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OTITIS EXTERNA PATHOLOGY-WPS Office.pptx
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- 2. CONTENTS • Introduction • Relevantanatomy • Epidemiology • Pathophysiology • Risk factors • Etiology • Classification • Diagnosis • Management • Prevention • Complication • Conclusion
- 3. INTRODUCTION • It isan inflammatory disorder of the external ear canal (usually infectious) • Painful condition of the ear
- 4. RELEVANT ANATOMY Auricle • Theauricle is composed of musculocutaneous tissue and elastic cartilage covered by skin. This structure is responsible for collecting and redirecting sound waves into the external auditory meatus
- 6. • External auditorymeatus • The external auditory meatus is typically 1 in. (2.5 cm) in length and is S-shaped. • Lateral ⅓ surrounded by cartilage (posterosuperior trajectory) • Medial ⅔ surrounded by temporal bone (anteroinferior trajectory) • Surrounding skin contains ceruminous and sebaceous glands → ear wax
- 7. • The Cartilaginousmeatus is continous with the cartilage of the auricle • The bony meatus is formed by 2 bones • Tympanic part of the temporal bone • Squamous part of the temporal bone
- 8. • Characteristics ofthe Cartilaginous part • Skin lining - thicker • Glands - sebaceous and ceruminous glands found • Hair follicles - present • Fissures - fissure of Santorini
- 9. • Characteristics ofthe bony part • Skin lining - thin (lacks subcutaneous layer) • Glands - absent • Hair folicles - absent • Foramen - foramen of Huschke
- 11.
- 12. • EAC • Anteriorwall and roof: auriculotemporal (V3). • Posterior wall and floor: auricular branch of vagus (CN X). • Posterior wall of the auditory canal also receives sensory fibres of CN VII through auricular branch of vagus
- 13. Histology • The outerear includes the pinna (the visible ear, consisting mostly of skin and cartilage) and the ear canal. The latter is lined by keratinized stratified squamous epithelium. This lining differs from skin by the presence of specialized ceruminous (ear-wax) glands. • Hair folicles, sebaceous glands, and the ceruminous glands (a type of modiied sweat gland) are found in the submucosa. • Ceruminous glands are coiled tubular glands that produce the cerumen or earwax a brownish, semisolid mixture of fats and waxes
- 14.
- 15. EPIDEMIOLOGY • Otitis externais estimated to have a prevalence of 0.4% per year, affecting approximately 10% of the population during their lifetime. • Age: • Occurs in all age groups • Most common iswchildren and swimmers • More likely to occur in the summer because of: • Humidity • Participation in water activities
- 16. PATHOPHYSIOLOGY • Defense mechanismsof the external ear • Tragus and conchal cartilage → prevent the entrance of foreign bodies • Hair follicles and isthmus narrowing → stop the entry of contaminants • Cerumen → creates an acidic environment → inhibits bacterial and fungal growth
- 17. • Pathogenesis ofotitis externa • Breakdown of the skin–cerumen barrier is caused by: • Damage to epithelium • ↓ Quantity and quality of cerumen • Moisture accumulation • Obstruction of the ear canal • ↑ pH of the ear canal → ear canal becomes a prime breeding ground for microscopic organisms → infection • Inflammation and edema of the skin → purulent exudate
- 18. RISK FACTORS • Swimmingor other water exposure • Hot, humid weather • Trauma • Ear canal occlusion: • Cerumen • Foreign body • Hearing aids • Headphones • Dermatologic conditions: • Eczema • Contact dermatitis • Psoriasis • Radiation therapy • Immunosuppression: • HIV/AIDS • Diabetes • Chemotherapy
- 19. ETIOLOGY • Bacterial infection(most cases): • Pseudomonas aeruginosa • Staphylococcus aureus • Staphylococcus epidermidis • Proteus vulgaris • Escherichia coli • Fungal infection (rare): • Candida albicans • Aspergillus niger
- 20.
- 21. SUBTYPES • Bacterial • Perichondritis •Acute localized otitis externa (Furunculosis) • Swimmers ear • Malignant (necrotising) otitis externa • Fungal • Otomycosis • Viral • Herpes zooster oticus • Hemorrhagic otitis externa
- 22. • reactive • Eczematousotitis externa • Seborrheic otitis externa • Neurodermatitis
- 23. Perichondritis Perichondritis and chondritis representinfections of the auricular perichondrium or cartilage. They result from blunt or penetrating trauma to the ear or by direct extension from an otitis externa. In the case of a blunt trauma, a hematoma on the lateral surface of the pinna that becomes infected is the initiating event.
- 24. • Penetrating traumamay result from various injuries, including ear piercing, assaults, bites, and iatrogenic injuries. • Increasingly popular piercing of the ear cartilage as opposed to the lobule may predispose to infection, and outbreaks have been reported. • Pseudomonas is the most frequent causative organism.
- 25. Furunculosis A furuncle (abscessor boil) is a walled-off collection of pus that is seen as a painful, firm, or fluctuant mass It arises from the hair follicles of the lateral ear canal. The causative organism is typically S. aureus.
