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Otitis Externa

Otitis externa refers to an infection or inflammation of the external auditory canal, the auricle, or both.


Presentation

The following are the more common signs and symptoms of otitis externa:

Pain
  • A 64-year-old diabetic male patient is described who presented with left ear pain and discharge for two months and did not respond to ordinary treatment. The patient also noticed a progressive facial weakness on the same side.[ncbi.nlm.nih.gov]
  • It often presents with ear pain, swelling of the ear canal, and occasionally decreased hearing. Typically there is pain with movement of the outer ear.[en.wikipedia.org]
  • The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. .Pain. 1990 ;41: 139 - 50 Google Scholar Medline ISI Beyer JE ,Knott[doi.org]
  • Ear pain as only presenting symptom was the major complain found in this study accounting for 68(51.1%).[ncbi.nlm.nih.gov]
  • Patients present with severe otalgia, otorrhoea with or without facial palsy, or rarely, facial pain as a symptomatic feature.[ncbi.nlm.nih.gov]
Fever
  • A 19-year-old woman presented to our Emergency Department with a chief complaint of fever, ear pain, and generalized weakness. She was noted to be in septic shock, with left neck erythema and swelling.[ncbi.nlm.nih.gov]
  • Fever, irritability, otalgia, and hearing loss are also often present. Infection can be serious and may lead to sepsis, sigmoid sinus thrombosis, and intracranial abscess if not treated appropriately.[oxfordmedicine.com]
  • Acetaminophen decreases pain and fever. It is available without a doctor's order. Ask how much to take and how often to take it. Follow directions. Acetaminophen can cause liver damage if not taken correctly.[drugs.com]
  • Also give him a call – according to his guidelines – if your baby develops a fever.[babycenter.com]
  • The skin on these ear parts becomes dry, scaling, and itchy, and there may be foul-smelling watery or purulent discharge, pain, fever, and intermittent deafness .[britannica.com]
Varicella-Zoster Virus Infection
  • Ramsay Hunt syndrome is a rare complication of herpes zoster in which reactivation of latent varicella zoster virus infection occurs in the geniculate ganglion, causing otalgia, auricular vesicles and peripheral facial paralysis.[ncbi.nlm.nih.gov]
Ankylosis
  • Septic arthritis of the temporomandibular joint (TMJ) is a very rare complication of otitis externa that can lead to ankylosis and destruction of the joint.[ncbi.nlm.nih.gov]
Pruritus
  • There was no difference in improvement of OTI-3 between groups at any time point, whereas Group A cytology scores and pruritus improved significantly more by Day 7 (P 0.0026 and P 0.0294, respectively).[ncbi.nlm.nih.gov]
  • Ear discomfort can range from pruritus (itching) to severe pain that is worsened by motion of the ear, e.g. chewing. Discharge from the ear varies between patients and may give a clue to the cause of the condition.[dermnetnz.org]
  • Initially it is characterized by a scant, odorless secretion as well as mild discomfort and pruritus associated with modest erythema.[aafp.org]
  • The following are the more common signs and symptoms of otitis externa: Otalgia Erythema Pruritus Fluid discharge from the ear (pus) Hearing impairment Swelling of the affected ear Patients suspected with otitis externa are brought to the physician for[symptoma.com]
Otalgia
  • We report the case of a patient who was diagnosed with simple otitis externa after presenting to the emergency department (ED) with a 3-day history of right-sided otalgia.[ncbi.nlm.nih.gov]
  • Clinical efficacy, in terms of otalgia, oedema, erythema and tenderness of the external auditory canal, was assessed before packing was applied and at follow up on the 3rd and 7th days of presentation.[ncbi.nlm.nih.gov]
  • Patients present with severe otalgia, otorrhoea with or without facial palsy, or rarely, facial pain as a symptomatic feature.[ncbi.nlm.nih.gov]
