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Otitis externa
- 1. Otitis Externa (OE) Ahmed AlMumtin MD
- 2. Anatomy and Physiology • Consists of the auricle and EAM • Skin-lined apparatus • Approximately 2.5 cm in length • Ends at tympanic membrane
- 3. Anatomy and Physiology • Auricle is mostly skin-lined cartilage • External auditory meatus • Cartilage: ~40%, Bony: ~60% • S-shaped, Narrowest portion at bony-cartilage junction
- 4. Anatomy and Physiology • EAC is related to various contiguous structures • Tympanic membrane • Mastoid • Glenoid fossa • Cranial fossa • Infratemporal fossa
- 5. Anatomy and Physiology • Innervation: cranial nerves V, VII, IX, X, and greater auricular nerve • Arterial supply: superficial temporal, posterior and deep auricular branches • Venous drainage: superficial temporal and posterior auricular veins • Lymphatics
- 6. Anatomy and Physiology • Squamous epithelium • Bony skin – 0.2mm • Cartilage skin • 0.5 to 1.0 mm • Apopilosebaceous unit
- 7. Otitis Externa • Bacterial, viral or fungal infection of external auditory canal • Categorized by time course • Acute • Chronic
- 8. Speculum findings: • the canal may be so swollen that a view into the ear is impossible • In swimmers, divers and surfers, chronic water exposure can lead to the growth of bony swellings in the canal known as exostoses. These can interfere with the drainage of wax and predispose to infection.
- 9. Differential diagnoses: • Otitis media • Ramsay Hunt syndrome • Furuncle • Skull base osteomyelitis • Preauricular cyst and fistula • Lacerations • Atopic dermatitis • Cerumen impaction • Exostosis and osteoma • Foreign body • Acute (bullous) and chronic (granular) myringitis
- 10. Organisms 1. Pseudomonas species 2. Staphylococci 3. Streptococci/Gram negative rods 4. Fungi (Aspergillus/Candida species)
- 11. Labs/workup Usually after failed empiric therapy: • bacterial and fungal culture • Adults with otitis externa: screening blood glucose and/or a urine dipstick test to rule out occult diabetes. • Additional tests (if available): • Gram stain of d/c • KOH prep smear (within 10 min)
- 13. Acute Otitis Externa (AOE) • “swimmer’s ear” • Preinflammatory stage • Acute inflammatory stage • Mild • Moderate • Severe
- 14. Factors contributing to AOE • High humidity • Water exposure • Maceration of canal skin • High environmental temperature • Local trauma • Perespiration • Allergy • Stress • Removal of normal skin lipids • Absence of cerumen • Alkaline pH of canal
- 15. AOE: Preinflammatory Stage • Oedema of stratum corneum and plugging of apopilosebaceous unit • Symptoms: pruritus and sense of fullness • Signs: mild edema • Starts the itch/scratch cycle
- 16. AOE: Mild to Moderate Stage • Progressive infection • Symptoms • Pain • Increased pruritus • Signs • Erythema • Increasing edema • Canal debris, discharge
- 17. AOE: Severe Stage • Severe pain, worse with ear movement • Signs • Lumen obliteration • Purulent otorrhoea • Involvement of periauricular soft tissue
- 18. AOE: Treatment • Most common pathogens: P. aeruginosa and S. aureus, E.coli and proteus.! • Four principles • Frequent canal cleaning; swap or suction • With sever EO, palcement of a wick made of sponge or gauze provides a pathway for drops to be delivered to the EAC wall skin for 48-72 hours! • Topical antibiotics, and if sever>> Systemic PO,ABT • Pain control • Instructions for prevention
- 19. AT A GLANCE. . . • Ostalgia • Tenderness on palpation or manipulation (tragus sign) • Ear fullness • Conductive hearing loss. • Erythaema of meatus and canal • Swelling and obstruction of canal • Crusting and discharge • Odor!
- 20. Furunculosis • Acute localized infection • Lateral 1/3 of posterosuperior canal • Obstructed apopilosebaceous unit • Pathogen: S. aureus
- 21. Furunculosis: Symptoms • Localized pain • Pruritus • Hearing loss (if lesion occludes canal)
- 22. Furunculosis: Signs • Edema • Erythema • Tenderness • Occasional fluctuance
- 23. Furunculosis: Treatment • Local heat • Analgesics • Oral anti-staphylococcal antibiotics • Incision and drainage reserved for localized abscess • IV antibiotics for soft tissue extension - tri-adcortyle!
