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Case Report:
Clinical Rotation
Department of Otorhinolaryngology-Head and Neck Surgery
Faculty of Medicine, Universitas Gadjah Mada
Group 17205
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Moderator: dr. Ashadi Prasetyo M.Sc Sp. THT-KL

Supervisor: dr. Tolkha Amarudin, Sp.THT-KL, M.Sc

Residence in Department of Head, Nose, Throat, and Surgery on Head and Neck

Presenting Team:
Agustian Winarno P 16/411540/KU/19775
Amima Meiza Azzyati 16/411516/KU/19780
Dicky Yulianda 16/411540/KU/19804
Erinda Maharani Rambu 16/411548/KU/19812
Karina Umma 16/411574/KU/19838
Naufal 16/411598/KU/19862
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• Otitis externa is inflammation of the external ear canal (EAC)
that can be acute or chronic caused by bacterial, viral and
fungal infection (Rosenfeld et. al., 2014).
• Acute diffuse otitis externa is the most common form of OE,
usually involves 2/3 inner part of EAC, with edema and
hyperemic EAC (Rosenfeld et. al., 2014).
• The annual incidence of AOE is between 1:100 and 1:250 of the
general population (Wipperman, 2014)
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• Nearly all (98%) AOE in North America is bacterial. The most common
pathogens are Pseudomonas aeruginosa and Staphylococcus aureus often
occurring as a polymicrobial infection (Rosenfeld et. al., 2014)
• The risk factor of OED is living in warmer, humid climates and swimming,
increased moisture in the ear canal, loss of protective cerumen, and trauma
to the ear canal (Schaeffer and Baugh, 2012)
• The mainstays of treatment for AOE include pain control, treatment of
infection, and avoiding precipitating factors (Wipperman, 2014)
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Basic Anatomy of External Ear

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Basic Anatomy of External Ear (1)
(Netter, 2010)
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Basic Anatomy of External Ear (2)
(Moore, 2010)
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Lymphatic Drainage of External Ear
(Moore, 2010)
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Vascularization of External Ear
(Moore, 2010)
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Otitis Externa
(Swimmer’s Ear)
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Definition (Schaeffer and Baugh, 2012)

• Otitis externa, external otitis or swimmer’s ear is an inflammation

of the outer ear and ear canal.
• Infection of the external auditory canal (EAC) is similar to
infection of skin and soft tissue elsewhere.
Classification (Murtazamustafa et al., 2015) P A G E 12

Based on duration and clinical findings

1.Acute localized otitis externa

• May occur as pustule or furuncle associated with hair follicles, it can be found in the 1/3 outer CAE
• Et : S. Aureus and S. Albus
• The main complaint is pain in the external ear and pain when open the mouth( temporomandibular
joint inv)

2.Diffuse otitis externa 3.Chronic otitis externa ( >3 months)

• Most commonly involves 2/3 inner part of CAE • Caused by untreated otitis externa, irritation
• The skin of canal edematous and red. from drainage through a perforated tympanic
• The ear itches and becomes increasingly painful, the membrane and repeatedly trauma, foreign
other symptom is tragic pain, regional body,
lymphadenopathy, tenderness, foul discharge from ear • Commonly features is stenosis, narrowing of
• Itching may be severe.
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4. Fungal otitis externa 5. Non-infectious otitis 6. Malignant otitis externa

• The symptom ranges from • Systemic diseases may • This is a severe necrotizing

cause otitis externa infection that spreads from the

itchy, fullness in the CAE,
squamous ephitelium of the ear
but often asymptomatic include atopic,
canal to adjacet area of soft
• The diagnosis is made by dermatitis, psoriasis, tissue, blood vessels, cartilage,
observing the unique seborrheic dermatitis, and bone
discharge in the external • Older, diabetic,
acne and lupus
auditory canal. immuocompromised, and
• Et: Pityrosporum, debilitated patients are at

Aspergillus particular risk

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(Schaeffer and Baugh, 2012)

• In North America, 98 percent of cases of acute

otitis externa are caused by bacteria. • Fungal pathogens, primarily those of
• The two most common isolates the Aspergillus and Candida species, occur
are Pseudomonas more often in tropical or subtropical
aeruginosa and Staphylococcus aureus. environments and in patients previously treated
with antibiotics
• Inflammatory skin disorders and allergic
reactions may cause noninfectious otitis
externa, which can be chronic.
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Impaired Defence
(Murtazamustafa et al., 2015; Johnson and Rosen,

