Common causes of ear infection

1. Ear infection
Dr Tengku Ezulia
ORL –HNS Specialist & Lecturer
University of Malaya

2. Anatomy:
External ear – Otitis externa, Malignant otitis externa
Middle ear – Acute otitis media, Chronic suppurative otitis media
Inner ear – Labyrintitis, Vestibular neuronitis
Organism:
Virus
Bacteria
Fungal

3. Otitis externa
Disease of external ear

4. Otitis Externa
• Otitis Externa (OE) is refered to a spectrum of external ear inflammation,
which may also involve the pinna or external ear canal.

5. Otitis Externa: Risk Factors
•Anatomic abnormalities
oCanal stenosis
oExostoses
oHairy ear canals
•Canal obstruction
oCerumen obstruction
oForeign body
oSebaceous cyst
•Cerumen/epithelial integrity
oEarplugs
oHearing aids
oInstrumentation/itching
oTrauma
o Dermatologic conditions
o Eczema
o Psoriasis
o Seborrhoea
o Other inflammatory dermatoses
o Water in ear canal
o Humidity
o Sweating
o Swimming or other prolonged water
exposure
o Miscellaneous
o Purulent otorrhoea from otitis media
o Immunosuppression
o Stress

6. Etiology:
• Bacteria(90 % of OE); pseudomonas aeruginosa, pseudomonas vulgris,
E.coli, S.aureus
Clinical feature:
Acute:
• Pain aggrevated by movement of auricle (traction of pinna or pressure
over tragus
• Otorrhea (sticky yellow purulent discharge)
• Conductive hearing loss +/- aural fullness secondary to obstruction of
ear canal by swelling and purulent debris
• Post auricular lymphadenopathy
• Pinna and/or periauricular soft tissue erythematous and swollen

8. Chronic
• Pruritus of external ear +/- excoration of ear canal
• Atrophic and scaly epidermal lining +/- otorrhea+/- hearing loss
• No pain with movement of auricle
• Tympanic membrane appear normal
Treatment:
• Ear toiletting
• Bacterial aetiology, send for c+s
* antipseudomonal otic drop e.g gentamycin, ciprofloxacin or combination of
antibiotic and steroid (e.g Garasone or Cipro)
* Do not use aminoglycoside if tympanic membrane (TM ) is perforated - risk of
ototoxicity
* Icthammol glycerine if external canal edematous
* Sytemic antibiotic if either cervical lymphadenopathy or cellulitis present

9. Otomycosis
Etiology :
Candida albicans, Aspergillus niger
Clinical features :
•Malodorous discharge
•Inflammation
•Pruritus
•Scaling
•Severe discomfort , suppuration can occur due to superimposed bacterial
infection commonly due to pseudomonas species and proteus species

12. Treatment :
•Meticulous ear toileting to remove fungal debris and hyphae
•Anti fungal – cotrimazole ear drop

13. Malignant Otitis Externa
Definition:
 Severe infection due to Pseudomonas aeruginosa causing osteomyelitis of
the skull base
 Common in immunocompromised and elderly diabetics.
 Life threatening.
Presentation:
• Severe pain
• Involvement of the floor of the ear canal
• Granulation tissue.
• If untreated, it can involve the cranial nerves and brain.
• Facial nerve palsy occurs in 50% of patients, IX to XII may also be involved.

14. Management:
Medical therapy
 Sugar control
 Correction of immunosuppressive state
 Ciprofloxacin x 6/52
Surgical treatment
 Debridement

15. Acute otitis media (AOM)
Disease of middle ear
Definition:
Acute inflammation of middle ear

16. Epidemiology:
• 60-70% of children have at least 1 episode of AOM before 3 years old
• 18 month to 6 years most common age group
• One third have had >3 episodes by age 3
Etiology
• VIRUSES : most episodes of AOM are preceded by respiratory tract
infection of viral origin
• Rhinovirus
• Respiratory syncytial virus
• BACTERIA :
• Streptococcus pneumoniae (30%)
• Haemophilus Influenza (20%)
• Moraxella catarrhalis (12%)

18. Predisposing factors:
• Eustachian tube dysfunction/obstruction:
 Swelling of tubal mucosa-URTI,allergic rhinitis,chronic sinusitis
 Obstruction/inflitration of eustachian tube ostium- tumor(NPC),
adenoid hyperthropy (not due to obstruction but by maintaining source
of infection), barotrauma (sudden change in air pressure)
 Inadequate tensor palati function-cleft palate
 Abnormal eustachian tube: Downs syndrome

20. Predisposing factors:
• Distruption action of :
 cilia in Katagener’s syndrome
Immunosuppression/deficiency due to chemotherapy, steroids,
diabetes mellitus

21. RISK FACTORS
• Host factors
 Age/Gender
 Genetic predisposition
 Cleft palate/Down syndrome
 Allergy/Immunity
• Environmental factors
 Daycare/Siblings
 Bottle (versus breast) feeding
 Pacifier use
 Smoking
 Low socioeconomic status
 Upper respiratory infections

