Case Report

Furunculosis External Otitis

Presentator : Pradhana Fajar Wicaksana

Moderator : Dr.dr. Sagung Rai Indrasari.,Mkes.Sp.T.H.T.K.L (K) FICS

Department of Health Ear Nose Throat - Head Neck Surgery

Faculty of Medicine, Universitas Gadjah Mada / Dr.Sardjito Hospital
Yogyakarta
2017

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CHAPTER I aureus. Damage to the hair follicle
allows these bacteria to enter deeper
INTRODUCTION
into the tissues of the follicle and the

Inflamatory changes in the tissue underneath. Furuncle/boils may

external ear are common and often occur in the hair follicles anywhere on

treated initially by a primary care the body. They are most common on

physician and otologist. It is important, the face, neck, armpit, buttocks, and

therefore, to be familiar with the thighs. There can be one or many

various type of external ear boils.2

inflammations, their hazards, and their Bacterial otitis externa is a

appropriate management. Different common problem for the otologist as

inflammatory conditions of the well as general practitioner. Thats why

external ear are interrelated to their as a medical professional we must

pathogenesis, sometimes making it understand how to diagnose the

difficult to differentiate the various disease and how to treat it with a

forms.1 reasonable therapy because disease

Inflamations of the external ear extention can produce intratemporal

may manifest acutely with severe pain, and intracranial complications through

subacutely, or may present with involvement neurovasculer pathway.3

chronic complaints. Acute

inflammations are often caused by
bacterial infection. The term otitis
externa usually refers to inflammation
of the external auditory canal. One
example of inflammations of the
external ear is furuncle.1 Furuncles are
very common. They are generally
caused by the bacteria Staphylococcus

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CHAPTER II constrictions, one near the medial
end of the cartilaginous part, the
OVERVIEW
other, the isthmus. The tympanic
membrane, which closes its medial
A. ANATOMY EXTERNAL EAR end, is obliquely set and
The external ear consists of the consequently the floor and the
auricle or pinna and the external anterior wall of the meatus are
acoustic meatus/external auditory longer than its roof and posterior
canal. The external acoustic wall. The lateral, cartilaginous part
meatus extends from the concha to is about 8 mm long. It is
the tympanic membrane. Its length continuous with the auricular
is 2.5 cm – 3 cm from the floor of cartilage and attached by fibrous
the concha and 4 cm from the tissue to the circumference of the
tragus. It has two structurally osseous part. This meatal cartilage
different parts; the lateral third is is deficient posterosuperiorly, and
cartilaginous and the medial two- the gap is occupied by a sheet of
thirds is osseous. It forms an S- collagen.3,4
shaped curve, directed at first The skin of the auricle
medially, anteriorly and slightly up continues into the external acoustic
(pars externa), then meatus and covers the external
posteromedially and up (pars surface of the tympanic membrane.
media) and lastly anteromedially It is thin, has no dermal papillae,
and slightly down (pars interna). It and is closely adherent to the
is oval in section, its greatest cartilaginous and osseous parts of
diameter is obliquely inclined the tube. Inflammation here is
posteroinferiorly at the external therefore very painful. The thick
orifice, but is nearly horizontal at subcutaneous tissue of the
its medial end. There are two cartilaginous part of the meatus
contains numerous ceruminous

3
glands which secrete ear wax or
cerumen. Their coiled tubular
structure resembles that of sweat
glands. The secretory cells are
columnar when active, but
cuboidal when quiescent. They are
covered externally by
myoepithelial cells. Ducts open
either on to the epithelial surface or
into the nearby sebaceous gland of
Figure of Coronal section of the ear canal. The
a hair follicle. Cerumen prevents skin of the cartilaginous and osseous canals
are magnified.
the maceration of meatal skin by (From Lilwani, 2008)
trapped water. Overproduction or
accumulation of wax may Two branches of the external
completely block the meatus or carotid artery provide most of the
obstruct the vibration of the arterial supply to the ear. The
tympanic membrane. Although superficial temporal artery supplies
ceruminous glands and hair the anterior portion of the external
follicles are largely limited to the canal and auricle, and the posterior
cartilaginous part, a few small auricular artery provides blood to
glands and fine hairs also occur in the mastoid region and the
the roof of the lateral part of the posterior portions of pinna and
osseous meatus.4,5 canal.6 Lymphatic drainage of
auricular are: 1) Pre-auricular
lymph nodes ( Parotid lymph
nodes ) anteriorly 2). Post-
auricular lymph nodes ( Posterior
lymph nodes ) posteriorly 3).

