otitis externa, otitis media ,furuncle, mastoiditis

1. Otitis Externa
Furuncle
Acute Otitis Media
Mastoiditis
By-VERMA ALOK KUMAR
Group-31

2. Otitis Externa

4. Anatomy and Physiology
• Consists of the auricle and EAM
• Skin-lined
• Approximately 2.5 cm in length
• Ends at tympanic membrane
• Auricle is mostly skin-lined cartilage
• External auditory meatus
– Cartilage: ~40%, Bony: ~60%
– S-shaped, Narrowest portion at bony-cartilage junction

5. Anatomy and Physiology
• EAC is related to
various contiguous
structures
– Tympanic membrane
– Mastoid
– Glenoid fossa
– Cranial fossa
– Infra-temporal fossa

6. • 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

7. OTITIS EXTERNA
• An acute or chronic infection of the whole
or a part of the skin of the external ear
canal
• Otitis externa is often referred to as
"swimmer’s ear" because repeated
exposure to water can make the ear canal
more vulnerable to inflammation

8. Etiology

9. 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.

10. Organisms
1. Pseudomonas species
2. Staphylococci
3. Streptococci/Gram negative rods
4. Fungi (Aspergillus/Candida species)

11. Acute Otitis Externa (AOE)
• “swimmer’sear”
• Pre-inflammatory stage
• Acute inflammatory stage
• Mild
• Moderate
• Severe

12. Factors contributing to AOE
• High humidity
• Water exposure
• Maceration of canal skin
• High environmental temperature
• Local trauma
• Perspiration
• Allergy
• Stress
• Removal of normal skin lipids
• Absence of cerumen
• Alkaline pH of canal

13. AOE: Pre-inflammatory Stage
• Oedema of stratum corneum and plugging
of apopilosebaceous unit
• Symptoms: pruritus and sense of fullness
• Signs: mild edema
• Starts the itch/scratch cycle

14. AOE: Mild to Moderate Stage
• Progressive infection
• Symptoms
• Pain
• Increased pruritus
• Signs
• Erythema
• Increasing edema
• Canal debris, discharge

15. AOE: Severe Stage
• Severe pain, worse
with ear movement
• Signs
• Lumen obliteration
• Purulent otorrhoea
• Involvement of peri-
auricular soft tissue

16. AOE: Treatment
• Most common pathogens: P. aeruginosa and S. aureus,
E.coli and proteus.
• Four principles
• Frequent canal cleaning; swab or suction
• With sever EO, placement 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 severe>> Systemic or
PO-ABT
• Pain control
• Instructions for prevention

17. AT A GLANCE. . .
• Otalgia
• Tenderness on palpation or manipulation
(Tragus sign)
• Ear fullness
• Conductive hearing loss.
• Erythema of meatus and canal
• Swelling and obstruction of canal
• Crusting and discharge
• Odor!

18. 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

19. 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

20. NEO: Diagnosis, Prevention and
Treatment:
• Prognosis; Reportedly mortality 20-53%
• Diagnosis : History, Physical Examn, Labs and
Imaging:
- Labs; CBC, Culture of discharge, ESR, Serum glucose,
Serum creatinine.
- Radiology; CT, or MRI (ear)
• 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

21. 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

22. 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

23. 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

24. COE: Signs
• Asteatosis
• Dry, flaky skin
• Hypertrophied skin
• Muco-purulent otorrhoea
(occasional)

25. 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

26. 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

27. Furunculosis
• Acute localized infection
• Lateral 1/3 of posterosuperior canal
• Obstructed apopilosebaceous unit
• Pathogen: S. aureus

28. Furunculosis: Symptoms
• Localized pain
• Pruritus
• Hearing loss (if lesion occludes canal)

29. Furunculosis: Signs
• Edema
• Erythema
• Tenderness
• Occasional
fluctuance

30. Furunculosis: Treatment
• Local heat
• Analgesics
• Oral anti-staphylococcal antibiotics
• Incision and drainage reserved for
localized abscess
• IV antibiotics for soft tissue extension

31. 1
Acute otitis media

32.  Acute inflammation in middle ear
 < 3 weeks (1 month)
 Often associated with a viral upper
respiratory infection
 Most common reason for medical therapy
for children younger than 5 years
 Recurrent otitis media:
 At least 4 episodes/ year
 At least 3 episodes/ 6 months
(with adequate therapy)
Acute otitis media

33.  Most children have at least one episode of
AOM (by age 3, 50-85%)
 Peak incidence age 6-15 months
 Increased incidence in the fall and winter
 Only 20% are adults
 >700 milion cases/year
Epidemiology

34.  Eustachian tube is lined with respiratory
mucosa
 Responds together with nasopharynx
mucosa
 Edema > narrowed
lumen
negative middle
ear pressure
 Influx of pathogens from nasopharynx is
possible
Causes
>

35. Causes
 Inflammatory response in middle ear worsens
the obstruction
 Trigger:
 Allergies
 Upper respiratory tract infections
 GER (especially children)
 Adenoid hypertrophy
 Other

36.  Viral (30-70%)
 RSV
 Rhinovirus
 Coronavirus
 Influenza, parainfluenza
 Bacterial (55%)
 Streptococcus pneumoniae (44%)
 Haemophilus influenzae (41%)
 Moraxella catarrhalis (14%)
 Gram negative enteric bacteria
 S. Aureus
• Combined (15%)
Causes

37.  Age: <7
 Their Eustachian tubes are short, floppy,
horizontal and poorly functioning
Risk factors

38. Handbook of Pediatric Otolaryngology : A Practical Guide for Evaluation and Management
of Pediatric Ear, Nose, and Throat Disorders

