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WEEK 11: 03/14 – 03/18/05
Learning Objectives: 1. Describe diagnostic features, and a short differential diagnosis of, otitis media and otitis externa in adults 2. Prescribe appropriate therapy for uncomplicated cases of otitis media or externa 3. Recognize more serious variants or complications of these conditions Author’s Note: Acute otitis media (AOM), the most common type of “ear infection” in children, is much less frequent in adults for a variety of reasons including evolution of eustachian tube anatomy, decreased frequency of viral URI’s, etc. There is correspondingly much less literature on this problem in adults; the clinical approaches described in most references are often extrapolated from those in children. Nonetheless, you are likely to encounter both otitis media and otitis externa in adult patients. CASE ONE: A 25-year-old woman presents with unilateral ear pain of several hours duration. The pain has now developed after several days of a viral URI, characterized by nasal congestion and mild cough. It’s worse with swallowing. The patient has no associated dizziness or fever, but the ear “feels like it’s blocked.” PMHx reveals no major medical problems. There is no history of recent ear trauma or infections, though she had many of the latter as a child.
Questions: 1. Assuming the remainder of the exam is normal in each case, describe your clinical impression and management plan if the ear exam shows: a. An intact, patent ear canal and the tympanic membrane have a dull appearance, with clear fluid and a couple of small bubbles visible through the TM in the middle ear. This patient has a middle ear effusion; the effusion and associated symptoms may be the result of virus-associated eustachian tube inflammation and dysfunction +/- a viral infection of the middle ear.
a common scar-like sequella of recurrent otitis media. Non-antibiotic therapies such as decongestants. later-generation macrolides. The usual therapeutic approach involves prescription of oral antibiotics. but have not been shown to be effective in treating the infection itself. influenza and most Moraxella catarrhalis are betalactamase positive and resistant in-vitro. An intact. The external and periauricular features here. and less often. non-typable Hemophilus influenzae. In practice. contiguous with the middle ear. Theoretically. [Refer housestaff to the Cochrane Database of Systematic Reviews. and tenderness. An intact. patent ear canal with dull tympanic membrane (TM) containing patches/plaques of embedded white material The white material is a “red herring” (no pun intended!). parenteral antibiotics. clinically evident mastoiditis. patent ear canal with a red. often develop subclinical inflammation/infection in AOM.those on otitis media therapy fail to describe much benefit. The prominent tympanic membrane and auricular/periauricular findings relative to the limited canal involvement also serve to distinguish this from otitis externa. c. aureus]. . [Ask what these are] Answer= Strep. There is also some mild postauricular erythema. b.] First-line alternatives would also include TMP/SMX. and questionable slight protrusion of the pinna compared with the contralateral ear. have also been tried. and amoxicillin/clavulanic acid. even though some H. This approach often works anyway due to the high spontaneous cure rate. including displacement of the auricle. although most of the data is from children. and otolaryngology should be consulted promptly.Early bacterial otitis media is a possibility. pyogenes or Staph.it represents tympanosclerosis. as in this case. bulging tympanic membrane and opaque fluid behind it This is a classic constellation of findings for acute suppurative otitis media caused by bacterial superinfection of a stagnant middle ear effusion (see above). second-generation cephalosporins. It would not be expected to cause her symptoms. swelling. indicate acute infectious mastoiditis complicating the picture of acute otitis media. d. While the mastoid air cells. these would be chosen to cover the most likely pathogens. Strep. Tympanic membrane as in (b) and the ear canal have some mild swelling and erythema along the posterior wall. with re-evaluation as needed if symptoms persist. pneumoniae. moraxhella catarrhalis. This patient may have eustachian tube dysfunction as in part (a). directed at the eustachian tube dysfunction. even without treatment. amoxicillin is often used initially. is a serious problem that may require hospitalization. but a trial of an analgesic alone (such as an NSAID) would be reasonable.
When seen by you three months ago for a routine physical exam. though not common. ENT consultation would be advisable. The ear canal is partially covered by some yellowish material with black dots. Describe your clinical impression and plan if ear exam today showed: a. The tympanic membrane is dull. in fact. b. This patient has a mild otitis externa likely due to superficial fungal infection. TMJ dysfunction. She wears a hearing aid on that side. 2. Describe your clinical impression and therapeutic approach to a patient like this in each of the following scenarios: a. dental problems). is the possibility of an occult head/neck tumor in an adult. Gentle removal of visible fluid/debris (accomplished in the generalist’s office with cotton swabs and/or irrigation) is recommended routinely in cases of otitis externa. Burow’s solution (aluminum . but most of his symptoms resolved except for some frontotemporal headaches. he had an asymptomatic middle ear effusion on that same side. while possibly residual from a recent URI. He had a URI a few weeks ago. but otherwise unremarkable. and further evaluation focused on these possibilities. should raise the possibility of other causes. she prides herself on the clean state of her ears. Normal landmarks and anatomy The absence of middle ear findings should raise index of suspicion for referred pain from other head/neck problems (e. 3.CASE TWO: A 55-year-old man presents with unilateral waxing/waning ear pain for the past week. and no other medical problems. Findings similar to Case 1(a) A persistent middle ear effusion. The periauricular exam is normal. There is no discomfort on retraction of the pinna. She has no history of ear trauma or infection.g. boric acid drops. If unrelenting. In addition. topical application of acetic acid (e. sinusitis.g. VoSol). CASE THREE: A 78-year-old woman presents with a several-day history of progressively worsening unilateral ear discomfort. Most concerning. There are no other symptoms. maintained through regular swabbing with Q-tips.