  • We recommend that a diagnosis of necrotizing OE be kept in mind when evaluating any patient who presents with severe otalgia, particularly in the presence of Pseudomonas aeruginosa infection of the external auditory canal, edema, granulation tissue, and[ncbi.nlm.nih.gov]
  • They had recurrence of otitis externa over a period of 6 months after-cure, as well as severe night otalgia and high ESR level.[ncbi.nlm.nih.gov]
Tinnitus
  • There is a history of increasing otalgia with or without: custard-like, thick ear discharge conductive hearing loss tinnitus dizziness or dysequilibrium (sometimes true vertigo) It is important to note any significant risk factors for severe AOE or development[entsho.com]
  • Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. 2014 Oct;151(S2):S1-40. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Kumar KA, Kramper M, Orlandi RR, Palmer JN, Patel, ZM, Peters A, Walsh S, Corrigan MD.[choosingwisely.org]
  • Pruritus may be quite intense, resulting in scratching and further damage to the skin lining Tinnitus (ringing in the ears) Atopic dermatitis Intensely itchy Typically part of a more generalised skin involvement, including the external ears, face and[dermnetnz.org]
  • OTO-311 is an NMDA receptor antagonist for the treatment of tinnitus that has completed a Phase 1 clinical safety trial with a Phase 2 trial expected to be initiated in the second half of 2017.[globenewswire.com]
  • Patients may also have the following signs and symptoms: Otalgia - Ranges from mild to severe, typically progressing over 1-2 days Hearing loss Ear fullness or pressure Erythema, edema, and narrowing of the EAC Tinnitus Fever (occasionally) Itching (especially[emedicine.com]
Ear Discharge
  • Acute diffuse otitis externa is the commonest diagnosis made with symptoms ranging from ear pain, ear discharge, hearing loss and itchiness. Most patients were treated empirically with significant success within first two visits.[ncbi.nlm.nih.gov]
  • In children the most likely diagnosis is going to be AOM, with a TM perforation, so that the ear discharge has caused a secondary OE. In this case the discharge will be mucoid (stringy) in consistency. References Kaushik V, Malik T, Saeed S R.[dontforgetthebubbles.com]
  • There is a history of increasing otalgia with or without: custard-like, thick ear discharge conductive hearing loss tinnitus dizziness or dysequilibrium (sometimes true vertigo) It is important to note any significant risk factors for severe AOE or development[entsho.com]
  • Gram stain and culture of ear discharge: Send for aerobic, anaerobic, and fungal culture with sensitivity.[clinicaladvisor.com]
Ear Fullness
  • Patients may also have the following signs and symptoms: Otalgia - Ranges from mild to severe, typically progressing over 1-2 days Hearing loss Ear fullness or pressure Erythema, edema, and narrowing of the EAC Tinnitus Fever (occasionally) Itching (especially[emedicine.com]
Hearing Impairment
  • The following are the more common signs and symptoms of otitis externa: Otalgia Erythema Pruritus Fluid discharge from the ear (pus) Hearing impairment Swelling of the affected ear Patients suspected with otitis externa are brought to the physician for[symptoma.com]
Claustrophobia
  • Five patients had complications attributable to HBOT: acute pulmonary oedema (n 2), seizure (n 1), tympanic membrane perforation (n 1) and claustrophobia (n 1). Average time to follow up was 47 months (range 1-94 months).[archive.rubicon-foundation.org]
Cellulitis of the Face
  • Severe infections may cause lymphadenitis or cellulitis of the face or neck.[emedicine.com]
Cranial Nerve Involvement
  • Nine patients had cranial nerve involvement. Twelve of 15 patients treated with medical therapy recovered, as did 11 of 12 patients that underwent surgery.[ncbi.nlm.nih.gov]
  • Physical exam findings include otorrhea, granulation tissue in the external auditory canal, tenderness and swelling of the mastoid process, fever, and cranial nerve involvement.[emdocs.net]
  • Acute otitis externa (AOE) can progress to necrotising otitis externa (NOE) , which is an oseteomyelitis of the temporal bone and skull base, sometimes with cranial nerve involvement.[entsho.com]

