Otitis externa: Difference between revisions

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==Background==
==Background==
[[File:Gray907.png|thumb|Ear anatomy]]
*Inflammation of the external auditory canal (EAC), often due to bacterial infection
*Common in all age groups, but in the US commonly present in childhood <ref>Beers SL, Abramo TJ. Otitis externa review. Pediatr Emerg Care. 2004 Apr;20(4):250-6. doi: 10.1097/01.pec.0000121246.99242.f5. PMID: 15057182.</ref>
*In rare cases, immunocompromised patients may have fungal otitis external from Aspergillus or Candida
===Microbiology===
===Microbiology===
*Staph/Strep
*[[Pseudomonas]] (most common)
*Pseudomonas
*[[Staph]]/[[Strep]]
*Enterobacter
*[[Enterobacter]]
*Proteus
*[[Proteus mirabilis]]
*Fungus
*Fungus (may present after antibiotic treatment or in immunocompromised patient)
**Aspergillus, candida (may present after abx tx)
**[[Aspergillus]]
**[[Candida]]


===Risk Factors===
===Risk Factors===
*Swimming
*Swimming
*Excessive Q-tip use
*Excessive Q-tip (or other instrument) use


==Diagnosis==
==Clinical Features==
* Rapid onset (generally within 48 hours) in the past 3 weeks, AND.<ref name="CPGENT2014">Clinical Practice Guideline: Acute Otitis Externa Executive Summary. Otolaryngology -- Head and Neck Surgery 2014 150: 161
[[File:Otitis externa mild.jpg|thumb|Mild otitis externa]]
[http://www.aepap.org/sites/default/files/otitis_externa_guia2014-rosenfeld-161-8_0.pdf PDF]</ref>
[[File:OtitisExterna severe.jpg|thumb|Severe otitis externa]]
* ''Symptoms'' of ear canal inflammation, which include:
;Rapid onset (generally within 48 hours) in the past 3 weeks, '''AND'''.<ref name="CPGENT2014">Clinical Practice Guideline: Acute Otitis Externa Executive Summary. Otolaryngology -- Head and Neck Surgery 2014 150: 161 DOI: 10.1177/0194599813517659 [http://www.aepap.org/sites/default/files/otitis_externa_guia2014-rosenfeld-161-8_0.pdf PDF]</ref>
**otalgia (often severe)
*''Symptoms''  
**itching, or fullness, WITH OR WITHOUT
**[[earache|Otalgia]]
**hearing loss or jaw pain AND...
**Fullness or itching of the ear
* ''Signs'' of ear canal inflammation, which include:
**[[Hearing loss]]
**tenderness of the tragus, pinna, or both OR
**Jaw pain
**diffuse ear canal edema, erythema, or both WITH OR WITHOUT
*''Signs''
**otorrhea
**Tenderness of the pinaa and/or tragus
**regional lymphadenitis
**Diffuse ear canal edema, erythema, and possibly debris
**tympanic membrane erythema, or  
**Tympanic membrane may not be visualized due to EAC edema
**cellulitis of the pinna and adjacent skin
**Otorrhea
**Local [[lymphadenitis]]
**Tympanic membrane erythema, or  
**[[Cellulitis]] of the pinna and adjacent skin


==Differential Diagnosis==
==Differential Diagnosis==
*[[Malignant Otitis Externa]]
{{Ear DDX}}
*Otomycosis
 
**Pts complain more of itching than pain
==Evaluation==
**Characteristic appearance on exam; like mold growing on spoiled food
*Normally clinical
**Treatment
**Routine labwork or EAC cultures typically not necessary
***Cleaning of ear canal
 
***Topical antifungal
==Management==
*Contact Dermatitis
===Hygiene===
**Chronic suppurative otitis media
*Clean the ear canal ([[EBQ:Evidence Levels|Grade C]])
**Ear canal findings are usually mild compared with bacterial external otitis
**Cerumen wire loop or cotton swab usually works best
*[[Ramsay Hunt syndrome]]
**1:1 dilution of 3% hydrogen peroxide if tympanic membrane is visible and intact
**Acetic acid wash for debridement of dead skin
*'''Place a wick if the ear canal is fully obstructed'''
**Instruct patient that the wick should fall out spontaneously in 3 days as swelling decreases; a clinician may remove it otherwise
 
===[[Analgesia]]===
*[[NSAIDs]]
*[[Acetaminophen]]


==Treatment==
===Prevention===
*Clean the ear canal
*Keep ear canal dry
**Cerumen wire loop or cotton swab
**1:1 dilution of 3% hydrogen peroxide if TM is visible and intact
*Analgesia
**NSAIDs
*Avoiding promoting factors
**Keep ear canal dry
**Abstain from water sports for 7-10 days
**Abstain from water sports for 7-10 days
*Counsel patient to avoid Q-tip or other foreign objects in the ear
===Antibiotics===
===Antibiotics===
{{Otitis Externa Antibiotics}}
{{Otitis Externa Antibiotics}}
*Instruct the patient to instill the medication into the ear while laying on their side and hold position for 3-5 minutes
**Typically a least 4 drops are needed to fill the entire ear canal
*Consider systemic antibiotics in specific cases:
**Immunosuppressed (HIV, poorly controlled diabetes, chemotherapy, chronic high dose corticosteroid use, immunosuppressive drugs, neutropenia) give systemic antibiotic ([[ciprofloxacin]] or [[ofloxacin]]) <ref> Santos F, Selesnick SH, Gurnstein E.  Diseases of the External Ear. In:Current Diagnosis and Treatment in Otolaryngology: Head and Neck Surgery, Lalwani AK (Ed), Lange Medical Books/McGraw-Hill, New York 2004. </ref>
**If TMs are able to be visualized and suggest otitis media
**If there is a suspicion of malignant otitis externa


