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Otitis externa


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Otitis externa

  1. 1. Otitis Externa (OE) Ahmed AlMumtin MD
  2. 2. Anatomy and Physiology• Consists of the auricle and EAM• Skin-lined apparatus• Approximately 2.5 cm in length• Ends at tympanic membrane
  3. 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. 4. Anatomy and Physiology• EAC is related to various contiguous structures • Tympanic membrane • Mastoid • Glenoid fossa • Cranial fossa • Infratemporal fossa
  5. 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. 6. Anatomy and Physiology• Squamous epithelium• Bony skin – 0.2mm• Cartilage skin • 0.5 to 1.0 mm • Apopilosebaceous unit
  7. 7. Otitis Externa• Bacterial, viral or fungal infection of external auditory canal• Categorized by time course • Acute • Chronic
  8. 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. 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. 10. Organisms1. Pseudomonas species2. Staphylococci3. Streptococci/Gram negative rods4. Fungi (Aspergillus/Candida species)
  11. 11. Labs/workupUsually 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)
  12. 12. Acute Otitis Externa (AOE)• “swimmer’s ear”• Preinflammatory stage• Acute inflammatory stage • Mild • Moderate • Severe
  13. 13. 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
  14. 14. 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
  15. 15. AOE: Mild to Moderate Stage• Progressive infection• Symptoms • Pain • Increased pruritus• Signs • Erythema • Increasing edema • Canal debris, discharge
  16. 16. AOE: Severe Stage• Severe pain, worse with ear movement• Signs • Lumen obliteration • Purulent otorrhoea • Involvement of periauricular soft tissue
  17. 17. 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
  18. 18. 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!
  19. 19. Furunculosis• Acute localized infection• Lateral 1/3 of posterosuperior canal• Obstructed apopilosebaceous unit• Pathogen: S. aureus
  20. 20. Furunculosis: Symptoms• Localized pain• Pruritus• Hearing loss (if lesion occludes canal)
  21. 21. Furunculosis: Signs• Edema• Erythema• Tenderness• Occasional fluctuance
  22. 22. Furunculosis: Treatment• Local heat• Analgesics• Oral anti-staphylococcal antibiotics• Incision and drainage reserved for localized abscess• IV antibiotics for soft tissue extension- tri-adcortyle!
  23. 23. 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
  24. 24. 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
  25. 25. Otomycosis: Signs • Canal erythaema • Mild oedema • White, gray, green, yellow or black fungal debrisOtomycosis: Symptoms • Often indistinguishable from bacterial OE • Pruritus deep within the ear • Otorrhoea • Dull pain • Hearing loss (obstructive) • Tinnitus
  26. 26. 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.
  27. 27. 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
  28. 28. 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 (Bells Palsy) • Associated with poor prognosis
  29. 29. 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
  30. 30. 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
  31. 31. 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.
  32. 32. 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
  33. 33. Perichondritis/Chondritis• Infection of perichondrium/cartilage• Result of trauma to auricle• May be spontaneous (overt diabetes)• Usual pathogens include pseudomonas species and mixed flora
  34. 34. Perichondritis: Symptoms • Pain over auricle and deep in canal • fever • PruritusPerichondritis: Signs • Tender auricle • Induration • Oedema • erythaema • Advanced cases • Crusting & weeping • Involvement of soft tissues
  35. 35. 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
  36. 36. 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
  37. 37. Relapsing Polychondritis• Fever, pain• Swelling, erythaema• Arthralgia!• Tenderness of the nasal septum may progress to complete destruction of the septum
  38. 38. 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
  39. 39. 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.
  40. 40. Symptoms• Early: burning pain in one ear, headache, malaise and fever• Late (3 to 7 days): vesicles, facial paralysisTreatment • Corneal protection • Oral steroid taper (10 to 14 days) • Antivirals (eg. Valacyclovir) • Facial nerve decompression (controversial)!
  41. 41. Bullous Myringitis• Viral infection• Confined to tympanic membrane• Primarily involves younger children
  42. 42. Bullous Myringitis: Symptoms • Sudden onset of severe pain • No fever • No hearing impairment • Bloody otorrhoea (significant) if ruptureBullous Myringitis: Signs • Inflammation limited to TM & nearby canal • Multiple reddened, inflamed blebs. • Hemorrhagic vesicles
  43. 43. Bullous Myringitis: Treatment • Self-limiting • Analgesics • Topical antibiotics to prevent secondary infection • Incision of blebs is unnecessary
  44. 44. 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 aetiologiesCOE: Symptoms • Unrelenting pruritus • Mild discomfort • Dryness, Crusting, and flaking of canal skin
  45. 45. COE: Signs• Asteatosis• Dry, flaky skin• Hypertrophied skin• Mucopurulent otorrhoea (occasional)
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. GM: Symptoms • Foul smelling discharge from one ear • Often asymptomatic • Slight irritation or fullness • No hearing loss or significant painGM: Signs • TM obscured by pus • “peeping” granulations • No TM perforations
  50. 50. 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
  51. 51. 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.
  52. 52. Conclusions• Careful History• Thorough physical exam• Understanding of various disease processes common to this area• Vigilant treatment and patience
  53. 53. Questions/Comments?