Journal Reading

OTITIS
EXTERNA
By
Amalia Zahrina
Deny Fasla
M Ali Alvin
Rizka Fadilah
OTITIS EXTERNA

Otitis externa is an inflammatory condition of

the external ear canal, with or without
infection
ACUTE OTITS
EXTERNA
 EPIDEMIOLOGY

>95% cases of otitis externa are acute

Each year, 1 to 2.5 in 100 people are affected.

Peak incidence arises among children of age 7
to 12 years
RISK FACTOR
Living in warmer, humid climates
and swimming

Risk factors relate to Removal of cerumen by excessive

increased moisture in
cleaning
the ear canal, loss of
protective cerumen,
and trauma to the ear
canal

Trauma to the ear canal

People with chronic dermatologic

conditions and
immunocompromised
 PATOPHYSIOLOGY
The external auditory canal is about 25 mm long and
curves in an S-shape toward the tympanic membrane.
The outer one-third of the canal base is cartilaginous
covered by cerumen glands and hair follicles, the inner
two-thirds is bony

Provides a waxy barrier that protects the epithelium from

breakdown caused by excessive moisture exposure

Cerumen
Cerumen has a slightly acidic pH and lysozymal activity that
inhibits bacterial and fungal growth

Disturbance in the normal acidic environment, lack of cerumen, and trauma to the
epithelial lining can lead to bacterial or fungal infection of the ear canal, causing an
inflammatory response
CLINICAL MANIFESTATION
Rapid onset of ear pain, fullness, and
otorrhea. Pain is worse with traction on the
pinna or palpation of the tragus

On initial stages, patients may experience mild

discomfort and ear pruritus. The ear canal may
be erythematous and slightly edematous, with
minimal discharge

Inflammation may spread to the tympanic

membrane. A sensation of ear fullness, as
well as hearing loss

Regional lymphadenitis and surrounding

cellulitis of the pinna. Systemic symptoms
suggest extension beyond the ear canal.
DIAGNOSIS
 TREATMENT

Aural Toilet A topical antibiotic

Topical steroid Over-the-counter oral

pain medication
If needed
Choice of antibiotic should be based on factors such as risk of ototoxicity, contact
sensitivity, availability, cost, dosing schedules, and patient compliance
Because topical antibiotics reach a high concentration in the ear canal, even bacterial strains
considered resistant to systemic antibiotics (ie, methicillin resistant Staphylococcus aureus) are
susceptible to topical antibiotic preparations
Finally, patients with AOE should avoid precipitating factors. In general,
swimming should be avoided until the infection is resolved, although
swimming may be allowed as long as patients do not submerge their
head
 MONITORING
AOE patients will experience
significant improvement within
24 hours

If patients do not
improve within 48
to 72 hours, they
should be
reevaluated
Referral is indicated in cases of
suspected malignant otitis
externa, lack of improvement, or
an inability to remove obstructing
debris or a foreign body
 PREVENTION

Limiting Avoid the sources of

predisposing factor ear trauma

Minimize the Adequately treat the

moisture retention underlying
in the ear canal dermatologic
conditions

In addition, acidifying
drops, such as acetic acid
Maintain the healthy 2% may be placed in the
skin barrier ear after water exposure to
dry the ear canal
COMPLICATIONS

Auricular or facial cellulitis,

perichondritis, or chondritis

Canal stenosis and

hearing loss

Malignant
(necrotizing) otitis
externa

Meningitis, dural sinus

thrombosis, cranial abscess,
and cranial nerve palsies
 CHRONIC OTITS
EXTERNA

Chronic otitis externa (COE) is more often attributed to

allergic or autoimmune causes than infectious etiology
CLINICAL PRESENTATION
Itching of the ear, clear or mucoid otorrhea,
and aural fullness

Ear pain or discomfort and hearing loss

Waxing and waning course over years with

intermittent exacerbations

At times patients may also experience AOE

 PHYSICAL EXAMINATION
Depending on the cause
Patients with
contact dermatitis
may exhibit a COE has also resulted
maculopapular rash from chronic otitis
with excoriations on media with tympanic
the skin of the membrane perforation
conchal bowel and
ear canal
The ear canal in
Patients with chronic patients with fungal
dermatologic infection (otomycosis)
conditions such as may show fluffy,
psoriasis and atopic cotton-like debris
dermatitis may show
eczema- tous
changes,
hyperkeratosis, and
lichenification of the
ear canal epithelium
DIAGNOSIS
Diagnosis of COE is made clinically at least
3 months’ duration
Culture for bacteria and fungi is
often prudent if chronic infection is
suspected

Skin-patch testing in cases of contact

dermatitis may be useful to elucidate
the cause

Chronic dermatologic disorders such as

psoriasis should be suspected when a
typical exanthem is visualized elsewhere
on the skin
 TREATMENT
Treatment of COE is aimed at identifying the underlying
cause and managing accordingly

Aural toilet Patients with chronic

bacterial infection should be
Preventive precautions as treated with topical
for AOE antibiotics, as for AOE

Topical steroid therapy with medium- For fungal otitis externa,

potency (triamcinolone 0.1% cream) and antifungal creams such as
high-potency (desoximetasone 0.05% clotrimazole 1% may be
cream) agents is often effec- tive for used
patients with contact dermatitis or
chronic dermatologic conditions
 COMPLICATIONS
The tympanic
Perforation of membrane may
tympanic appear to be
membrane oriented laterally
and have fibrotic
changes

Fibrosis of the Conductive hearing

medial canal loss
CONCLUSION

Otitis externa is a common

condition seen by primary care
clinicians. AOE most often is
infectious in origin, and can be easily
treated with a combination of
topical antibiotic and steroid
preparations. Systemic antibiotics
are rarely needed. In both AOE and
COE, prevention is fundamental
Thank you