Abstract

Objective

Patients presenting to otorhinolaryngology (OHL) clinics with isolated external auditory canal (EAC) pruritus are common. Although there are many etiological reasons for this complaint, psychological factors have long been ignored. Psychocutaneous diseases must be considered in the differential diagnosis when no symptoms that might cause pruritus are detected in the OHL examinations, including anamnesis and microscopic otoscopy, of patients with isolated EAC pruritus. Recent studies have shown that psychological factors or disorders must not be ignored in patients with isolated EAC pruritus.

Method

A total of 60 patients who applied to the OHL clinic with EAC pruritus and had not received psychiatric treatment before or yet were included in the patient group (PG) in the study, after excluding other causes of EAC pruritus. We included 62 individuals in the control group (CG) who had no previous or current complaints of EAC pruritus and who had not received psychiatric treatment. We filled out the sociodemographic data form that we had prepared for the PG and CG participants we included in the study. We also applied the psychiatric symptom screening list (SCL-90-R) and Maudsey obsessive compulsive symptom list (MOCI) scales to the participants. However, we had to exclude 3 of the 62 healthy participants in the control group because they filled out the SCL-90-R and MOCI tests incompletely, and we formed the control group with 59 healthy participants.

Results

The difference between SCL-90-R test overall scores and sub-parameters of SCL-90-R test between PG and CG in our study were the difference between obsessive-compulsive symptoms, somatization, interpersonal sensitivity, depression, anxiety, anger-hostility, phobias, paranoid symptoms, psychoticism and additional scale scores was statistically significant (p<0.05). A statistically significant difference was also detected between the MOCI test total scores applied to PG and CG and the MOCI test sub-parameters control, cleanliness, slowness, suspicion, and rumination scores (p<0.05).

Conclusion

The data obtained in this study showed that the complaint of isolated EAC pruritus might have a psychological basis. The statistically significant difference in the parameters measuring the obsession and compulsion scores between the two groups in this study suggested that EAC pruritus might be a somatic obsession. Furthermore, the statistically significant difference between all parameters of the scales in the comparison between the two groups supported the hypothesis that EAC pruritus might have a psychological basis. This result, which was detected in the present study, indicated that psychological factors must not be ignored in EAC-related pruritus. However, more extensive studies are needed on this subject.

Introduction

The external auditory canal (EAC) or external ear canal is a cartilaginous structure that includes apocrine and sebaceous glands, and the skin contains hairy cells. EAC pruritus or itching is a common symptom of several etiological factors. Various pathologies, such as seborrheic dermatitis, contact dermatitis, dermatomycosis, psoriasis, dermatophyte (Id) reaction, and EAC carcinoma, should be considered as the etiological causes of EAC pruritus (1).

EAC pruritus can be accompanied by pain, burning, or stinging sensations. The severity of itching could be mild or extreme if sleep disturbance is observed in the patient. Patients commonly present in the otorhinolaryngology (OHL) outpatient clinics with only EAC pruritus. This condition was defined as “itchy ear syndrome” in the literature (2). When there is no evidence of bacterial infection, active dermatological disease (psoriasis, atopic dermatitis, etc.), or otomycosis in the OHL examination, which includes anamnesis and microscopic otoscopy, psychocutaneous diseases should be considered in the differential diagnosis. Several psychocutaneous diseases, such as neurodermatitis, primary essential pruritus, and delusional parasitosis, can cause EAC pruritus (3).

Obsessive compulsive disorder (OCD) is characterized by unwanted recurring thoughts (obsessions) and behaviors intended to ward off the anxiety caused by these thoughts (compulsions). There are several types of obsessions and compulsion. Somatic obsessions are only one type of these (4). Somatic obsessions are obsessive and distorted thoughts that can be observed in OCD, and they involve tactility, mobility, or various sensations associated with a certain body part (5). In the literature, certain studies indicated that individuals with obsessive-compulsive personality traits or OCD were more susceptible to EAC pruritus (6). This may be because OCD patients over-focus on the sensations they feel in their bodies. Based on these studies, we concluded that all possible causes of EAC pruritus should be investigated in addition to general anamnesis and examinations in patients who presented to the OHL outpatient clinic with EAC pruritus complaints, and the patient’s psychology should be evaluated after all possible organic factors are excluded.