Epithelial Cerumen

Skin Acidi Hydro

c phopi
Coat c
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Anatomical Risk Factors
(Murtazamustafa et al., 2015; Johnson and Rosen,

Auditory canal Warm

(a cul-de-sac Dark
structure) Prone to be moist

Very thin, easily

Skin traumatized

Curve of Junction of Cause Cerumen

the Cartilage and
Bone, and the Hair impelled
Symptoms and Sign (Schaefer and Baugh, 2012)

• Ear pain s
• Itching
• Fullness with
or without
hearing loss
or jaw pain
Symptoms and Sign (Schaefer and Baugh, 2012)

• Inspection:
Sig Ear canal
edema/erythema with
n or without otorrhea
• Palpation:
tenderness of
tragus/pinna, local
• Otoscopy:
Canal Edema
Tympanic membrane
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Diagnosis can be defined by anamnesis

and clinical findings of ear canal
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(Wippermen, 2014)
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Supporting Examination
mostly redundant, except for patient with immunocompromised
immune system/complication (Schaefer and Baugh, 2012)

Radiologic Examination Gram Staining

Radiologic Examination and Culture
To define the etiology
with Computed
and plan for effective
Tomography (CT) Scan treatment for
can be used to investigate immunocompromised
Otitis Externa complication
such as Necrotizing Otitis 2F5%2Fshutterstock_268541150_bact

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Based on Disease Progression (Kedel et. al., 2009)

1. Preinflammatory
Pain and tenderness of the auricle
2. Acute inflammatory
More edema and a thicker more profuse exudate
3. Chronic inflammatory
Infection extend beyond the limits of the canal
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1. Preinflammatory
 Removing cerumen
 The use of acidifying ear drops shortly
before swimming, after swimming, at
bedtime, or all 3 times
 The use of earplugs while swimming
 The avoidance of trauma to the external
auditory canal helps to prevent otitis
externa diffuse.
(Johnson and Rosen, 2014; Rosenfeld et al.,
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2. Acute inflammatory

 Aural toilet :
1. Hydrogen peroxide
2. Saline solution
3. Body-temperature
 Antibiotic topical
 Analgesic
(Rosenfeld et. al., 2014)
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3. Chronic Inflammatory
Systemic antibiotics –
Aural toilet :
1. Hydrogen peroxide
2. Saline solution
3. Body-temperature water
Antibiotic topical
(Rosenfeld et al., 2014)
Aural Toilet & Cerumen Excavation P A G E 26

(Schaefer and Baugh, 2012)

• Aural toilet and Cerumen

Excavation  to remove debris in
ear canal
Topical P A G E 27
(Schaefer and Baugh, 2012)

• Main treatment:
Topical Antimicrobials w/ or w/o topical corticosteroids
e.g. Aminoglycosides, Polymyxin B, quinolones, acetic
• Topical Corticosteroids
More rapid improvement in symptoms such as pain,
canal edema and erythema
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Oral Antibiotics
(Schaefer and Baugh, 2012)

• In uncomplicated otitis externa  no difference with topical medication

• Increase risk of adverse effects, generate resistant organism, and

“ Systemic antibiotics are appropriate for acute otitis externa only in

certain conditions (e.g., infection beyond the ear canal, uncontrolled
diabetes, inability to use topical antibiotics)

Complication (Murtazamustafa et al., 2015)

• Cellulitis
Cellulitis is a deep-layer bacterial skin infection that can occur as a result of otitis

• Malignant Otitis Externa

Spreading infection to the bone that surrounds ear canal
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Patient Education
(Schaefer and Baugh, 2012)

• Keep ear canal dry

• Avoid swimming
• How to use ear drop properly
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Case Report
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Patient Identity

• Name : Ms. DA
• Gender : Female
• Age : 21 y.o.
• Address: Pakisrejo
• Religion: Islam
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Chief Complaint
> Pain in the right ear since 1 week
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Anamnesis (2)

• History of Current Illness

Fullness in right ear since 3 years ago
Pain in the ear since 1 week ago, tragic pain (+), Hearing disturbance (+),
tinnitus (-), discharge (-)
Current treatment (-)
Cough (-), Sneezing (-), One-sided headache (+), dizziness (+)
Risk Factor: Swimming (-), cotton bud usage (-)
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Anamnesis (3)

• History of Past Illness

Complaint about food allergy during childhood (+)
Migraine Headache
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Physical Examination (1)

• General Appearance: Compos Mentis

• Vital Sign
• Blood Pressure: 112/76
• HR : 90 x/min
• RR : 24 x/min
• Temperature : 37.2 oC
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Physical Examination (2)