- 24. Erysipelas • Acute superficial cellulitis • Group A, beta hemolytic streptococci • Skin: bright red; well- demarcated, advancing margin • Rapid treatment with oral or IV antibiotics if insufficient response
- 25. Otomycosis • Mostly in children who are exposed to warm, moist climates or who have a Hx of chronic use of antibiotic ear drops. • Fungal infection of EAC skin • Primary or secondary • Most common organisms: Aspergillus and Candida
- 26. Otomycosis: Signs • Canal erythaema • Mild oedema • White, gray, green, yellow or black fungal debris Otomycosis: Symptoms • Often indistinguishable from bacterial OE • Pruritus deep within the ear • Otorrhoea • Dull pain • Hearing loss (obstructive) • Tinnitus
- 27. Otomycosis: Treatment • Thorough cleaning and drying of canal • Topical antifungals (clotrimazole for eg., amphotericine B, oxytetracycline-polymyxin, and nystatin are very effective!) • Acidifying of the EAC with drops like 2% acetic acid, 3% boric acid or sulzberger’s powder are also helpful in the t/t of fungal infections.
- 28. Necrotizing (malignant) External Otitis(NEO) • Potentially lethal infection of EAC and surrounding structures • Pseudomonas aeruginosa is the usual culprit • Risk Factors: - Diabetes Mellitus - Elderly - Immunocompromised state - Human Immunodeficiency Virus (HIV) • Typically seen in diabetics and immunocompromised patients
- 29. NEO: Signs & Symptoms • Similar to Otitis Externa except • Severe, unrelenting Ear Pain and Headache • Persistent discharge • Does not respond to topical medications • Commonly associated with Diabetes Mellitus • Granulation tissue in posterior and inferior canal • Pathognomonic for necrotizing otitis • Occurs at bone-cartilage junction • Extra-auricular findings • Cervical Lymphadenopathy • Trismus (TMJ involvement) • Facial Nerve Palsy or paralysis (Bell's Palsy) • Associated with poor prognosis
- 30. NEO: Dx, Prevention and T/T: • Prognosis; Reportedly mortality 20-53% • Dx: Hx, PE, Labs and Imaging: - Labs; FBC, Culture of discharge, ESR, Serum glucose, Serum creatinine. - Radiology; CT, or MRI (ear),Tc 99m medronate methylene bone scanning, Ga 67 scintography. • Prevention: - Avoid use of cotton swabs in ear and other canal trauma. - Use caution when irrigating ear of high risk patients. - Treat eczema of ear canal and other pruritic dermatitis
- 31. NEO: Treatment • Intravenous antibiotics for at least 4 weeks – with serial gallium scans monthly • Local canal debridement until healed • Pain control • Use of topical agents controversial • Hyperbaric oxygen experimental • Surgical debridement for refractory cases
- 32. NEO: Diagnosis • Cohen and Friedman – criteria from review: They were divided into two categories: obligatory and occasional. The obligatory criteria are: pain, edema, exudate, granulations, microabscess (when operated), positive bone scan or failure of local treatment often more than 1 week, and possibly pseudomonas in culture. The occasional criteria are diabetes, cranial nerve involvement, positive radiograph, debilitating condition and old age. All of the obligatory criteria must be present in order to establish the diagnosis. The presence of occasional criteria alone does not establish it. The importance of Tc99 scan in detecting osteomyelitis is stressed. When bone scan is not available, a trial of 1-3 weeks of local treatment is suggested. Failure to respond to such treatment may assist in making the diagnosis of MEO.