22. Clinical feature:
• Triad- otalgia, fever, conductive hearing loss
• Rarely tinnitus, vertigo or facial nerve palsy
• Otorrhea if if tympanic membrane perforated
• Infant/toddler- ear tugging, hearing loss, vomiting, diarrhea, anorexia
Otoscopy of TM
• Hyperemia
• Bulging, pus seen behind TM
• Loss of landmark: handle and long process of malleus not visible

23. PATHOPHYSIOLOGY
Stage of Complications

24. STAGE OF HYPERAEMIA
• First stage of infection  hyperemia
of the mucus membrane of the
tympanic cavity, the mastoid air cells
& ET
• Infection of the ET  ET becomes
occluded by oedema & hyperaemia
 changes in middle ear pressure,
mucocilliary transport & surfactant-
like substance in ET  retraction of
TM

25. STAGE OF EXUDATION
• Prolonged tubal occlusion  invasion of pyogenic organisms 
exudate in M.E.  TM congestion & bulges under pressure
• Symptoms:
• Marked earache (throbbing nature)
• Deafness & tinnitus (only complained in adults)
• High fever & restlessness (in children)
• Systemic symptoms: anorexia, vomiting, diarrhea
• Signs
• Congestion of pars tensa
• Cartwheel appearance of TM
• Later, whole of TM inc. pars flaccida becomes red
• Pneumatic otoscope  reduce mobility

26. STAGE OF SUPPURATION: BEFORE
PERFORATION
• Symptoms:
• Excruciating earache
• Increasing deafness
• High fever
• Signs:
• TM read & bulging with loss of landmark
• Handle of malleus engulfed by the swollen & protruding
TM
• Yellow spot on TM  rupture
• Tenderness over mastoid antrum

27. STAGES OF SUPPURATION : AFTER
PERFORATION
• Symptoms:
• Otalgia subsides with
onset of discharge
• Fever comes down
• Signs:
• EAC may contain blood-
tinged discharge 
mucopurulent
• Pin-hole perforation

28. STAGE OF RESOLUTION
• With drainage of the pus and host defense/treatment 
inflammation resolves
• Pin-hole perforation heals
• Symptoms:
• Acute symptoms subside
• Ear becomes dry
• Eventually hearing restored
• Signs
• Dry pin-hole perforation
• Later – healed perforation

29. Treatment:
Amoxicillin is the usual first-line for 5 days. If severe symptoms present, or there has
been a previous episode of AOM within the last month, use high doses
Erythromycin or Clarithromycin are alternative antibiotics if allergic to penicillin

30. Symptomatic therapy:
• Antipyretics/analgesic
• Decongestant- may relieve nasal congestion but not treat AOM
Prevention:
• Parent education about risk factor
• Antibiotic prophylaxis
• Pneumococal and influeanza vaccine
• Surgery-in recurrent AOM(depend on local factor i.e eustachian
tube factor or regional factor) e.g adenoid hyperthropy

31. DISTINGUISHING OM WITH OME
• Otitis media and otitis media with effusion(OME) are two distinct
entities and often are part of the disease continuum
• OME is defined as the presence of middle ear fluid without acute
signs or symptoms.
• Acute signs and symptoms associated with OM should be identified
as absent by history taking and physical examination.
• The presence of fluid in the middle ear can be determined by
physical examination using electric otoscopy, pneumatic otoscopy,
otoendoscopy, or otomicroscopy with support of tympanometry

32. Serous Otitis Media

33. Otitis media+effusion-Glue ear
Features
• Dull retracted TM
• May show air-fluid level
• Conductive hearing loss
• Common in children; often after AOM and can persist for weeks
• Reduced hearing noticed by parents/teacher
• Unsteadiness
80% clear at 8 weeks

34. Hearing tests?
A hearing test is not appropriate at the initial presentation if there is no
evidence of significant hearing loss or developmental delay. If signs and
symptoms of OME continue, hearing should be assessed after 3 months,
where OME can be regarded as persistent.

35. Management
Adults presentation - the nasopharynx is examined to exclude tumour.
Secretory otitis media is uncommon in adults. It usually follows a cold and
spontaneously resolves; this may take up to 6 weeks
In Children- 50% of cases will resolve spontaneously within 6 weeks
Persistence of bilateral Otitis media with effusion (OME) and hearing loss in a
child should be confirmed over a period of 3 months before intervention is
considered
Surgery: adenoidectomy or myringotomy and grommet insertion.