• Ear
• Dextra
Cerumen (+)
Intact Tympanic Membrane
Edema and redness of Canalis
Auricula Externa
Thick Yellowish discharge
• Sinistra
• Nose and Throat
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AD Otitis External Diffuse

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Topical Antibiotics with Corticosteroids:
Otopain (Per 5 mL Polymyxin B sulfate 50,000 IU, neomycin sulfate 25 mg,
fludrocortisone acetate 5 mg, lidocaine HCl 200 mg)

Cerumen Excavation

• Proper Ear Drop Usage

• Follow-Up examination in the following week


• Bonam
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Otitis Externa diffuse is determined by patient clinical

The patient is diagnosed with Otitis Eksterna Diffusa
based on the anamnesis that the patient experiences
pain and tragic pain in the right ear since 1 week
ago. She experienced fullness and hearing
disturbance in right ear since 3 years ago. During
physical examination, an hyperaemic and oedematous
canal was seen. There was also thick yellowish
discharge on the wall of right canalis auditory externa.
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(Johnson and Rosen, 2014)

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Firstly, we’ve done an aural toilet to this patient,

This patient is given otopain. Traditionally neomycin has been use with
polymixin B for their activities against S. aureus and Pseudomonas
aeruginosa for topical treatment.

This patient is given K Ddiclofenac as pain relief

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1. Aural Toilet

We’ve done an aural tiolet to this patient to remove cerumen and discharge from her right ear that
can disturb the effectivity of topical treatment

• For topical antibiotics to be effective, they must contact the epithelial lining. Therefore, in patients
with a significant amount of debris or otorrhea, aural toilet may be necessary (Wipperman, 2014)
• Aural toilet may be done with a gentle lavage using body-temperature water, saline solution, or
hydrogen peroxide. Alternative methods of aural toilet include physically removing the obstructing
debris with suction or dry mop (blotting with cotton). Adequate visualization for suctioning may be
facilitated by using an otoscope with an open head or a binocular otologic microscope (Rosenfeld,
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2. Topical Antibiotic

This patient is given otopain for a week and education how to applied it

• Topical antimicrobials are beneficial for AOE, but oral antibiotics have limited utility (Rosenfeld et
al., 2006).
• The oral antibiotics selected are usually inactive against P aeruginosa and S aureus may have
undesirable side effects, and, because they are widely distributed, serve to select out resistant
organisms throughout the body (Kaushik et al., 2010; Manolidis et al., 2004).
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• Traditionally neomycin has been use with polymixin B for their activities
against S. aureus and Pseudomonas aeruginosa for topical treatment
(Rosenfeld, 2006)
• If the tymphanic membrane intact, and there is no concern in
hypersensitivity to aminoglycoside, a neomycin/polymixin B/ hydrocortisone
otic preparation would be the first line therapy because it’s effectiveness and
low cost(Rosenfeld, 2006).
• The addition of a topical steroid to topical antimicrobial drops has been
shown to has ten pain relief in some randomized trials (Manolidis et. al.,
• A 2010 Cochrane review found no difference in efficacy between classes of
eardrop antibiotics for acute otitis externa (Kaushik, 2010)
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• Meta-Analysis show there are no significant differences in clinical outcomes

of AOE for antiseptic vs antimicrobial, quinolone antibiotic vs nonquinolone
antibiotic(s), or steroid-antimicrobial vs antimicrobial alone (Rosenfeld,
• Ofloxcin and ciprofloxcin are approved are approved in middle ear use and
should be used if the tymphanic membrane is not intact or its status cannot
be determined visually (Rosenfeld, 2014)
• In general, patients should be treated for 7 to 10 days. Practically, patients
may be advised to use drops for 1 week. If symptoms are not resolved they
may continue to use drops until a few days after symptoms resolve, up to 1
additional week. If symptoms still persist at day 14, this should be
considered a treatment failure (Rosenfeld, 2014)
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• Proper use of topical antibiotics is important, and misunderstanding of

technique can lead to treatment failure. For this reason, placement of drops
should be taught in the office. Up to 40% of patients do not self-administer
drops correctly. Having someone else administer topical preparations is
therefore usually more effective. Patients should lie on their side with the
affected ear up. Drops should be placed to run along the side of the ear
canal until it is filled, gently moving the pinna to eliminate air trapping and
ensure filling. Patients should remain in this position for at least 3 to 5
minutes (Wipperman, 2014)
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3. Pain relief