- 26. • If untreated,the infection usually progresses to a localized abscess which then discharges into the external ear canal. • Providing there is adequate drainage the infection will resolve spontaneously. • The infection can also spread towards the deeper tissues, where it may cause a diffuse soft tissue infection spreading to the pinna, post-auricular skin and parotid gland. • Repeated infection can cause permanent scarring and fibrosis of the external canal with subsequent meatal stenosis. • Ultimately, this may also predispose to chronic diffuse otitis externa.
- 27. Diffuse otitis externa(Swimmers ear) • It is diffuse inflammation of meatal skin which may spread to involve the pinna and epidermal layer of tympanic membrane. • Disease is commonly seen in hot and humid climate and in swimmers. • Excessive sweating changes the pH of meatal skin from that of acid to alkaline which favours growth of pathogens.
- 28. • Two factorscommonly responsible for this condition are: • trauma to the meatal skin and • invasion by pathogenic organisms. • The clinical course of diffuse otitis externa is extremely variable but has been divided into the following stages: • Stage 1: Pre-inflammatory • Stage 2: Acute inflammatory (mild, moderate or severe) • Stage 3: Chronic inflammatory
- 29. MALIGNANT OTITIS EXTERNA • Alsoknown as necrotizing otitis externa, this is an invasive, life- threatening infection of the external auditory canal and skull base. • Etiology: • Almost always caused by Pseudomonas aeruginosa (>90%) • Risk factors: • Elderly • Diabetes mellitus • HIV • Along with above risk factors, the condition is more frequently seen in individuals with a prior history of ear irrigation.
- 30. • Clinical presentation: •Extreme otalgia (disproportionate to findings) and otorrhea • Significant pain unresponsive to topical measures • Pain can extend to the temporomandibular joint. • Granulation tissue may be visible in the inferior portion of the external auditory canal. • Can lead to cranial nerve palsies (especially cranial nerves VII, IX, XI, XII) if the disease progresses to osteomyelitis of the skull base and temporomandibular joint
- 32. OTOMYCOSIS • Most fungusfound in ear are saprophytic • Fungal infections of ear canal are generaly opportunistic: Candida and Aspergillus spp. • Usually seen after treatment of bacterial infections of ear canal • DM and immunocompromised states • Candida sp causes superficial infection of ear canal, especially those using hearing aids • Aspergillus sp causes more aggressive infection involving epithelial and subcutaneous layer
- 33. • In casesof resistant otomycosis, it is essential to exclude fungal infection elsewhere in the body • Rarely, fungi can cause invasive otitis externa, especially in immunocompromised patients. Aggressive systemic antifungal therapy is required in these patients who often have a high mortality from the condition.
- 34. VIRAL OTITIS EXTERNA External earcan also be involved inflamed due to Herpes zoster virus Appears as few blisters or vesicles in the auricle, external ear canal or lateral surface of tympanfe membrane
- 35. Herpes zooster oticus Herpes (orvaricella) zoster virus can cause a recrudescent infection involving the external ear. It is an uncommon infection that more frequently affects immunosuppressed patients or elderly individuals in whom immunity to the virus has waned. When the ear is involved, virus is most commonly believed to be harbored in the geniculate ganglion and spreads along the sensory fibers of the facial nerve
- 36. Other sensory gangliahave also been implicated, including the fifth and eighth cranial nerves. A subgroup of patients manifest Ramsay Hunt syndrome, defined by facial paralysis in the presence of herpes zoster oticus.
- 37. Hemorrhagic otitis externa • Itis characterized by formation of haemorrhagic bullae on the tympanic membrane and deep meatus. • The etiology is believed to be primarily viral; however, Mycoplasma has been identified in some cases. • It typically occurs in association with upper respiratory infections and is more common in winter • The condition causes severe pain in the ear and blood- stained discharge when the bullae rupture.
- 38. CHRONIC OTITIS EXTERNA •Allergic reactions to topical agents, manifests as maculopapulars eruptions on the skin of the conceal and ear canal • Contact dermatitis - reaction to hairspray, Shampoo, hair dye, hearing aid moulds • Psoriasis or systemic dermatitides such as seborrhoea can involve ear canal- results in hyperkeratosis and lichenification of the ear canal skin • Granular otitis externa- chronic infection by bacteria or fungus. Manifests as granulation and excoriation
- 39. ECZEMATOUS OTITIS EXTERNA •It is the result of hypersensitivity to infective organisms or topical ear drops such as chloromycetin or neomycin, etc. • It is marked by intense irritation, vesicle formation, oozing and crusting in the canal.
- 40. Seborrhoeic otitis externa •It is associated with seborrhoeic dermatitis of the scalp. • Itching is the main complaint. • Greasy yellow scales are seen in the external canal, over the lobule and postauricular sulcus.
- 41. Neurodermatitis • It iscaused by compulsive scratching due to psychological factors. • Patient’s main complaint is intense itching. • Otitis externa of bacterial type may follow infection of raw area left by scratching.
- 42. DIAGNOSIS • The diagnosisof otitis externa is based on the history and physical examination. • Culture of the ear canal or discharge is indicated for severe, recurrent, or chronic cases.