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 superficial cervical lymph nodes cartilaginous portion of the ear
inferiorly.7 canal. The infection occurs most
The innervations of the pinna commonly at the junction of the
and external auditory canal derives concha and canal skin.1,8
from the auriculotemporal branch
of trigeminal nerve which B.2.Etiology
innervates the anterior canal wall Furunculosis is conditions
and tympanic membrane, as well resulting from gram positive
as the anterior aspect of the pinna. infections, usually staphylococcal,
The greater auricular nerve of the hair follicles.8
supplies the mastoid process and
both lateral and medial of the B.3.Pathogenesis
posterior pinna and tympanic The two factors that are
membrane. The auricular branch of required for external otitis to
the vagus innervates the inferior develop are (1) the presence of
bony canal and tympanic germs that can infect the skin and
membrane, the posterosuperior (2) impairments in the integrity of
cartilaginous canal, and the cymba the skin of the ear canal that allow
concha. Branches of the facial and infection to occur. Inflammation of
chorda tympani nerves innervate the ear canal skin typically begins
the posterosuperior bony external with a physical insult, most often
auditory canal.3 from injury caused by attempts at
self-cleaning or scratching with
B. FURUNCULOSIS cotton swabs, pen caps, finger
B.1.Definition nails, hair pins, keys, or other
Furuncle (also known as small implements.9 Glandular
circumscribed otitis externa) is a secretions from the
circumscribed lesion caused by an apopilosebaceous unit combine
acute bacterial infection of the with sloughed squamous

5
epithelium (cerumen) to coat the water-filled balloon. Pain gets
external ear canal and maintain an worse as it fills with pus and dead
acidic pH. Local mechanical tissue. Is usually pea-sized, may
trauma and contamination of the develop white or yellow centers
ear canal lead to obstruction of the (pustules).11 The primary lesion is
hair follicles or glandular ducts, usually a small well circumscribed
followed by staphylococcal pustule that may enlarge to become
infection of the pilosebaceous a furuncle or merge with several
units.1 similar lesion to form a carbuncle.
Pushing the tragus, the tablike
B.4.Diagnosis portion of the auricle that projects
Diagnosis of furunculosis out just in front of the ear canal
external otitis derives from opening, so typically causes pain in
signs/symptoms of the patient and this condition as to be diagnostic of
physical examinations. Pain external otitis on physical
(otalgia) is the most presenting examination. For additional
symptom which may be severe examination to ensure the
particularly when the ear is diagnosis, we can use the infected
touched, that is because the skin is skin or mucous biopsy culture, that
intimately adherent to the may show the specific germ
underlying cartilage. Other include staphylococcal or other
symptoms of furunculosis can be bacteria. The differential diagnosis
hearing loss, tinnitus, otorhea when of furunculosis external otitis are
the furuncle ruptures so purulent diffuse external otitis and
discharge starts flowing, even otomycosis.8,11
trismus.10 Based on physical
examination a furuncle may begin B.5.Treatment
as a tender, pinkish-red, swollen For treatment to be successful,
nodule but ultimately feel like a any accumulated infectious

6
 material must be removed.
Spontaneous drainage can often be
encouraged by the use of warm
soaks, supplemented by topical and
oral antibiotics. If this fails to
relieve obstruction of the canal,
incision and drainage under local
anesthesia are indicated.6,8
History of present illness:
Since 2 days ago, patient complain
his left ear so painful especially
when he touched on tragus. The
pain was felt constantly and become
more severe. he also complained
lump in his left ear canal. Initially
the patient felt water got enter into
his ear canal after she took a bath

CHAPTER III about a week ago, then he

manipulated his ear using his finger
CASE REPORT
and cotton bud until several days
after that he felt pain in her ear and
A. Identity
there was no fever. He denied
Name : Mr. F
discharge from the ear, there is no
Age : 19
complaint buzzing in the ear,
years old
hearing loss, dizziness or vertigo.
Gender : Laki -
No complaint on the right ear, nose,
laki
or throat.
Address :
History of past illness:
Yogyakarta
 History of the same complains (-
 No MR :
)
1.86.32.22
 History of alergy (-), Diabetic (-)
History of illness in family
members:
B. Anamnesis
 History of the same complains (-

Chief complaint : earache in the )

left ear..  History of alergy (-) Diabetic (-)

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 Patient feels
pain if the
C. Physical Examination tragus is being
 General status : well conscious, pressed and the
adequatly nourished. auricle was
 Vital sign : Blood Pressure being pulled.
: 110/70 mmHg NRS Score is
Pulse 4. It is difficult
: 80 x/min to examine the
Respiration left canal and
: 20 x/min tympanic
Temperature membrane
: 37 0C because of the
 Otorhinolarygology swelled area
examination: and earache
when we touch
Left Ear : The inspection
the left ear. No
of the left ear
discharge from
at left meatus
the left ear
acusticus
canal.
externus
Right Ear :
(posterior the
Auricle,CAE,ty
tragus) there is
mpanic
circumscribed
membrane
lesion,swelled,
were within
with a pustule,
normal limits.
hyperemic area
Nose : Within normal
surround it and
limits
have punctum.

