skin care, topical steroids when indicated, silicone films, and, in experienced centers, photobiomodulation. [67]

Additional tables

Table 8. Dose guidelines for hearing (head and neck RT planning)

Organ	Parameter	Target/threshold
Snail	Average dose (Dmean)	≤45 Gy (preferably ≤35 Gy if possible)
Snail (SRS/hypofraction)	Max single	<14 Gy (to maintain “audible” speech)
Principle	-	ALARA (as low as reasonably possible)

Table 9. Points of application of therapy by pathogenesis

Target	Problem	Tool
Skin inflammation	Cytokine cascade	Topical steroids in short courses
Maceration of NSP	Moisture/biofilms	Sanitation, dry ear, refusal of occlusion
Pain/wet wound	Nerve endings/exudation	Silicone/hydrogel dressings
NSP granulations	Excessive tissue growth	Gentle coagulation in ENT
Infection	Bacteria/fungi	Combined drops/dressings according to sowing

Table 10. Key differences between radiodermatitis and otitis externa

Sign	Radiodermatitis	External otitis
Trigger	LT field	Moisture, trauma, films
Pain	Skin/contact	Increased by traction of the auricle
Discharge	Scanty/serous (without infection)	Often expressed
Treatment	Skin care, steroid/bandage	NSP sanitation, AB drops + steroid