In this study, we set out with the hypothesis that pruritus in patients with EAC pruritus may have a psychological cause when other causes of EAC pruritus are excluded and that this condition may be a somatic obsession (3, 5). For this purpose, routine oto-microscopic external ear canal evaluation was performed in patients included in the study. The examinations were performed by the same otolaryngologist using the same ear microscope in a similar manner for all patients. We applied the symptom checklist (SCL-90-R) and the Maudsley Obsessive-Compulsive Inventory (MOCI) to the patient group (PG) and healthy control group (CG) and compared the results between the two groups.

Materials and Methods

Sixty (n=60) 18-65-year-old patients who presented to the OHL outpatient clinic at Mardin Training and Research Hospital with pruritus compliance and voluntarily agreed to participate were included in the study. In addition to a detailed ear, nose, and throat examination, microscopic examination of the EAC and external ear auditory secretion was conducted to exclude infectious and allergic factors that could cause EAC pruritus.

We included 62 individuals in the control group (CG) who had no previous or current complaints of EAC pruritus and who had not received psychiatric treatment. We filled out the socio-demographic data form that we had prepared for the PG and CG participants we included in the study. We also applied the psychiatric symptom screening list (SCL-90-R) and Maudsey obsessive compulsive symptom list (MOCI) scales to the participants. However, we had to exclude 3 of the 62 healthy participants in the control group because they filled out the SCL-90-R and MOCI tests incompletely, and we formed the control group with 59 healthy participants.

The study was approved by the Non-Interventional Clinical Research Ethics Committee of Mardin Artuklu University (date: 06/04/2022, number: 2022-7). Approval of the participants included in the study was obtained using a voluntary consent form.

Data Collection Instruments

Socio-demographic participant data were collected using a form developed by the authors. SCL-90-R and MOCI were also applied to the participants.

SCL-90-R

SCL-90-R is a 90-item checklist developed by Derogatis (7). This test is used to screen for psychological symptoms, including somatization, obsessive-compulsive symptoms, interpersonal sensitivity, anxiety, depression, phobia, anger/hostility, paranoid traits, psychoticism, an additional scale and general evaluation items. The validity and reliability of the Turkish version of the scale were determined by Dağ (8).

MOCI

The MOCI was developed by Hodgson and Rachman (9) to investigate the type of OCD symptoms and was validated in the Turkish language by Erol and Savaşır (10). The inventory includes checking, cleaning, slowness, doubting, and rumination subdimensions.

Statistical Analysis

IBM SPSS 21.0 for Windows statistical software was used for the statistical analysis of the study data. Measured variables are presented as mean ± standard deviation and median, and categorical variables are presented as counts and percentages (%). The normal distribution of the data was checked. The Mann-Whitney U test was employed to compare group data without normal distribution. The chi-square (χ²) test was employed to compare qualitative variables between the groups. P<0.05 was accepted as statistically significant.

Results

The hg included 46 females (n=46, 76.7%), 14 males (n=14, 23.3%), 60 (n=60) participants. The CG included 41 women (n=41, 69.5%) and 18 men (n=18, 30.5%); a total of 59 (n=59) participants. The socio-demographic data are presented in Table 1.

The age and employment status of the patient and CGs were statistically similar. The distribution of participants according to gender and education level was different (p<0.05, Table 1).We determined that the difference between the general evaluation scores of the patient and CGs was statistically significant in the SCL-90-R. Furthermore, the differences between obsessive-compulsive symptoms, somatization, interpersonal sensitivity, depression, anxiety, anger-hostility, phobia, paranoid symptoms, psychoticism subdimension, and additional scale scores of the groups were statistically significant in the SCL-90-R (p<0.001, Table 2).

The difference between the total scores of the two groups in the MOCI was statistically significant. The difference between the MOCI checking, cleaning, slowness, doubting, and rumination subdimension scores of the PG and CG was statistically significant (p<0.001, Table 3).

Discussion

Isolated EAC pruritus is a common symptom, the etiology of which is still not clear. The literature generally reported that allergic contact dermatitis is responsible for the etiology of isolated ear itching (11). However, Acar et al. (12) reported that patients with isolated EAC pruritus did not exhibit allergic contact dermatitis symptoms on histopathological analysis (12). Therefore, there is no consensus on the underlying pathology of isolated EAC pruritus, and the etiologic factors have not been completely determined (13). Due to this uncertainty, patients are frequently diagnosed with idiopathic EAC pruritus. However, recent studies have demonstrated that psychological factors (e.g., somatization disorder) should be kept in mind as well as other etiologies in patients with EAC pruritus complaints before describing the symptoms as idiopathic (14).

