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=== | ||
*[[Pseudomonas]] (most common) | |||
*[[Staph]]/[[Strep]] | *[[Staph]]/[[Strep]] | ||
*[[Enterobacter]] | *[[Enterobacter]] | ||
*[[Proteus mirabilis]] | *[[Proteus mirabilis]] | ||
*Fungus | *Fungus (may present after antibiotic treatment or in immunocompromised patient) | ||
**[[Aspergillus]] | **[[Aspergillus]] | ||
**[[Candida]] | |||
===Risk Factors=== | ===Risk Factors=== | ||
*Swimming | *Swimming | ||
*Excessive Q-tip use | *Excessive Q-tip (or other instrument) use | ||
==Clinical Features== | ==Clinical Features== | ||
[[File:Otitis externa mild.jpg|thumb|Mild otitis externa]] | [[File:Otitis externa mild.jpg|thumb|Mild otitis externa]] | ||
[[File:OtitisExterna severe.jpg|thumb|Severe otitis externa]] | [[File:OtitisExterna severe.jpg|thumb|Severe otitis externa]] | ||
;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> | ;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> | ||
*''Symptoms'' | *''Symptoms'' | ||
** | **[[earache|Otalgia]] | ||
**itching | **Fullness or itching of the ear | ||
** | **[[Hearing loss]] | ||
**Jaw pain | |||
*''Signs'' | *''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== | ==Differential Diagnosis== | ||
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==Evaluation== | ==Evaluation== | ||
*Normally clinical | *Normally clinical | ||
**Routine labwork or EAC cultures typically not necessary | |||
==Management== | ==Management== | ||
===Hygiene=== | ===Hygiene=== | ||
* | *Clean the ear canal ([[EBQ:Evidence Levels|Grade C]]) | ||
**Cerumen wire loop or cotton swab usually works best | **Cerumen wire loop or cotton swab usually works best | ||
**1:1 dilution of 3% hydrogen peroxide if tympanic membrane is visible and intact | **1:1 dilution of 3% hydrogen peroxide if tympanic membrane is visible and intact | ||
**'''Place a wick if the ear canal is fully obstructed''' | **Acetic acid wash for debridement of dead skin | ||
===Analgesia=== | *'''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]] | *[[NSAIDs]] | ||
*[[Acetaminophen]] | |||
===Prevention=== | ===Prevention=== | ||
*Keep ear canal dry | *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== | ||
*Follow up in 1- | *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== | ==External Links== | ||
*[https://youtu.be/8JXUGTkIC1Q Ear Wick Placement for Otitis Externa] | *[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)] | |||
==References== | ==References== | ||
Latest revision as of 00:41, 9 November 2023
Background
- 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
- Pseudomonas (most common)
- Staph/Strep
- Enterobacter
- Proteus mirabilis
- Fungus (may present after antibiotic treatment or in immunocompromised patient)
Risk Factors
- Swimming
- Excessive Q-tip (or other instrument) use
Clinical Features
- Rapid onset (generally within 48 hours) in the past 3 weeks, AND.[2]
- Symptoms
- Otalgia
- Fullness or itching of the ear
- Hearing loss
- Jaw pain
- 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
- Auricular hematoma
- Auricular perichondritis
- Cholesteatoma
- Contact dermatitis
- Ear foreign body
- Herpes zoster oticus (Ramsay Hunt syndrome)
- Malignant otitis externa
- Otitis externa
- Otomycosis
- Tympanic membrane rupture
Internal
- Acute otitis media
- Chronic otitis media
- Mastoiditis
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
- Ofloxacin (Floxin otic): 5 drops in affected ear BID x 7 days[2]
- Safe with perforations
- 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
- Ciprofloxacin-dexamthasone (Ciprodex): 4 drops in affected ear BID x 7 days
- Similar to Cipro HC but safe for perforations
- Often more expensive
- 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
- ↑ 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.
- ↑ 2.0 2.1 Clinical Practice Guideline: Acute Otitis Externa Executive Summary. Otolaryngology -- Head and Neck Surgery 2014 150: 161 DOI: 10.1177/0194599813517659 PDF
- ↑ 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.
- ↑ 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.