Master the Boards: USMLE Step 3

To treat osteomyelitis
appropriately, a bone
biopsy/culture must be
performed.

Gram-negative bacilli (Salmonella and Pseudomonas are the ones to consider): This is the only form of osteomyelitis that can be successfully and
reliably treated with oral antibiotics.
- You must confirm it is gram-negative with a bone biopsy.
- The organism must be sensitive to antibiotics.
- There is no urgency to treating chronic osteomyelitis. You can obtain the
biopsy, move the clock forward, and treat what you find on the culture.

Head and Neck Infections

Otitis Externa
Presents with itching and drainage from the external auditory canal. This is a
form of cellulitis of the skin of the external auditory canal. It is often difficult
to visualize the tympanic membrane because of the swelling of the canal. It is
also painful, especially when the tragus of the ear is manipulated.
It is associated with swimming, because swimming washes out the acidic
environment normally found in the external auditory canal. Other causes
include foreign objects in the ears (e.g., repeated use of cotton swabs, hearing
aids, etc.).
Diagnostic Testing
No specific tests are necessary; diagnosis is based on exam. Do not perform a
routine culture of the ear canal.
Treatment
Topical antibiotics, such as ofloxacin or polymyxin/neomycin. Add topical
hydrocortisone to decrease swelling and itching. Adding acetic acid and
water solution to reacidify the ear can help eliminate the infection.

Malignant Otitis Externa

This is an extremely different disease from simple otitis externa. Malignant otitis externa is really osteomyelitis of the skull from Pseudomonas in a patient
with diabetes. It is an extremely serious disease, because it can lead to a brain
abscess and destruction of the skull. Treat it like osteomyelitis: x-ray, MRI,
bone biopsy/culture.

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SUBASH KC/NMC-15