This patient is given K Diclofenac as pain relief

• Administering a nonsteroidal anti-inflammatory drug during the acute phase

of diffuse AOE significantly reduces pain compared with placebo (Rosenfeld,
• The addition of a topical steroid results in reduced canal edema and
otorrhea, and has tens pain relief (Kaushik, 2010)
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A 21 years old woman was presented with Otitis External
Diffuse in the right ear. The Patient is given ear drop
Otopain 4 drops 4 times a day for 7 days and K diclofenac
50 mg 2 times for 7 days. The diagnosis is defined by the
clinical presentation of the patient and given ear drop that
contain broad spectrum antibiotics and corticosteroids,
and also oral NSAID to relief pain. The patient is advised
to have follow up visit in the following week.
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Flint, P.W., Haughey, B.H., Lund, V.J., Niparko, J.K., Robbins, K.T., Thomas, J.R. and Lesperance, M.M. (2015),
Cummings Otolaryngology Head and Neck Surgery.
Gharaghani, M., Seifi, Z. and Zarei Mahmoudabadi, A. (2015), “Otomycosis in Iran: A Review”, Mycopathologia, Springer
Gurov, A.V., Kriukov, A.I., Kunelskaya, V.Y., Isotova, G.N., Shadrin, G.B., Luchsheva, Y.V., Yakimov, V.O., et al. (2017),
“Evaluation of the efficacy and tolerability of oral ciprofloxacin used in the comprehensive treatment of external
bacterial otitis: An observational prospective study”, International Archives of Otorhinolaryngology, Vol. 21 No. 4, pp.
Johnson, J.T. and Rosen, C.A. (2014), Bailey’s Head & Neck Surgery Otolaryngology, Fifth Edit., Lippincott Williams &
Kaushik, V., Malik, T. and Saeed, S.R. (2010), “Interventions for acute otitis externa”, Cochrane Database of Systemic
Reviews, No. 1, pp. 1–118.
Kedel, I.W.M., Samodra, E. and Rianto, B.U.D. (2009), “The effectiveness of Rifanol Tampon(R) compared with burowi
tampon in acute diffuse otitis externa”, Berkala Ilmu Kedokteran, Vol. 41 No. 3, pp. 157–163.
Manolidis, S., Friedman, R., Hannley, M., Roland, P.S., Matz, G., Rybak, L., Stewart, M.G., et al. (2004), “Comparative
efficacy of aminoglycoside versus fluoroquinolone topical antibiotic drops”, Otolaryngology - Head and Neck
Surgery, Vol. 130 No. 3 SUPPL., pp. 83–88.
Moore, K.L., Dalley, A.F. and Agur, A.M.R. (2014), Clinically Oriented Anatomy, 7th ed., Lippincott Williams & Wilkins,
available at: Oriented
Anatomy%2C Sixth Edition&lr&pg=PR4#v=onepage&q=Clinically Oriented Anatomy, Sixth Edition&f=false.
Murtazamustafa, Patawari, P., Sien, Muniandy, R., Tan, T. and Zinatara, P. (2015), “Acute Otitis
Externa:Pathophysiology,Clinical Presentation, and Treatment”, IOSR Journal of Dental and Medical Sciences Ver.
I, Vol. 14 No. 7, pp. 2279–861.
Pond, F., McCarty, D. and O’Leary, S. (2002), “Randomized trial on the treatment of oedematous acute otitis externa
using ear wicks or ribbon gauze: clinical outcome and cost.”, The Journal of Laryngology and Otology, England, Vol.
116 No. 6, pp. 415–419.
Rosenfeld, R.M., Schwartz, S.R., Cannon, C.R., Roland, P.S., Simon, G.R., Kumar, K.A., Huang, W.W., et al. (2014),
“Clinical Practice Guideline: Acute Otitis Externa”, Otolaryngology-Head and Neck Surgery, Vol. 150, pp. S1–S24.
Rosenfeld, R.M., Singer, M., Wasserman, J.M. and Stinnett, S.S. (2006), “Systematic review of topical antimicrobial
therapy for acute otitis externa”, Otolaryngology-Head and Neck Surgery, Vol. 134 No. 4_suppl, pp. S24–S48.
Sander, R. (2001), “Otitis Externa: A Practical Guide to Treatment and Prevention”, American Family Physician, Vol. 63
No. 5, pp. 941–2.
Schaefer, P. and Baugh, R.F. (2012), “Acute Otitis Externa: An Update”, American Family Physician, available at:
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