likely caused by bacterial superinfection. amoxicillin-clavulanic acid or perhaps a respiratory-pathogen-effective quinolone. In addition to superficial aspiration/swabbing to remove visible purulent material. In the acute setting. and perhaps topical anti-fungal drops would be helpful here. The ear canal is erythematous along part of its circumference. which is not protruding at rest. it has become apparent that many topical (otic drops) antibiotics can be used safely (particularly the quinolones) even in the presence of a TM perforation (where the drops would wash into the middle ear compartment). Cortisporin. a canal filled with purulent fluid may present confusion between otitis externa. The periauricular exam is normal. instillation of topical antibiotic/anti-inflammatory drops using indwelling cotton wicks may be necessary to penetrate the medial aspect of the canal. but a clear view of the tympanic membrane (dull but otherwise unremarkable). mild cases like this may resolve with topical antibiotic/anti-inflammatory drops (e. and has underlying diabetes mellitus. you may need to treat empirically for both. Close follow-up. with some flaky yellow-green material along the inferior aspect. d. A case of diffuse acute otitis externa. The periauricular exam is normal. and no other medical problems. The ear is draining yellowish fluid that precludes adequate examination of the canal or tympanic membrane. This is a case of localized acute otitis externa. this was often done using a broad-spectrum oral antibiotic. within 1-2 days initially. but the patient has severe pain and a fever. There are no other symptoms. such as quinolones. The ear canal is swollen and erythematous for the short distance that is visualizable before the lumen is blocked by wet yellowish curdlike material in the lumen. c. e. would be important to ensure response/resolution. but is otherwise healthy. (staph aureus and pseudomonas most frequently) may be needed. In recent years. . In the absence of visible canal inflammatory changes or significant pain on pinna retraction. Oral antibiotics effective against the likely pathogens [again. or Cipro-HC) alone. She has nasal congestion and a cough.g.g. [Ask which pathogens are usually involved: answer=pseudomonas aeruginosa or staph aureus]. e. There is minimal discomfort on retraction of the pinna. except that there is moderate pain on retraction of the pinna. b. the latter is sometimes associated with RELIEF of pain. As in (c). Historically. an astringent) and alcohol rinses. In addition to gentle removal of debris. There is minimal discomfort on retraction of the pinna.acetate in water. and otitis media with tympanic membrane perforation. But where differentiation is difficult. As in (d).
Describe your clinical impression and plan. In addition to involvement of a different spectrum of bacteria (including aerobes. This description suggests chronic suppurative otitis media. These may need to be removed when not in use. Usage of a hearing aid. ENT consultation would also be prudent. (quinolones) could be tried. This is usually associated with a non-healing TM perforation. there may be an underlying cholesteatoma (a non-malignant but locally invasive/destructive squamous epithelial overgrowth that can cause permanent damage/hearing loss).No discussion of adult infectious ear problems would be complete without mention of necrotizing (“malignant”) otitis externa. Topical antibiotics similar to those discussed in Case 3c. Frequent swimming (hence the common lay term “swimmer’s ear”). extension of cellulitis onto the auricle. parenteral antibiotics initiated [same pathogens as in diffuse OE]. c. Ear exam is notable for normal external structures. cotton-tipped swabs for cleaning the ear (disrupts the ear’s usual self-cleansing mechanisms. anaerobes. This may be accomplished with alcohol drops. Swimmers should ensure adequate drying of the ear canal afterwards. non-respiratory gram negatives). Some have also used hair blow dryers. However. 5. pushes debris deeper. . prescribed at two different walk-in clinic visits. What advice would you give to a patient to prevent otitis externa? Practices or activities in adults that predispose to otitis externa include: a. and/or an ipsilateral facial nerve palsy. esp. Other worrisome features might include red granulation tissue visible in the canal. but inability to view into the canal because of purulent fluid. and otolaryngology consulted emergently. unilateral ear drainage that has not improved despite treatment with a course of amoxicillin and a course of cefaclor. 4. CASE FOUR: A 49-year-old woman presents with several weeks of malodorous. A more aggressive approach is required for necrotizing OE. absence of pain on pinna retraction.the patient should be hospitalized. and can abrade the delicate skin lining the canal). Foreign-body insertion. an uncommon but very serious infectious (not neoplastic!) complication to which patients with diabetes or other immunosuppressive conditions are more susceptible. This practice should be discouraged in everyone! b.
He feels like his speech is slightly slurred. .1736.3. 6th edition.Textbook of Primary Care Medicine. Del Mar. Mosby. his tongue and ipsilateral eye feel “funny. 2001:1731. in view of the substantial rate of permanent deficit. Sanders.CASE FIVE – EXTRA CREDIT: A previously healthy 65-year-old man presents with lancinating right ear pain for the past two days. CB. Dec. John Noble MD (Editor-in-chief). Otitis Externa. 3rd edition. Also worth consulting “on the fly” in clinic are the chapters in Barker’s Principles of Ambulatory Medicine. Cochrane Database of Systematic Reviews 2004.e. it may be prudent to consult otolaryngology. acyclovir +/or steroids +/or surgical decompression) have been controversial. Hayem. What does this patient have? A case of Ramsay-Hunt syndrome. References: Otologic Infections.3. Glasziou. from “shingles” in the distribution of cranial nerve VII. Up-To-Date. 1. and Goroll’s Primary Care Medicine textbook. However. and vesicles in the right ear canal. 2.g. 6. herpes zoster oticus. Antibiotics for acute otitis media in children. Additional References: 1. 2. which is otherwise unremarkable.” He has a mild right facial droop. M. giving rise to a peripheral facial nerve palsy. Specifics of treatment (e. i. 2004. PP. SL.
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