Workup

Patients suspected with otitis externa are brought to the physician for initial evaluation of the outer ear for evident signs. An otoscopic examination is then conducted to see the inner canal and the condition of the tympanic membrane. In complicated cases of otitis externa, patients are usually referred to an otolaryngologist  for further evaluation and management.

Sample of secretions or ear debris may be taken for laboratory culture and sensitivity testing to determine the ideal antibiotics to be used in case the preliminary antibiotics prove to be ineffective. Imaging technique with computed tomography (CT) of the skull may be implored to elucidate the bony erosions with necrotizing cases of malignant otitis externa [7]. Magnetic Resonance Imaging (MRI) is indicated where suspected deep soft tissue involvement is entertained for better visualization [8].

Glucose Increased
  • Blood glucose increased related to delayed admission time (p 0.001). CRP results were independently elevated from the admission time (p 0.112).[ncbi.nlm.nih.gov]

Treatment

Majority of otitis externa is treated medically while some cases may require surgical drainage as a treatment option.

These are the medical modalities available for the treatment of otitis externa:

  • Analgesics: Patients may benefit from pain relievers like naproxen and ibuprofen. In severe cases of otitis externa, narcotics may be given to subdue the pain [9].
  • Antibiotics: This is the mainstay on the treatment of otitis externa. Antibiotic therapy may be taken orally, eardrops form or in combination where the cure rate reaches 87-97% in uncomplicated case [10].
  • Steroids: Severe inflammation may be controlled by the oral intake of steroids
  • Antifungals: Fungal coinfection with otitis externa may need antifungal medications.
  • Acidic solutions: Ear drops that may restore the normal pH of the ear to fend off invading bacteria.

Prognosis

The majority of otitis externa patient will resolve within 48-72 hours without complication after the administration of pharmacotherapy. Full recovery is usually expected within 7 to 10 days. Surgical drainage and debridement may be necessary to drain abscesses in the ear.

Untreated local infections may lead to malignant otitis externa which may complicate morbidity and cause mortality in severe forms. The necrotizing form of malignant otitis externa may reach a mortality rating of 20% especially among immune-compromised hosts and may even reach 50% if no medical interventions are done.

Complications

Otitis externa may give rise to any of the following given medical complications:

  • Temporary auditory disturbance: Temporary hearing loss may be experienced during the inflammatory process which is usually due to impacted cerumen. This could resolve spontaneously within one week.
  • Cellulitis: The uncontrolled spread of bacteria in contiguous structures like the face may sometimes occur. 
  • Chronic otitis externa: Acute otitis externa with recurrent symptoms beyond 3 months becomes chronic otitis externa. This is caused by tougher bacterial strain which may be resistant to treatment, an allergic response, or a coinfection with a fungus.
  • Necrotizing infection: The inward spread to the deeper tissue and the bones is severe complication of otitis externa which can cause mortality.
  • Spread of infection: The uncontrolled infection may spread to the brain and cause abscess.

Etiology

The most common cause of otitis externa is retained water in the ear that breeds the bacterial pathogen. Any break in the integrity of the skin of the ear canal can lead to the infection of the ear. Abrasions happen with frequent scratching, chronic use of ear piece and the ungentle application of cotton swabs during ear cleaning.

The accumulated cerumen may hold moisture and propagate the growth of bacterial organisms that may lead to infections. The majority of otitis externa is caused by bacterial infection; however, fungal (otomycosis) and psoriatic etiology may rarely initiate the disease process [1].

The most common pathogen in otitis externa is Pseudomonas aeruginosa representing 38% of cases followed by Staphylococcus species, anaerobes and gram-negative organisms [2].

Epidemiology

In the United States, otitis externa has been recorded across all states with an average incidence of 4 cases per 1000 population per year [3]. Infection of the external ear abounds during the summer season where it’s warm and humid and presumably because water activities are common during this time [4]. Otitis externa are more prevalent in tropical countries than in temperate countries.

The disease affliction peaks at 7–12 years of age and is also common among young adults. The prevalence of otitis externa slightly peaks again beyond the age of 65 years old because of comorbid factors like diabetes and rheumatoid arthritis, and there is a large sector of elders that uses hearing aids which can propagate the infections. Patient with allergic rhinitis and asthma are more prone to otitis externa [5].

Sex distribution
Age distribution

Pathophysiology

The pathophysiology in the development of otitis externa can be divided into four mechanisms of origin:

Obstructive: The accumulation of cerumen may accumulate water and moisture causing a maceration of the outer skin layer which invites bacterial invasion.

Drying: The absence of cerumen and loss of natural moisture of the ear canal skin due to frequent ear cleaning can cause fissuring and thinning of the skin membranes. The compromised skin layer may invite invading bacteria to cause the infection.

Trauma: Any break in the skin layer due to trauma from cotton wabs, fingernails or instruments may cause abrasion and eventual infection of the ear canal.

Alteration of skin natural pH: Patient on radiotherapy, chemotherapy and on chronic steroids use can alter the skin’s pH making it less resistant to bacterial invasion. Immuno-compromised patients may develop a severe necrotizing form of infection known as malignant otitis externa [6].

Prevention

The best way to prevent water from accumulating in the ear canal is to wear ear plugs and swimming caps during swimming and diving activities. Practice tilting of one’s head in both directions after shower and swimming to rid-off excess water from both ears. Cleaning of ears must be done in moderation in up to once weekly to prevent the drying of the ear canal.

Patient Information

Otitis externa or outer ear infection is an infection of the outer ear canal. Patients must observe strict compliance in the intake of antibiotics to avoid antibiotic resistance of bacterial infection. One must call the attention of the attending physician if no improvements are observed after 3 days of treatment to merit reevaluation of treatment and prevent serious complications. Any notable discharges must also be reported to proper medical authorities for further investigation and evaluation.

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Last updated: 2019-07-11 22:03