Updated: 12/17/2021

Otitis Externa

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  • Snapshot
    • A 12-year-old boy presents to his pediatrician for ear pain. His ear pain began approximately 5 days ago and is associated with ear itching and mild hearing difficulty. His past medical history is unremarkable. He recently joined the swimming team of his school. Physical examination is notable for otalgia with palpation of the tragus and traction of the pinna. There is mild edema and swelling of the external auditory canal with poor visualization of the tympanic membrane. His ear is cleaned and is started on topical hydrocortisone and ciprofloxacin.
  • Introduction
    • Definition
      • inflammation of the external ear canal
  • Epidemiology
    • Incidence
      • acute uncomplicated otitis externa is most common in children
      • malignant otitis externa is more common in immunocompromised patients (e.g., elderly, diabetes, HIV, and on immunosuppresants)
    • Risk factors
      • prolonged swimming
  • Etiology
    • Pseudomonas aeruginosa (most common)
    • Staphylococcus aureus
    • Pathogenesis
      • disruption of protective barriers (e.g., skin or cerumen) within the external ear canal leads to cellulitis
        • cerumen creates an acidic environment that impairs bacterial and fungal growth
        • inflammation and edema in the external ear creates a favorable for bacterial growth
          • this is because impaired cerumen and epithelial migration makes the pH of the external ear more alkalotic
  • Presentation
    • Symptoms
      • pruritus
      • otalgia
      • hearing loss
    • Physical exam
      • pain with manipulation/pulling of the ear
  • Studies
    • Making the diagnosis
      • this is a clinical diagnosis
  • Differential
    • Otomycosis
      • differentiating factors
        • fungal filaments and spores that appear like mold growing under magnified vision
    • Contact dermatitis
      • differentiating factors
        • lack of response to appropriate treatment to otitis externa
    • Perichondritis
      • infection of connective issute of the ear that involves the cartilage
      • management
        • anti-pseudomonal antibiotics +/- incision and drainage
  • Treatment
    • Conservative
      • cleaning the external ear
        • indication
          • first step in management
        • comments
          • involves removing cerumn, desquamated skin, and purulent material from the ear canal
            • facilitates penetration of ear drops and healing
    • Medical
      • topical medications
        • indication
          • mild disease
            • acetic acid and hydrocortisone
          • moderate disease
            • hydrocortisone and ciprofloxacin
            • hydrocrotisone and neomycin and polyxin
          • severe disease
            • same as moderate disease but with also a wick placed
      • systemic antibiotics
        • indication
          • in infection that extends beyond the external auditory canal
          • in immunocompromised patients
        • comments
          • topical antibiotics are also given
        • medications
          • quinolones
  • Complications
    • Malignant otitis externa
      • most commonly seen in immunocompromised patient
      • caused by spread of the infection to the bone and marrow from the skin
      • the diagnosis is supported by CT and MRI findings of bone involvement

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(M2.ET.17.4694) A 60-year-old diabetic male presents to your clinic for right ear pain. The patient reports noting worsening right ear pain for three weeks, purulent otorrhea initially which has resolved, and facial asymmetry for the past several days. He reports being poorly compliant with his diabetes medication regimen. His temperature is 100.4 deg F (38 deg C), blood pressure is 140/90 mmHg, pulse is 90/min, and respirations are 18/min. On physical exam, the patient’s right external auditory canal is noted to have granulation tissue at the bony cartilaginous junction. He is also noted to have right facial droop. Which of the following is the best next step in treatment?

QID: 107782

Oral amoxicillin-clavulanic acid for 10 days

18%

(2/11)

Intravenous ciprofloxacin for 6 weeks

64%

(7/11)

Topical polymyxin and neosporin for 14 days

0%

(0/11)

Hyperbaric oxygen treatment for 4 weeks

0%

(0/11)

Surgical intervention

18%

(2/11)

M 6 B

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(M3.ET.13.1) A 68-year-old woman presents to the emergency department complaining of ear pain. She states it started a few days ago and it has been gradually worsening. She also endorses subjective fevers and neck stiffness. The patient is an adamant swimmer and swims 2-3 times per day. She has a history of diabetes, hypertension, and morbid obesity. Her temperature is 103°F (39.4°C), blood pressure is 177/99 mmHg, pulse is 110/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for the finding in Figure A. Which of the following is the most likely diagnosis?

QID: 102600
FIGURES:

Malignant otitis externa

83%

(15/18)

Mastoiditis

0%

(0/18)

Meningitis

6%

(1/18)

Otitis externa

0%

(0/18)

Otitis media

11%

(2/18)

M 10 E

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