otitis externa
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Etiology
- infection
- bacterial (generally acute)
- Staphylococcus
- Streptococcus
- Pseudomonas (necrotizing otitis externa)
- older diabetic patients
- ear irrigation may be predisposing factor
- Proteus
- Mycoplasma (Bullous myringitis)
- Actinomyces (chronic)
- fungal (chronic)
- bacterial (generally acute)
- local trauma or environmental exposure
- cotton-tipped swab
- hairpin
- swimmer's ear
- may be secondary infection
- cerumen impaction - seborrheic external otitis
- eczematoid external otitis
- foreign body
Pathology
- cellulitis of the external auditory canal[9]
- localized infection as in a pustule or furuncle which arises in hair follicles in the outer portion of the ear canal
- local trauma or environmental exposure leading to diffuse inflammation (swimmer's ear)
- chronic irritation from a perforated otitis media with suppuration
- chronic eczema
- conductive hearing loss
History
- swimming
- trauma
- upper respiratory tract infection
Clinical manifestations
- earache (otalgia)
- itching (pruritus)
- conductive hearing loss
- Weber test lateralizes to the affected ear
- vertigo
- tympanic membrane appearance is normal
- erythema of auricle: cellulitis; furuncle
- pain on movement of auricle or with mastication
- ear discharge
- white, cheezy or mucous-like material may prevent visualization of the tympanic membrane
- may be green or yellow
- may be copious & foul-smelling to minimal with malignant otitis
- black discharge suggests fungal origin
- periauricular & cervical lymphadenopathy
- seborrheic or eczematoid otitis externa
- flaking, crusting or weeping of skin
Laboratory
- KOH preparation of discharge if fungal infection is suspected
- cultures of discharge only if patient is immunocompromised or does not respond to standard therapy
- if necrotizing otitis externa is suspected
Radiology
- computed tomography (CT) if suspected necrotizing otitis externa
Differential diagnosis
- eustachian tube dysfunction
- may be associated with seasonal allergies
- cutaneous neoplasm (persistent inflammation)
- malignant otitis externa (necrotizing otitis externa)
- associated with diabetes mellitus or immunosuppression
- systemically ill
- otalgia out of proportion to visible findings[9]
- evidence of infection spread beyond the external auditory canal
- recurrent furuncles suggests diabetes mellitus
- Ramsay-Hunt syndrome caused by Herpes zoster
- acute myringitis due to Mycoplasma or viral infection
- see earache
Management
- factors that modify management[7]
- ear hygiene
- clear as much debris from the external auditory canal as possible[2]
- cerumen impaction
- wax softeners
- pulsating irrigation device (contraindicated if infection suspected)
- seborrheic or eczematoid external otitis
- treat underlying seborrhea with selenium sulfide shampoo weekly
- hydrocortisone topical cream/lotion to auricle
- add antibiotic if secondary infection is suspected
- topical agents (infection, inflammation)
- Auralgan (benzocaine & antipyrene)
- fill ear as needed for pain
- steroid/antibiotic topical, 4 drops TID/QID
- ciprofloxacin/dexamethasone (Ciprodex) 4 drops BID for 5 days
- ciprofloxacin/hydrocortisone (Cipro-HC) 5 drops BID for 5 days
- Corticosporin otic (polymyxin B, neomycin, hydrocortisone)
- Coly-Mycin S (neomycin, colistin sulfate, hydrocortisone, thonzonium bromide)
- treatment of choice[3]
- gentamicin or tobramycin ophthalmic may be used[4]
- Vosol or Domeboro otic (acetic acid, 2%) 3-5 drops BID for mild otitis externa[2]
- acetic acid + triamcinolone better than acetic acidalone[3]
- introducing cotton wick into the ear canal with forceps may facilitate delivery of antibiotic drops
- for otitis externa in patients with perforated eardrum, use Ciprodex (ciprofloxacin/dexamethasone) or ofloxacin otic; these are sterile, Cipro HC is not[5]
- Auralgan (benzocaine & antipyrene)
- systemic antibacterial agents
- indicated for malignant otitis externa
- amoxicillin (Amoxil) 250-500 mg TID 30-50 mg/kg/day divided TID for child
- erythromycin 500 mg BID 30-50 mg/kg/day divided TID/QID for child
- Augmentin 1 tab TID
- pediazole
- systemic antipseudomonal cephalosporin &/or fluoroquinolone for for necrotizing otitis externa in diabetics
- IV ceftazidime, IV ciprofloxaxin
- ref[2] recomments hospitalization & IV antibiotics
- systemic glucorticoid & antiviral agent for Ramsay-Hunt syndrome
- patient education
More general terms
More specific terms
- eczematoid otitis externa
- malignant otitis externa
- otomycosis; fungal otitis externa
- swimmer's ear (tropical ear)
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 40-42, 82-83
- ↑ 2.0 2.1 2.2 2.3 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012
- ↑ 3.0 3.1 3.2 Journal Watch 24(2):17, 2004 van Balen FAM et al, BMJ 327:1201, 2003 http://bmj.bmjjournals.com/cgi/content/full/327/7425/1201 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14630756
- ↑ 4.0 4.1 Prescriber's Letter 13(10): 2006 Alternative or 'Off-label' Routes of Drug Administration Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=221012&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 5.0 5.1 Prescriber's Letter 16(8): 2009 COMMENTARY: Drug Treatments for Swimmer's Ear: An Update GUIDELINES: Acute Otits Externa Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=250821&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ Osguthorpe JD, Nielsen DR. Otitis externa: Review and clinical update. Am Fam Physician. 2006 Nov 1;74(9):1510-6. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17111889
- ↑ 7.0 7.1 7.2 Rosenfeld RM et al Clinical Practice Guideline. Acute Otitis Externa Executive Summary Otolaryngol Head Neck Surg February 2014 150(2):161-168 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24492208 <Internet> http://oto.sagepub.com/content/150/2/161.full
- ↑ Prescriber's Letter 21(6): 2014 Treatment of Acute Otitis Externa Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=300607&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 9.0 9.1 9.2 9.3 NEJM Knowledge+ Otolaryngology
Rosenfeld RM, Schwartz SR, Cannon CR et al Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014 Feb;150(1 Suppl):S1-S24. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24491310 Review - ↑ Hajioff D, MacKeith S. Otitis externa. BMJ Clin Evid. 2015;2015. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26074134