==Disposition==
==Disposition==
*F/u in 1-2wks for pts with moderate disease  
*Discharge
**Follow up with PCP or ENT in 1-2 weeks for patients with moderate disease


==See Also==
==See Also==
*[[Otitis Media (Peds)]]
*[[Otitis Media (Peds)]]
*[[Malignant Otitis Externa]]
*[[Malignant Otitis Externa]]
*[[In-Training Exam Review]]
==External Links==
*[https://youtu.be/8JXUGTkIC1Q Ear Wick Placement for Otitis Externa]
*[http://www.entnet.org/sites/default/files/AOEGuidelinePLSFinal.pdf PLAIN LANGUAGE SUMMARY: Acute Otitis Externa (Swimmer’s Ear)]


==Source==
==References==
<references/>
<references/>


[[Category:ENT]]
[[Category:ENT]]
[[Category:ID]]
[[Category:ID]]

Latest revision as of 00:41, 9 November 2023

Background

Ear anatomy
  • Inflammation of the external auditory canal (EAC), often due to bacterial infection
  • Common in all age groups, but in the US commonly present in childhood [1]
  • In rare cases, immunocompromised patients may have fungal otitis external from Aspergillus or Candida

Microbiology

Risk Factors

  • Swimming
  • Excessive Q-tip (or other instrument) use

Clinical Features

Mild otitis externa
Severe otitis externa
Rapid onset (generally within 48 hours) in the past 3 weeks, AND.[2]
  • Symptoms
  • Signs
    • Tenderness of the pinaa and/or tragus
    • Diffuse ear canal edema, erythema, and possibly debris
    • Tympanic membrane may not be visualized due to EAC edema
    • Otorrhea
    • Local lymphadenitis
    • Tympanic membrane erythema, or
    • Cellulitis of the pinna and adjacent skin

Differential Diagnosis

Ear Diagnoses

External

Internal

Inner/vestibular

Evaluation

  • Normally clinical
    • Routine labwork or EAC cultures typically not necessary

Management

Hygiene

  • Clean the ear canal (Grade C)
    • Cerumen wire loop or cotton swab usually works best
    • 1:1 dilution of 3% hydrogen peroxide if tympanic membrane is visible and intact
    • Acetic acid wash for debridement of dead skin
  • Place a wick if the ear canal is fully obstructed
    • Instruct patient that the wick should fall out spontaneously in 3 days as swelling decreases; a clinician may remove it otherwise

Analgesia

Prevention

  • Keep ear canal dry
    • Abstain from water sports for 7-10 days
  • Counsel patient to avoid Q-tip or other foreign objects in the ear

Antibiotics

  1. Ofloxacin (Floxin otic): 5 drops in affected ear BID x 7 days[2]
    • Safe with perforations
  2. Ciprofloxacin-hydrocortisone (Cipro HC): 3 drops in affected ear BID x 7 days
    • Contains hydrocortisone to promote faster healing
    • Not recommended for perforation since non-sterile preparation
  3. Ciprofloxacin-dexamthasone (Ciprodex): 4 drops in affected ear BID x 7 days
    • Similar to Cipro HC but safe for perforations
    • Often more expensive
  4. Cortisporin otic (neomycin/polymixin B/hydrocortisone): 4 drops in ear TID-QID x 7days
    • Use suspension (NOT solution) if possibility of perforation
    • Animal studies suggest possible toxicity from the neomycin although rigorous data is lacking[3]
  • Instruct the patient to instill the medication into the ear while laying on their side and hold position for 3-5 minutes
    • Typically a least 4 drops are needed to fill the entire ear canal
  • Consider systemic antibiotics in specific cases:
    • Immunosuppressed (HIV, poorly controlled diabetes, chemotherapy, chronic high dose corticosteroid use, immunosuppressive drugs, neutropenia) give systemic antibiotic (ciprofloxacin or ofloxacin) [4]
    • If TMs are able to be visualized and suggest otitis media
    • If there is a suspicion of malignant otitis externa

Disposition

  • Discharge
    • Follow up with PCP or ENT in 1-2 weeks for patients with moderate disease

See Also

External Links

References

  1. ↑ Beers SL, Abramo TJ. Otitis externa review. Pediatr Emerg Care. 2004 Apr;20(4):250-6. doi: 10.1097/01.pec.0000121246.99242.f5. PMID: 15057182.
  2. ↑ 2.0 2.1 Clinical Practice Guideline: Acute Otitis Externa Executive Summary. Otolaryngology -- Head and Neck Surgery 2014 150: 161 DOI: 10.1177/0194599813517659 PDF
  3. ↑ Wright, C. et al. Ototoxicity of neomycin and polymyxin B following middle ear application in the chinchilla and baboon. Am J Otol. 1987 Nov;8(6):495-9.
  4. ↑ Santos F, Selesnick SH, Gurnstein E. Diseases of the External Ear. In:Current Diagnosis and Treatment in Otolaryngology: Head and Neck Surgery, Lalwani AK (Ed), Lange Medical Books/McGraw-Hill, New York 2004.
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