- 33. NEO: Mortality • Death rate essentially unchanged despite newer antibiotics (37% to 23%) • Higher with multiple cranial neuropathies (60%) • Recurrence not uncommon (9% to 27%) • May recur up to 12 months after treatment
- 34. Perichondritis/Chondritis • Infection of perichondrium/cartilage • Result of trauma to auricle • May be spontaneous (overt diabetes) • Usual pathogens include pseudomonas species and mixed flora
- 35. Perichondritis: Symptoms • Pain over auricle and deep in canal • fever • Pruritus Perichondritis: Signs • Tender auricle • Induration • Oedema • erythaema • Advanced cases • Crusting & weeping • Involvement of soft tissues
- 36. Perichondritis: Treatment • Aspiration of the pus • Use antibiotics of gram-negative coverage, specifically anitpseudomonals. • If frank chondritis develops, incisions should be made in the cartilage in order to provide adequate drainage. • Mild: debridement, topical & oral antibiotic • Advanced: hospitalization, IV antibiotics • Chronic: surgical intervention with excision of necrotic tissue and skin coverage
- 37. Relapsing Polychondritis • Uncommon progressive inflammatory disorder that may affect children, but more commonly in adults. • Episodic and progressive inflammation of cartilages • Autoimmune etiology? • External ear, larynx, trachea, bronchi, and nose may be involved • Involvement of larynx and trachea causes increasing respiratory obstruction
- 38. Relapsing Polychondritis • Fever, pain • Swelling, erythaema • Arthralgia! • Tenderness of the nasal septum may progress to complete destruction of the septum
- 39. Dx and T/t • Weak +ve RF -Systemic steroids • ANA +ve such as prednisolone • High ESR, -In resistant cases; • Anaemia dapsone, cyclophosphamide or • And difinitve Dx is made azithioprine may be by a biopsy from the used affected cartilage
- 40. Herpes Zoster Oticus (Ramsay Hunt Syndrome) • J. Ramsay Hunt described in 1907 • Viral infection caused by varicella zoster • Infection along one or more cranial nerve dermatomes (shingles). - herpes zoster of the pinna with otalgia. - facial paralysis - sensorineural hearing loss - Bullus myringitis - A vesicular eruption of the concha of the pinna and the EAC.
- 41. Symptoms • Early: burning pain in one ear, headache, malaise and fever • Late (3 to 7 days): vesicles, facial paralysis Treatment • Corneal protection • Oral steroid taper (10 to 14 days) • Antivirals (eg. Valacyclovir) • Facial nerve decompression (controversial)!
- 42. Bullous Myringitis • Viral infection • Confined to tympanic membrane • Primarily involves younger children
- 43. Bullous Myringitis: Symptoms • Sudden onset of severe pain • No fever • No hearing impairment • Bloody otorrhoea (significant) if rupture Bullous Myringitis: Signs • Inflammation limited to TM & nearby canal • Multiple reddened, inflamed blebs. • Hemorrhagic vesicles
- 44. Bullous Myringitis: Treatment • Self-limiting • Analgesics • Topical antibiotics to prevent secondary infection • Incision of blebs is unnecessary
- 45. Chronic Otitis Externa • Acute otitis externa occurs in 4 of every 1000 people per year • Otitis externa is defined as chronic when the duration of the infection exceeds 4 weeks or when more than 4 episodes occur in 1 year • Bacterial, fungal, dermatological aetiologies COE: Symptoms • Unrelenting pruritus • Mild discomfort • Dryness, Crusting, and flaking of canal skin
- 46. COE: Signs • Asteatosis • Dry, flaky skin • Hypertrophied skin • Mucopurulent otorrhoea (occasional)
- 47. COE: Treatment • Similar to that of AOE • Topical antibiotics, frequent cleanings • Topical Steroids • Surgical intervention • Failure of medical treatment • Goal is to enlarge and resurface the EAC
- 48. Radiation-Induced Otitis Externa • OE occurring after radiotherapy • Often difficult to treat • Limited infection treated like COE • Involvement of bone requires surgical debridement and skin coverage
- 49. Granular Myringitis (GM) • Deepithelization of the TM • Localized chronic inflammation of pars tensa with granulation tissue • Sequela of primary acute myringitis, previous OE, perforation of TM • Common organisms: Pseudomonas, Proteus
- 50. GM: Symptoms • Foul smelling discharge from one ear • Often asymptomatic • Slight irritation or fullness • No hearing loss or significant pain GM: Signs • TM obscured by pus • “peeping” granulations • No TM perforations
- 51. GM: Treatment • Careful and frequent debridement • Topical anti-pseudomonal antibiotics • Occasionally combined with steroids • At least 2 weeks of therapy • May warrant careful destruction of granulation tissue if no response
- 52. Eczema • External clue to OE (atopic, contact and sebrrheoic) dermatitis • Usual symptom is itching. • P/E; erythaema, oedema, flaking and crusting. • T/t: - Local cleansing. - Usage of corticosteroid and drying agents. • Metal sensitivity is the most common form of chronic dermatitis involving the ear.! • Nickel is the most common offending metal. • Women are affected more than men. - Ear peircing is an important cause of primary sensitization to nickel.
