Presented by :

Richard Gunawan
 Otitis Externa is one of the most common conditions seen in the
otolaryngology practice. It encompasses a wide range of conditions,
from those that cause mild inflammation and discomfort to those that
are life-threatening.
 The management of these conditions requires a clear understanding of
the anatomy and physiology of the ear canal, the microbiology of
pathogens and familiarity with the clinical presentation.
 Otitis externa is an inflammation or infection of the external auditory
canal (EAC), the auricle, or both and does not go further than the
eardrum.
Consist of :
 Auricle (pinna)

- Made of elastic cartilage

- Helix (rim)

- Lobule (ear lobe)

 External auditory canal

- Approx. 2,5 cm

- 1/3 outer surrounded by cartilage, 2/3 inner by mastoid bone

- Lies within temporal bone & connects to ear drum (tympanic)

- Contains ceruminous glands which secrete ear wax

 Tympanic membrane

- Between the outer and middle ear

- Transmits sound waves to middle ear

- Changes acoustic energy into mechanical energy

Etiology
 Organism : Bacteria(Pseudomonas, Sthapylococci,
Streptococci), Fungi (Aspergillus, Candida), virus.
 Previous episodes of OE
 Water Exposure or participating in aquatic activities (swimming, diving)
 Trauma (Use of earplugs, hearing aid or probing of the EAC)
 Absence of cerumen (Excessive Cleaning)
 Hot, Humid weather
 Obstruction (Cerumen build-up, Exostosis)
 Comorbidities such as DM, AIDS, leukopenia, or malnutrition
 OE is found in all regions of the United States, occurring in 4 of every
1000 people annually.
 The infection is believed to be more prevalent in hot and humid
conditions such as prevail during the summer months, presumably
because participation in aquatic activities is higher.
 Acute, chronic, and eczematous OE are also common. Necrotizing OE
is rare.
Age-, sex-, and race-related demographics
 Although the infection can affect all age groups, OE appears to be most
prevalent in children aged 7-12 years.
 A single epidemiologic study from the United Kingdom found a slight
increase in prevalence for those older than 65 years, as well as an
increase in the use of hearing aids, which may cause trauma to the
EAC.
 OE affects both sexes equally.
 No racial predilection has been established, though people in some
racial groups have small ear canals, which may predispose them to
obstruction and infection.
Classification OE
 Acute Diffuse OE – swimmers ears
 Acute Localised OE (Furunculosis)
 Chronic OE (>6 weeks)
 Otomycosis
 Herpes Zoster Oticus (Ramsay Hunt Syndrome)
 Eczematous / Dermatoses OE
 Malignant (Necrotizing) OE - occurs primarily in immunocompromised
adults (eg, diabetics, patients with AIDS)
 The key physical finding of OE is pain upon palpation of the tragus
(anterior to ear canal) or application of traction to the pinna (the
hallmark of OE).

Patients may also have the following signs and symptoms:

 Otalgia - Ranges from mild to severe, typically progressing over 1-2
days
 Hearing loss
 Ear fullness or pressure
 Erythema, edema, and narrowing of the EAC
 Tinnitus
 Itching (especially in fungal OE or chronic OE)
 Severe deep pain - Immunocompromised patients may have
necrotizing (malignant) OE
 Discharge - Initially, clear; quickly becomes purulent and foul-smelling
 Bilateral symptoms (rare)
 History of exposure to or activities in water (frequently) (eg, swimming,
surfing)
 History of preceding ear trauma (usually) (eg, forceful ear cleaning, use
of cotton swabs, or water in the ear canal)
 The patient’s history and physical examination, including otoscopy,
usually provide sufficient information for the clinician to make the
diagnosis of OE. Note that a patient who is diabetic or
immunocompromised with severe pain in the ear should have
necrotizing OE excluded by an otolaryngologist.
Typically, laboratory studies are not needed, but they may be helpful if
the patient is immunocompromised, if the usual treatment measures are
ineffective, or if a fungal cause is suspected. Tests may include the
following:
 Gram stain and culture of any discharge from the auditory canal
 Blood glucose level
 Urine dipstick
Imaging studies are not required for most cases of OE. However, radiologic
investigation may be helpful if an invasive infection such as necrotizing
(malignant) OE is suspected or if the diagnosis of mastoiditis is being
considered.

Imaging modalities may include the following:

 Computed Tomography (CT-scan) - Preferred; better depicts bony erosion
 Radionucleotide bone scanning
 Gallium scanning
 Magnetic resonance imaging (MRI) - Not used as often as the other
modalities; may be considered secondarily or if soft-tissue extension is the
predominant concern
 Otitis Media
 Cerumen Impaction
 Exostosis and osteoma
 Foreign Body
 Acute (bullous) and chronic (granular) myringitis
Most persons with OE are treated empirically. Primary treatment involves
the following:
 Pain management
 Removal of debris from the EAC
 Administration of topical medications to control edema and infection
 Avoidance of contributing factors
 Topical medications
 Analgesic agents
 Antibiotics otic
 Oral antibiotics
 Antifungal agents
 Surgical debridement of the ear canal - Usually reserved for necrotizing
OE or for complications of OE (eg, external canal stenosis); often
necessary in more severe cases of OE or in cases where a significant
amount of discharge is present in the ear; mainstay of treatment for
fungal infections
 Incision and drainage of an abscess
 During treatment of OE and for 1-2 weeks after its resolution, advise
the patient to keep the ear canal dry. During bathing or showering,
advise the patient to place an earplug or cotton ball lightly coated with
petroleum jelly in the ear canal to prevent water penetration.
 Patients involved in aquatic activities may resume these activities once
the infection has been eradicated, generally within 4-5 days.
AVOID : ENSURE : USE :
 Trauma  The ear canals are • Prophylactic eardrops after each
emptied of water after exposure to water to assist in
 Frequent
swimming or bathing drying and acidifying the ear canal
Washing ear with (a combination of 70% isopropyl
soap alcohol and acetic acid in a 2:1
ratio may be used)
 Swimming in the
Poluted waters • Some have recommended wearing
earplugs for swimming and bathing
but others have argued that the
use of earplugs should be avoided,
on the grounds that they may
cause trauma to the ear canal and
thereby predispose to the
development of OE.
Complications of OE are rare and may include the following:
 Necrotizing OE (the most significant complication)
 Mastoiditis
 Chondritis of the auricle (from spread of acute OE to the pinna,
particularly in patients with newly pierced ears)
 Bony erosion of the base of the skull (skull base osteomyelitis [15] )

 Central nervous system (CNS) infection

 Cellulitis or lymphadenitis