- 43. CLINICAL PRESENTATION • Earpain • Ranging from mild to severe • Pruritus • Fullness • Discharge (otorrhea) • Hearing loss • Conductive mainly • Sensorineural in Ramsey Hunt syndrome • Itching • Vertigo and Tinnitus
- 44. • Water exposure •Use of cotton swabs • History of immunosuppression • History of contact allergies or skin conditions (e.g eczema) • Previous ear surgeries or procedures
- 45. Physical findings • Tendernesswith tragal pressure • Pain with manipulation of the auricle • Edema and erythema of the ear canal • Yellow, white, gray, or brown purulent debris • Vessicles • Scaly lesions
- 46. OTOSCOPIC FINDINGS • Bacterialotitis externa- erythematous and edematous canal with purulent tear discharge and squamous debris • Fungal otitis externa- slight erythema of canal wall • Candida sp characterised by cheesy, white debris in ear canal • Aspergillus Niger - characterised by moist white plug doted with black debris(appears like wet newspaper) • In allergic or contact dermatitis- thickened erythematous canal • Granulation tissue- over tympanic membrane and in the canal caused by chronic infection
- 47. INVESTIGATIONS • Investigations arerarely required for cases of otitis externa • Microbiology • Pus for culture and sensitivity • Fungal culture in cases of persistent or refractory otitis externa • Biopsy • Should be undertaken in cases of presumed otitis externa not responding to appropriate anti microbial therapy. • Biopsy is done to exclude malignancy of external ear (e.g squamous cell carcinoma, melanoma, temporal bone malignancy) • Moreover malignancy sometimes mimics otitis externa
- 48. • FBC • ESR •FBS/HBA1c • RVS
- 49. • Imaging • CTscan: • Preferred initial imaging • Bony erosion • Middle ear radiolucency • MRI: • Helpful in determining extent of infection • Also useful in determining presence of intracranial extension • Radionuclide bone scan
- 50. Treatment • Preventive • Nonsurgical • Surgical
- 51. PREVENTIVE • Remove obstructingcerumen • Use earplugs while swimming. • Apply acidifying ear drops: • Before swimming • After swimming • At bedtime • Dry ear canal with a hair dryer. • Avoid trauma to the ear canal. • Avoid inserting towels, cotton swabs, or other foreign objects into the ear canal. • Remove hearing aids nightly, and clean them regularly
- 52. • Debridement ofear canal (toileting) • Helps in clearance of infectious organism • Cleans debris, which is food for fungus is • Allows topical ear drops to reach the target tissue • Protect ear from water • Packing of ear canal • In case of canal edema for better delivery of medicines and to reduce canal edema • Pain relief • Topical antibiotic/antifungal ear drop • Mainstay of treatment of otitis externa
- 53. IDEAL EAR-DROP • Broad-spectrumcoverage for pathogenic bacteria • An acidic vehicle • No potential for ototoxicity, which is an important property in the case of a perforated tympanic membrane • No potential for allergic reactions • No deposition of precipitate from the drop • Low cost • A steroid to decrease edema more rapidly and, perhaps, alleviate pain more rapidly
- 54. • Oral antiviralsfor herpes zooster oticus • (e.g., valacyclovir, 1000 mg three times daily for 7 days) and High-dose steroids (e.g., prednisone, 1 mg/kg/day) • Eczematous otitis externa • Discontinue offending agent/irritant • Seborrhoeic otitis externa • Application of a cream containing salicylic acid and sulfur, and attention to the scalp for seborrhoea. • Neurodermatitis • Ear pack and bandage to the ear are helpful to prevent compulsive scratching.
- 55. • Malignant otitisexterna • Patient should be admitted to the hospital. • Culture ear canal discharge to determine definitive antibiotic treatment. • IV antibiotic therapy (empiric treatment with antipseudomonal coverage): • Ciprofloxacin • Note: About 50% of P. aeruginosa infections show resistance to fluoroquinolones so use other options if local resistance rate is high. • Piperacillin–tazobactam • Ceftazidime • Cefepime • Meropenem
- 56. • Surgical • Debridementand grafting • Chondrectomy • Meatoplasty • Canaplasty • I&D
- 57. • Cranial nervepalsies • Meningitis • Brain abscess • Dural sinus thrombophlebitis • Skull base osteomyelitis COMPLICATIONS • Cellulitis • Hearing loss • Peforation of TM • Abscess formation • Granulouma formation • Malinant Otitis externa
- 58. Differential diagnosis • Otitismedia • Foreign body in ear • Carcinoma of ear canal • Referred pain
- 59. CONCLUSION • Otitis externais common but manageable with proper care • Early diagnosis and treatment can prevent complications • Emphasize prevention in high risk individuals
- 60. References • Diseases ofear, nose and throat & Head and neck surgery, Dhingra 7th edition • Scott-Brown's Otorhinolaryngology and Head and Neck Surgery, Eighth Edition: Volume 2 • Cummings otolaryngology head & neck surgery 5th edition • Lecturio.com • Medscape.com