36. COMPLICATIONS OF ACUTE OTITIS
MEDIA

37. Mastoiditis
Definition: infection of mastoid air cells, most commonly seen
approximately 2 weeks after onset of untreated or inadequate treat
AOM

38. Etiology
-same organisme as in AOM
Clinical feature:
• Otorrhea
• Tenderness to pressure over mastoid
• Retroauricular swelling with protuding ear
• Fever,hearing loss +/- TM perforation(late)
• CT scan: opacity of mastoid air cell by fluid and interruption of
normal trabeculation of cell

39. MASTOIDITIS - PRESENTATION
• Signs:
• Abnormal-appearing tympanic
membrane (88%)
• Fever (83%)
• Narrowed EAC (80%)
• Post auricular edema (76%)
Gliklich RE, Eavey RD, Iannuzzi RA, Camacho AE. A contemporary analysis of acute
mastoiditis. Arch Otolaryngol Head Neck Surg. 1996 Feb;122(2):135-9.

41. IMAGING
HRCT Temporal bone
-Bony destruction with Coalescence of the mastoid
-Fluid in mastoid

42. Treatment
• IV antibiotics
• Cortical mastoidectomy
Indication of surgery:
 Failure of medical treatment after 48H
 Symptom intracranial complication
 Aural discharge persistant for 4 wks and resistant to antibiotics

43. Chronic suppurative otitis
media
Disease of middle ear

44. CSOM without cholesteatoma
CSOM with cholesteatoma
Presentation:
ear discharge
hearing loss
pain
•AOM chronic suppurative OM if involve 3month duration

47. Unsafe attic perforation
Any defect or
apparent perforation
in the attic must be
considered unsafe
and should be
referred for ENT
assessment. This
crust in the attic
represents a large
underlying
cholesteatoma sac.
Note the bulging
eardrum too.

48. Marginal perforation plus cholesteatoma formation
Unsafe because it is a
perforation involving the
drum margin

49. Cholesteatoma
Disease of middle ear
Definition:
A cyst compose of keratinizing squamous epithelium occuring in middle
ear,mastoid and temporal bone

50. • 2 type: congenital & acquired
Congenital
• Present of small white pearl behind intact TM or as conductive hearing
loss
• Believe due to aberrant migration of external canal ectoderm during
development
• Not ass with OM/Eustachian tube dysfunction
Acquired:
• Consequence of OM & chronic Eustachian dysfunction
• Frequently ass with retraction pocket in pars flaccida and marginal
perforation of TM
• Ass with chronic inflammatory process cause progessive distruction of
surrounding bony structures

51. Clinical feature:
• Symptom:
 Hx of OM ventilation tube,ear surgery
 Progessively hearing loss(conductive)
 Otalgia, aural fullness, fever
• Sign:
 Retraction pocket in TM,may contain keratin debris
 TM perforation
 Granulation tissue, polyp visible on otoscopy
 Maladorous otorrhea

52. Complication
Local
• Ossicular erosion:conductive
hearing loss
• Inner ear erosion:
Sensoryneural hearing
loss,dizziness,labyrinthitis
• Temporal bone
infection:mastoiditis,parositis
• Facial paralysis
Intracranial
• Meningitis
• Sigmoid sinus thrombosis
• Intracranial
abcess(subdural,epidural,cerebe
llar)

53. Investigation:
• Audiogram and CT scan
Treatment:
• No conservative therapy for cholesteatoma
• Surgical: mastoidectomy+/-tympanoplasty+/-ossicular reconstruction

54. Cholesteotoma

55. Labyrintitis
Disease of inner ear
Labyrinthitis (inflammation of the labyrinth) occurs when an infection
affects both branches of the vestibulo-cochlear nerve, resulting in
hearing changes as well as dizziness or vertigo.

56. Organism:
•Virus: herpes, influenza, measles, rubella, mumps, polio, hepatitis,
and Epstein-Barr.
•Bacterial
Presentation:
•dizziness
•vertigo
•nausea and vomiting
•tinnitus, which is characterized by a ringing or buzzing in your ear
•loss of hearing

57. Management:
•Hearing test
•Blood test – FBC, sugar level
Treatment:
•Medication to control nausea
•Antihistamines: desloratadine (Clarinex), loratadine (Claritin)
•Steroid
•Anti-viral
•Antibiotic if suspect bacterial
•Bed rest

58. Vestibular neuritis
Disease of inner ear
Neuritis (inflammation of the nerve) affects the branch associated with
balance, resulting in dizziness or vertigo but no change in hearing.
The term neuronitis (damage to the sensory neurons of the vestibular
ganglion) is also used.

59. Organism:
•Virus: herpes, influenza, measles, rubella, mumps, polio, hepatitis,
and Epstein-Barr.
•Bacterial
Presentation:
•dizziness
•vertigo
•nausea and vomiting
•tinnitus, which is characterized by a ringing or buzzing in your ear
•NO loss of hearing

60. Management:
•Hearing test
•Blood test – FBC, sugar level
Treatment:
•Medication to control nausea
•Antihistamines: desloratadine (Clarinex), loratadine (Claritin)
•Steroid
•Anti-viral
•Antibiotic if suspect bacterial
•Bed rest

61. THANK YOU