otitis externa Flashcards
define otitis externa
localised
acute
chronic
Inflammation of the external canal – SWIMMER’S EAR
Localised – folliculitis
Diffuse – swimmer’s ear -) inflammation of skin and subdermis of the external ear canal
Duration – acute (3 weeks or less) and chronic (longer than 3 months)
define MOE
otitis externa spreads into the bone surrounding the ear canal (mastoid and temporal bones)
causes if OE
Acute
1) Bacteria – pseudomonas aeruginosa or staph aureus
2) Fungal – aspergillus or candida albicans
3) Seborrheic dermatitis maybe ass with
a. Dandruff
b. Blepharitis
c. Eyebrow scaling
d. Facial redness
e. Scaling
4) Contact dermatitis – topical med (NEOMYCIN)
a. Allergic – sudden inset -erythematous, itchy, oedematous and exudative lesions
b. Irritant – insidious onset with lichenification
5) Trauma – cotton buds, foregin objects
6) Envi factors – high temp/humidity, swimming in polluted water esp
Chronic
1) Allergic contact dermatitis
2) Irritant contact dermatitis
3) Seborrheic dermatitis
4) Fungal – prolonged and extensive use of topical Abx or steroids predispose to sec fungal infections
5) Bacterial persistent infection, thickening skin
Signs and symptoms of acute otitis externa
Signs
- red, swollen, or eczematous with shedding of scaly skin
- swelling in the ear canal – LOCALISED OTITIS EXTERNA with yellow or white centre filled with pus
- discharge may be present (serous or purulent)
- inflamed eardrum difficult to visualise
Symptoms
- itchy
- severe ear pain
- hearing loss
- pain made worse when tragus or pinna is moved or when inserting otoscope
- tenderness on moving the jaw
- tender regional lymphadenitis – less common
- if furuncle breaks a relieve of pain (rare)
- loss of hearing (rare)
signs and symptoms of chronic otitis externa
CHRONIC OTITIS EXTERNA
Signs
- lack of earwax
- dry hypertrophic skin - partial canal stenosis
- pain on manipulation
symptoms
- constant itch in the ear
- mild discomfort
- pain, if present
signs and symptoms of MOE
signs
- granulation tissue at bone-cartilage junction, exposed bone at the ear canal
- facial drooping
- fever above 38
symptoms
- vertigo, dizzy
- hearing loss
- pain and headache
differentials for OE
AOM Cholesteatoma MOE trauma barotrauma skin conditions mastoiditis referred pain ramsay hunt syndrome impacted ear wax foreign body in the ear
initial management for OE
manage any aggravating or precipitating factors
Consider cleaning the external auditory ear canal if earwax or debris obstructs the application of topical medication
- syringing or irrigation
- dry swabbing
- microsuction
analgesia
topical antibiotic or a combined topical antibiotic with a steroid
- Flucoxacillin
topical AB with steroids
Quinolone - ciprofloxacin Pseudomonas is suspected 7 days 2 times - can use it with TM perforation
acetic acid
if the tympanic membrane is perforated aminoglycosides are traditionally not used*
if the canal is extensively swollen then an ear wick is sometimes inserted
analgesia
when to consider oral ABs
systemically unwell
immunocompromised
cellulitis extending
PRIMARY CARE FLUCOXACILLIN 7 DAYS
self care advise for pts w OE
keep the ears dry - do not go swimming wear plugs or tight cap
dry with hair dryer
avoid trauma to ear canal
acidifying drops before after swim
treatment for chronic OE
- Fungal – topical antifungal o Clotrimazole 1% o Clioquinol and a corticosteroid - Allergic – corticosteroid - Seborrheic – antifungal.corticosteroid combination - No cause evident o 7 day corticosteroid with acetic spray o FAIL TOPICAL ANTIFUNGAL
Risk factors for MOE
- Diabetes mellitus — present in most cases of malignant otitis.
- Compromised immunity, such as from HIV/AIDS, chemotherapy, or chronic kidney disease.