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 Throat : Within normal G. Planning
limits Control again after 3 days of
treatment to evaluate the boil.

D. Diagnosis
Based on the result from anamnesis
and physical examinations, this
patient was diagnosed with the
Furunculosis External Otitis or
Localized External Otitis at Left
Ear.

E. Treatment
 Antibiotic tampon
 Fluocinolon acetonid +
Neomycin sulfat 3 times a days
applied to her left ear.
 Na Diclofenac 2 x 50 mg a day
take if only feel pain after
meal.
CHAPTER IV
 Advise the patient not to
DISCUSSION
manipulate her ear without
medication purposes, take the
The diagnosis of this patient
medication regularly.
derives from anamnesis and
physical examination. The main
F. Problem
complain of the patient is pain in
Treatment
the ear (otalgia) after she

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manipulates her ear using her NRS are it is short, easy to
finger and cotton bud. Her left ear administer, and is validated as a
is so painful especially when she measure of intensity of pain in
touches on auricular area. Then populations with known pain.
from physical examination we find However, no studies have
at left meatus acusticus externus evaluated its accuracy as a
there is circumscribed lesion, screening test to identify patients
swelled, with a pustule, hyperemic with clinically important pain. This
area surround it, and have patient mention the NRS Score 4.
punctum. Patient feels pain if the No. need to make an incision and
tragus is being pressed and the drainage. We hope spontaneous
auricle is being pulled. According drainage can often be encouraged
to Cummings and Ballenger by the use of warm soaks,
(2005), clinical manifestations supplemented by topical and oral
include localized pain, particularly antibiotic.
to touch and the examination may To reduce her suffering from
be difficult because of pain and the pain, we must use appropriate
swelling. According to Bhargava analgesic and for this patient we
(2002) pain is presenting symptom can use dicofenac. According to
which may be severe as the skin is Laurence (2006), diclofenac has
intimately adherent to the analgesic, antipyretic, and
underlying cartilage. antiinflammatory activities and has
Based on Barclay (2008), the rapid absorption, extensive protein
NRS on which patients rate their binding..
pain as 0 ("no pain") to 10 ("worst This patient is diagnosed as
pain") has become the most widely furunculosis external otitis or
used instrument for pain screening. localized external otitis, based on
The potential advantages of the Probst et al (2006), circumscribed
otitis externa is also known as a

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furuncle, this is a circumscribed In this case we also use
lesion caused by an acute bacterial fluocinolone acetonide combined
infection of the cartilaginous with neomycin sulfate is a
portion of the ear canal. According member of aminoglycosides.
to Habif TM (2009), furuncles are According to Mayer (2010),
generally caused by the bacteria aminoglycosides are active against
Staphylococcus aureus. Furuncle many gram-negative and some
may occur in the hair follicles gram-positive bacteria. They are
anywhere on the body including not useful for anaerobic bacteria,
cartilaginous part of external since oxygen is required for uptake
auditory canal. Staphylococcal of the antibiotic, or for intracellular
infections are related to bacteria. Fluocinolone is member
pathological conditions such boil, of steroid. Acording to Katzung
acne, pneumonia, meningitis, and (2006), steroid dramatically reduce
arthritis. According to Todar the manifestations of
(2011) and Laurence (2006), inflammation. This is due to their
staphylococci (staph) are gram- suppressive effects on the
positive spherical bacteria so the inflammatory cytokines and
appropriate treatment is using chemokines and on other mediators
antibiotic which sensitive with of inflammation.
gram positif bacteria. According to The problem of this patient is
Laurence (2006), antibiotic which the habitual, because he has habit
sentitive with gram positive manipulating his ear using his
bacteria are beta lactam, quinolone, finger and cotton bud so he must
cotrimoxazole, tetracycline, and be educated no to manipulate his
macrolide. According to Habif TM ear and keep the hygiene of the ear.
(2009), antibacterial soaps and But in this moments we also use
antibiotics placed on the skin are topical ointment that needs for
little help once a boil has formed. manipulating her ear so we can

11
educate that he can manipulate his
ear just for medication pusposes. If
there is any complaint in the ear
during the treatment he must come
to the otolaryngologist to examine
it.
CHAPTER V
CONCLUSSION

Have been reported a patient, a

male, 19 years old, with chieft
complaint is pain in the left ear
(otalgia) and diagnosed as
furunculosis external otitis at left
ear. The patient had being gotten a
treatment, but still must be
followed up to evaluate our
treatment, manage soon if the
complication was happened,
educate the patient not to
manipulate his ear without
medication purposes, to take the
medication regularly. If there is
any complaint in the ear she better
come to the otolaryngologist.

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