- 53. Conclusions • Careful History • Thorough physical exam • Understanding of various disease processes common to this area • Vigilant treatment and patience
Hinweis der Redaktion
- Ramsay Hunt syndrome: This condition, more accurately known as herpes zoster oticus, is caused by varicella-zoster viral infection. Ramsay Hunt syndrome is characterized by facial nerve paralysis and sensorineural hearing loss, with bullous myringitis and a vesicular eruption of the concha of the pinna and the EAC. A painful otitis externa may be present as well. Treatment includes use of an antiviral agent (eg, valacyclovir) and systemic steroids. The role of facial nerve decompression remains controversial. Furuncle: Staphylococcal infection of a hair follicle is the usual cause of a furuncle. This infection occurs in the lateral cartilaginous hair-bearing portion of the EAC. On otoscopic examination, a furuncle is a localized infection, which may develop into an abscess, rather than the diffuse inflammatory process characteristic of otitis externa. Skull base osteomyelitis: This serious infection, also known as malignant otitis externa, occurs most often in patients who are diabetic or immunocompromised. The pathogenic bacteria are usually Pseudomonas aeruginosa . Other predisposing conditions include arteriosclerosis, immunosuppression, chemotherapy, steroid use, and other immunodeficient states. The diagnosis is strongly suggested by a history of diabetes mellitus, severe otalgia, cranial neuropathies, and characteristic EAC findings.The EAC may be filled with friable granulation tissue, which is primarily found inferiorly. Because this presentation may be identical to that of a soft tissue malignancy, prudence dictates a tissue biopsy, even if a history of diabetes mellitus is present. Bare bone of the EAC floor may be exposed; small bony sequestra may be observed as well.CT scanning demonstrates bone erosion, and gallium scanning can be performed at points throughout treatment to monitor resolution. Treatment consists of administration of an antipseudomonal IV antibiotic such as ceftazidime (in some cases) or oral ciprofloxacin (in less dramatic cases). Extended treatment for at least 6 weeks is most appropriate. Hyperbaric oxygen therapy may also be effective. Surgical debridement is reserved for granulation tissue and bony sequestra. Preauricular cyst and fistula: Abnormal development of the first and second branchial arch may result in the formation of a preauricular cyst or fistula, which may manifest as persistent discharge or recurrent infection. A draining sinus may be present anterior to the tragus; when infected, the cyst distends with pus and the overlying skin is erythematous. These lesions are managed by complete surgical excision if they become repeatedly infected. The facial nerve is at risk of injury during the excision of these lesions because of the close relationship of the preauricular cyst or fistula to the superior branches of the facial nerve within the parotid gland.First branchial cleft anomalies have a more complex embryologic origin than preauricular cysts and fistulas. These lesions may not have an obvious sinus tract on the skin and may manifest as an abscess extending deeply into the EAC, parotid, and/or neck. Lacerations: Full-thickness auricular lacerations may be observed after blunt or sharp trauma. These injuries are managed surgically by closing both the perichondrium and the skin. In contrast, external canal lacerations may occur after attempts at cleaning the ear canal using cotton-tipped applicators. These lacerations are usually managed by microscopically placing any skin flaps in their normal position, packing the ear canal, and administering topical antibiotic drops. Atopic dermatitis: Drug sensitivity to topical antibiotic solutions is well known. Neomycin allergy occurs in up to 5% of patients treated with the medication. Suspect drug sensitivity if worsening of symptoms associated with skin excoriation and weeping occurs in the distribution of the topical medication exposure after application of drops.Metal sensitivity also manifests as excoriation, erythema, and edema around the exposure site (eg, a piercing hole). A common allergen is nickel, an impurity that may be present in precious metals. Atopic dermatitis is managed by removal of the allergen, such as an earring, and beginning topical steroid and antibiotics if the wound is secondarily infected. The diagnosis of metal sensitivity is confirmed by performing a skin patch test. Cerumen impaction: Cerumen impaction is the most common abnormality found on otoscopic examination, yet only a