- Radiotherapy to the head or the neck.
- Aural irrigation with tap water, especially in people with other risk factors.
Complciations of OE
• Abscess.
• Chronic otitis externa.
• Regional dissemination of infection with: auricular cellulitis, chondritis, parotitis, spreading cellulitis.
• Fibrosis, leading to stenosis of the ear canal and conductive deafness.
• Myringitis (inflammation of the tympanic membrane).
• Tympanic membrane perforation.
• Malignant otitis.
The complications of malignant otitis include:
• Facial nerve paralysis.
• Meningitis
role of ear wax
Protects the EAC skin.
- Cleans and lubricates the skin.
- Antiseptic properties.
- Insect stopped
what is irrigation
A mechanical irrigation system flushes the wax out with warm water. Similarly, the ear can be syringed.
what is tympanosclerosis
scarring of the eardrum, which may occur after injury or surgery.
tympanosclerosis on otoscopy
right white scarring on the membrane
second line management for OE
consider contact dermatitis secondary to neomycin
oral antibiotics (flucloxacillin) if the infection is spreading
taking a swab inside the ear canal
empirical use of an antifungal agent
key features in history for malignant otitis externa
Diabetes (90%) or immunosuppression (illness or treatment-related)
Severe, unrelenting, deep-seated otalgia
Temporal headaches
Purulent otorrhea
Possibly dysphagia, hoarseness, and/or facial nerve dysfunction
diagnosis of MOE
CT scan
management of MOE
- non-resolving otitis externa with worsening pain should be referred urgently to ENT
- Intravenous antibiotics that cover pseudomonal infections CIPROFLOXACIN
what is furunculosis
infection of a hair follicle in the outer ear canal
clinical features of furnuculosis
Severe throbbing pain with pyrexia precedes rupture of the abscess
management of furnuculosis
Examination and drainage under anaesthetic may be required.
what is myringitis bullosa
localized form of otitis externa where blisters form
on the eardrum and deep meatus.
what is acute otitic barotrauma
descent in aircraft. It leads to severe otalgia and occasionally rupture of the eardrum with a bloody otorrhoea.
causes of referref otalgia in children
tonsillitis referred pain
URTI
dental pain
periauricular sinus
Common congenital condition in which an epithelial defect forms around the external ear
Small sinuses require no treatment
Deeper sinuses may become blocked and develop episodes of infection, they may be closely related to the facial nerve and are challenging to excise
risk factors for OE
Radiotherapy to the ear, neck or head.
Previous ear surgery, such as tympanostomy.
Previous topical treatments for otitis externa or otitis media.
Atopic, allergic, or irritant dermatitis.
Dermatoses.
Trauma to ear canal from cleaning, scratching, or instrumentation.
Use of hearing aid or ear plugs.
Exposure to water or humid climate.
Diabetes, immunosuppression, and older age.
irrigation
chemical injury
management for chronic otitis externa
fungal cause
dermatitis
no cause identified
fungal cause
- clotrimazole
- acetic acid
- clioquinol
dermatitis
irritant/allergic - topical steroid
seborrhoeic - cloquinol adn corticosteroid
no cause
- topical steroid no AB
when can TM perforation be assumed
Has had a tympanostomy tube inserted in the past 12 months and there is no documentation of extrusion and closure of the tympanic membrane.
Can blow air out of the ear when the nose is pinched, or
Can taste medication placed in the ear.
when to swab ear from someone with OE
Treatment fails.
Otitis externa is recurrent or chronic.
Topical treatment cannot be delivered effectively (for example, if the ear canal is occluded due to swelling or debris).
The infection has spread beyond the external auditory canal.
The condition is severe enough to require oral antibiotics.
what is mild case of otitis externa and treatment
mild discomfort and/or pruritus; no deafness or discharge), consider prescribing topical acetic acid 2% spray.
When features of more severe inflammation are present, such as in this case, they advise 7 days of a topical antibiotic with or without a topical steroid.
