Chronic right aural fullness / itching / and too much self i | Figure 1

Chronic right aural fullness / itching / and too much self instrumentation.

42 yo male, hx seasonal allergies/eczema, seb. derm, GERD, presents with chronic ear itching, fullness on RIGHT. Uses q-tips occasionally ("only on outside"), uses warm water flush PRN. Swimmer.

Chronic = years. Notes it is worse when GERD is worse. Takes ppi generally which controls those symptoms. Was told by ENT has LPR and uses alginates as well.

Associated (?) right tonsillar gland, he says "chronic x 2 years" pending neck U/S as he notes waxes and wanes w/above (ear/GERD). It's semifirm, fixed and minimally tender.

Periodically notes severe nocturnal ear itching.

He bled recently after q tipping deeper in ear. See black scab material on pictures. Bleed was why he presented, and wants to reduce overall symptoms burdwn.

Hearing w/normal screening audiogram in office.

Recent labs (TSH/CBC/CMP) wnl. (Ordered during his "yearly" with his PCP).

No RX for seborrhea, just cleansing and OTC Ketoconazole 1% shampoo biweekly.

I suspect it's a combination of chronic irritant/atopic vs. seborrheic otitis externa, with dry and inflamed outer ear canal due to over cleaning and skin barrier disruption. Suggested biweekly distilled white vinegar + decreased instrumentation. Ref. To ENT for further evaluation of the rest (fullness, LPR, weird looking canals...). Has the osteoma I see (is a swimmer), but would appreciate advice on the rest of the weirdness, what might be done / thought of etc.

First 4 pics are the RIGHT (AFFECTED) ear, last 2 are the LEFT.

How the heck would someone even begin to restore the skin barrier in an ear this dry and irritated? I once heard of using a glycerin supp. to "paint just edges of canal," but there's got to be a better way to manage. (Old school fm doc suggested this). I also have concern this gland may be more ominous but given I'm prone to overthinking I'm awaiting the u/s to characterize it prior to ENT eval.

Please heavily critique my thought process / DDX and plan. Or just say hi!