small proportion of the general population requires regular disimpaction because the EAC has the innate ability to produce and clear itself of cerumen. Cerumen may vary in color and consistency and may exist with other pathologies. Of note, debris in the EAC from cholesteatoma or tumors may be confused with cerumen, indicating that considerable care is required when attempting debridement of the EAC. Debridement may be accomplished with microinstruments or by aspirating the ear canal contents with a No 5 or No 7 Barton suction, while under direct vision through the otoscope or microscope. Irrigation of the ear canal is another option, but use of a pressurized irrigation system entails the risk of trauma. Exostosis and osteoma: The 2 most common bony lesions of the EAC, exostoses and osteomas, differ histologically and clinically. Exostoses tend to arise from the anterior and/or posterior floor of the medial EAC. Exostoses have a sessile base and are covered with normal-appearing skin. Both anterior and posterior exostoses may be found simultaneously.Osteomas may arise from any region of the bony EAC and often are pedunculated. Osteomas may also be either single or multiple and are covered by normal skin. Exostosis and osteomas require surgical treatment only if they are so large that they lead to a conductive hearing loss or intractable otitis externa. Foreign body: Foreign bodies are not infrequently encountered in the EAC. In children, parts of toys or even food may be found in the EAC, and, thus, appearance varies. In adults, fragments of cotton swabs are the most common finding. Erythema and edema surrounding the foreign body are commonly present. Using microinstruments, the foreign body may be removed under a microscope, depending on the patient's ability to cooperate. Acute (bullous) and chronic (granular) myringitis: Acute myringitis is usually caused by a mycoplasma or viral infection and is observed in adults and children. It is characterized by hemorrhagic bullae involving the tympanic membrane and a flulike syndrome. It is self-limiting and requires pain and fever management.Chronic myringitis is defined as deepithelization of the tympanic membrane, granulation tissue formation, and discharge. Treatment includes topical application of eardrops, a caustic solution in unresponsive cases, and mechanical removal of polypoidal granulations.
- In the early stages of EO, heat, humidity, maceration, or other factors may act to remove cerumen or change the pH of the canal. These changes may cause itching that then elicits digital manipulation or instrumentation of the canal that traumatizes the skin, thus allowing bacteria to enter the surrounding soft tissue. An increase in infection and iflammation may cause canal oedema or complete obstruction of the canal in sever cases.
- -lateral one third >> hair bearing portion of the canal.
- Localized furucle infection but may proress into an abscess.
- Nystatine, neomycine,gramicidine, triamsonolone - Iv-24h / flucloxacillin
- Both the moisture and ab alter the cerumen and normal bacterial flora of the EAC. These black dots (spores) are the appearance of fungal infection ( aspergillus niger ), with other fungi the spores may be white or yellow chronic otitis externa : Although the canal wall is not swollen, the skin is excoriated and red. The drum is essentially normal.
- Some may aquire histo o granulation tissue. Galium has high sensitivity for current infx, and usefull for F/U.
- Admit to hospital Anti-pseudomonal antibiotics Intravenous Antibiotic options Ciprofloxacin 400 mg IV q12 hours Imipenem 0.5 mg IV q6 hours Meropenem 1.0 grams IV q8 hours Ceftazidime 2.0 grams IV q8 hours Cefepime 2.0 grams IV q12 hours Gentamicin 1 to 1.66 mg/kg IV or IM/IV with Ticarcillin or Piperacillin Timentin 3.0 grams IV q4 hours Oral antibiotic options (after initial IV course) Ciprofloxacin 750 mg PO q12 hours Course Start with IV antibiotics Continue antibiotics for 4-8 weeks Consult Otolaryngology (ENT) Surgical debridement may be required Clean ear canals meticulously on a daily basis Clean and debride canal Apply topical antibiotic agents Other modalities to consider Hyperbaric oxygen chamber
- Blood and/or serum collects in the potential space between the cartilage and perichondrium and infection of this fluid results in perichondritis and chondritis.
- Destruction of the cartilage due to inflammatory infiltrates is often followed by granulation and then fibrosis and calcification
- Destruction of the septum ultimately lead to a nasal-suddle deformity in some cases. DDx: rheumatoid arthritis (juvnile) lymphoma or infectious perichondritis