39. Risk factors
 Genetic predisposition
 Eustachian tube dysfunction
 Allergic tendencies
 Bottle feeding (first 3 months)
(breast milk contains lactoferrin, oligosaccharide
and surface immunoglobulin A that inhibit
bacterial colonization)
(sucking generates negative pressure)
 Incorrect posture while breastfeeding

40. Risk factors
 Underlying pathology
 Unrepaired cleft palate
 Parental smoking
 Large familys/attending daycare
 Immunocompromised states

41.  Otalgia (not always)
 Fever
 Hearing loss
(speech delay for children)
 Headache
 Nausea
 Cough
 Rhinitis
 Conjunctivitis
Signs and symptoms

42.  Pneumatic otoscopy/otoscopy:
 Red or opaque eardrum
 Retracted eardrum
 Immobile or hypo-mobile eardrum
 Presence of fluid behind eardrum
(purulent, serous, mucoid)
 Retraction pockets
 Bullous myringitis
Physical
Examination

45.  Otorrhea (in case of
tympanostomy tube, perforation)
 Mastoid tenderness
 Anteriorly rotated pinna
 Tympanometry
 Audiometry
 Inspection or pharynx and
nasal cavity
Physical
Examination

46. Diagnosis
 Acute onset of signs and syptoms
 The presence of middle ear effusion
(hypomobile eardrum, air-fluid level)
 Signs and symptoms of middle ear inflamation
(erythema, otalgia)

47.  Acute mastoiditis
 Abscess formation
 Facial paralysis
 Otitis media with effusion
 PersistentAOM
 RecurrentAOM
 Hearing loss
 Perforation of eardrum
Complications

48. Complications (rare)
 Lateral sinus thrombosis
 Otitic hydrocephalus
 Septic shock
 Meningitis
 Encephalitis
 Extradural abscess
 Labyrinthitis

49.  Antibacterial therapy for:
 Children of age <6months
 6 months to 2 years with severe illness
 Recurrent or billateral AOM
 Immunocompromised patients
 Patients with a perforated tympanic membrane
 Pain management (Ibuprofen, Diclofenac,
paracetamol)
 Decongestants and/or antihistamines,
nasal steroids
Treatment

50. Antibacterial therapy
 Amoxicilin 750-1500mg/day 50-100 mg/kg/day
(has not recived amoxicilin in past 30 days and has no
allergy to penicilin)
 Amoxicillin-clavulanate 875/125mg/day
90/6.4 mg/kg/day
(alternative for amoxicilin)
 Ceftriaxone 1-2g/day 50mg/kg/day or
Cefuroxim 500mg/day 30mg/kg/day
 Azithromycin, clarithromycin, erythromycin in
case of allergy to penicilin
 5-7-10 days

51. Recurrent AOMtreatment
 +Tympanostomy

52. Non-drug Treatment
 Myringotomy in case of sevare pain
 Tympanocentesis in case of severe pain andas a diagnostic
procedure if there is no improvement with
• 2nd line of antibiotics
(local anesthesia)
(narcosis)

53.  Avoiding risk factors if possible
 Vaccination: ?
 S. Pneumonia (PCV-7)
 Influenza
• Adenoidectomy
• Polipectomy
Preventive measures

54. Differential diagnosis
 Otitis externa
 Impacted cerumen or foreign body in ear
 Tympanosclerosis
 Otitis media with effusion
 Injury of the ear

55. MASTOIDITIS

56. • INTRODUCTION
• The mastoid process is the portion of the temporal bone of the skull that
is behind the ear which contains open, air-containing spaces.
• DEFINITION
• It is an inflammation of the mastoid process behind the ear and of the
air space connecting it to the cavity of the middle ear.

57. • CLASSIFICATION
1.Acute mastoiditis: It is a rare complication of acute otitis media.
2.Chronic mastoiditis: It is most commonly associated with CSOM or
with cholesteatoma formations.
• CAUSES & RISK FACTORS
1.Infection of the middle ear.
2.Injury of the mastoid bones and cells.
3. Cholesteatoma.
4.Upper respiratory infection.

58. SIGNS AND SYMPTOMS
1.Otalgia.
2.Swelling on the mastoid bone.
3.Perforation of the ear drum.
4.Loss of hearing.
5.Severe pain at eating time.
6.Increased cranial pressure.
7.Painless discharge from the affected ear.
8.Otorrhoea(purulent discharge) may be odorless or foul smelling.
9.Nausea, vomiting.

59. PATHOPHYSIOLOGY

60. DIAGNOASTIC EVALAUTION
1.History collection.
2.Physical examination.
3.Mastoid bone x ray.
4. CT scan.
5.Lab: CBC, DLC, Blood culture, tympanocentesis.
6.Audiography.

61. Treatment
• MEDICAL MANAGEMENT
1. Antibiotic and steroid eardrop for infection and inflammation, e.g.
Ciplox-D.
2. Ear-irrigation: For removing purulentdischarge.
3. Analgesics drugs: Aspirin, Nimuslide.
• SURGICAL MANAGEMENT
1. Mastoidectomy: It is a surgical procedure that removes diseases
mastoid air cells.
2. Myringotomy: It is a surgical procedure in which a tiny incision is
created in the eardrum relieves pressure caused by excessive buildup
of fluid orpus.
3. Tympanoplasty: also called eardrum repair. It is the surgical
reconstruction of the perforated eardrum or the small bones of the
middle ear.