It has been known for a long time that psychological factors can be effective in the treatment of itching in general (15). The degree of depression or anxiety symptoms was directly associated with the severity of itching in various pruritic skin diseases (16-18). It is also known that itching severity can increase in patients with psychiatric disorders (19, 20). Pruritus strongly reduces quality of life and can often be comorbid with other psychiatric disorders, including suicidal ideation (21). Studies have reported a positive correlation between pruritus and depression scores. Patients with high depression scores scored higher on the itching severity test than those with low depression scores (22).

Psychogenic pruritus can accompany other psychiatric conditions, such as depression, anxiety, obsessive-compulsive disorder, psychosis, and substance use (18, 23, 24). Pruritus is also a symptom of somatoform dissociation, and even milder degrees of dissociation may play a role in the development of psychogenic pruritus (25). Thus, the psychological state of patients with persistent itching should be considered. This approach may also be applicable to isolated EAC pruritus (26).

The obsessions and compulsion observed in OCD patients tend to change over time. Somatic obsessions are among the types of obsessions. Somatic obsessions are when individuals with OCD become excessively interested in any part of their body and/or focus their thoughts on it, causing them to perceive minimal or non-existent physical symptoms more intensely and develop obsessions and compulsions about this issue over time (27). In OCD, somatic obsession can be recognized as abnormal body awareness (27). The following bodily processes are common in individuals who suffer from somatic obsessions: breathing, blinking, salivation, and swallowing; body position; tactile sensations such as heartbeat or itching, tinnitus, “floaters in eyesight”, and other visual distractions (e.g., seeing the profile of own nose in peripheral vision) (6).

Yilmaz  et al in a 2016 study, Yilmaz et al. (26) claimed that almost half (43%) of patients with isolated ear canal pruritus had a type D personality. These individuals have high levels of anxiety, worry about unimportant thoughts or behaviors, over-attribute thoughts, are introverted, have high social shyness, and fear rejection or disapproval (28). Type D personality has recently been associated with various diseases, such as irritable bowel syndrome, heart disease, anal fissures, type 2 diabetes, and hemorrhoids (29, 30). Yilmaz et al. (26) reported that patients with type D personality experienced more severe pruritus than controls, and higher depressive and anxiety symptoms were observed in these patients than in controls. Furthermore, there was a negative correlation between the extraversion dimension score of the revised Eysenck personality questionnaire short form score and the severity of pruritus (26). Before these patients are diagnosed with idiopathic EAC pruritus, they should undergo a psychiatric examination (26).

The present study findings confirmed that EAC pruritus can be induced by psychological factors. We observed a significant difference between the general evaluation and other subdimension SCL-90-R scores of the patients and CG. Among these parameters, the high obsessive comppulsion, anxiety, depression, somatization, interpersonal sensitivity, phobia, anger-hostility and other scores in the PG supported our hypothesis. In the CG, the general evaluation and subdimension scores were lower than those in the HG. These findings suggested that the HG exhibited more psychiatric symptoms.

A review of type D personality traits would reveal similarities with OCD-associated traits, especially perfectionism, social inhibition, and introversion. Thus, the MOCI was applied to PG and CG in our study, and we observed that the findings were more significant than expected. The checking, cleaning, slowness, doubting, and rumination subdimension scores of the HG were significantly higher than those of the CG. There were statistically significant differences between the subdimension scores of the two groups.

Study Limitations

However, the scarcity of similar studies in the literature, the small sample size of the current study, and the fact that some biochemical diagnostic tests were not applied prevented generalization of the hypothesis. These are the limitations of our study. Therefore, more comprehensive analytical studies should be conducted on the same patient population and on patients with OCD and somatic obsessions.

Conclusion

The findings of this study strongly supported the hypothesis and suggested the following: Is EAC pruritus an obsession, and in particular, is it a type of somatic obsession? Both the SCL-90-R and MOCI scores demonstrated that individuals with EAC pruritus should undergo a psychiatric examination after excluding other etiologic factors.