PEMICU 6

FELITA SHELLA IRAWAN

405160190
 Otitis Externa

 Generalized condition of the

skin of the external auditory
canal that is characterized by
general oedema & erythema
associated with itchy discomfort
and usually an ear discharge

Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
Pathology
1. Pre-inflammatory :
• Stage 1 : the protective lipid/acid balance of the ear is lost
& the stratum corneum becomes oedematous, blocking off the
sebaceous & apocrine glands producing aural fullness &
itching.
• With further oedema & scratching, there is disruption of the
epithelial layer & invasion of resident / introduced organisms

Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
2. Acute inflammatory (mild, moderate or severe)
• Progressively thickening exudate, further oedema,
obliteration of the lumen (mild, little or no obliteration;
moderate, subtotal obliteration; severe, complete
obliteration) and icreasing pain
• In the severe stages, auricular changes and cervical
lymphadenopathy are often seen

Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
3. Chronic inflammatory (mild, moderate or severe)
• Occurs after 6 months, most clinicians probably regard a
resistant inflammation lasting longer than 3 weeks as entering
the chronic phase
• Some evidence  individual whose skin has a tendency to
remain at a low pH are more prone to develop a chronic
problem
• Stage 3 is characterized by thickening of the external canal
skin and fibrous canal stenosis

Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
Diagnosis
 Clinical diagnosis based on the following symptoms & signs :
a. Pain
b. Itch
c. Oedema & erythema of the external auditory canal with
purulent otorrhoea & debris in the meatus

Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
AETIOLOGY
 Any condition or situation that disturbs the lipid/acid balance
of the ear will predispose an individual to otitis externa
 Water & moisture  change from a predominantly Gram-
positive skin flora to a Gram-negative one
 As the ear become inflamed, healthy cerumen (with its
bactericidal properties) is rapidly removed from the ear and is
no longer produced

Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
Secondary Bacterial Infection
 Major feature of the disease
 Pseudomonas aeruginosa strains in ear disease are different to
those found elsewhere in the human body  may have special
adherence properties that allow the bacteria to enhance their
pathogenicity

Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
Irritant / Allergic Reactions
 Treatment is often with topical medications
 40-58%  sensitive to ingredients in topical agents on patch
testing
 Recent review concluded that using topical which include
neomycin are most likely to cause sensitivity
 Hypersensitivity can be through both atopic & non-atopic
allergic mechanisms and may or may not involve IgE
 Resistant  should be investigated for topical hypersensitivity
to possible therapeutic agents

Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
Outcomes and Complications
 Untreated  mild attacks of otitis externa often spontaneously
resolve as the epithelial barrier becomes reestablished, the
piloapocrine units produce normal secretion and the pH of the
canal returns to normal
 Inflammation progresses faster than repair, increasing pain,
otorrhea and oedema of the canal occurs & patient’s condition
will deteriorate
 Rich lymphatic drainage of the area  lymphadenopathy
often occurs & soft tissue infection progress rapidly 
perichondritis, chondritis, cellulitis, parotitis and/or erysipelas
 Immunocompromised host, malignant otitis externa
(periostitis/osteomyelitis of the skull base)  develop
significant associated morbidity & mortality
Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
Management Options
1. Aural toilet
 Remains the most effective single treatment
 Severe complications as a result of irrigation’
 As microscopic toilet is not readily available to most general
practitioners  patients are often treated with steroid-
antibiotic medication in the form of drops or sprays without
prior toilet

Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
2. Topical medication
 Sensitivity of the bacteria to the antibiotic in topical medication
does not seem to influence outcomes
 Glycerol & ichthammol (90:10 percent) is commonly used with
an aural wick for moderate and severe cases of otitis externa
 Dehydrating & antiinflammatory properties and antibacterial
 against Streptoccoci & Staphylococci, poor activity to
Pseudomonas
 Dehydrating  reduce canal oedema & helps reduce pain,
oral analgesia is usually necessary in moderate / severe cases
 NSAID, if not contraindicated  excellent analgesics
 Topical sensitivity  resistant / recurrent cases
Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
3. Systemic antibiotics
 No evidence for the efficacy of systemic antibiotic
therapy for uncomplicated diffuse otitis externa

Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
Prevention of Reccurence
 Prone to reccurent attacks  avoidance of water penetration
into the ear is a major management issue
 Cotton wool with petroleum jelly (e.g. Vaseline) will work well
in the bath or shower
 Neoprane head bandages  useful adjunct with the above
for children in swimming pools
 The use of alcohol / proprietary preparations (e.g. Aqua-ear
or Ear-calm) after swimming will help remove any water that
has penetrated into the canal
 Blow-driers (not on hot setting) can also help remove moisture
from the external auditory canal

Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
Traumatic Tympanic Membrane Perforations

 May occur as the result of a pressure wave in the external ear

canal / by direct penetration
 50% are attributable to slap injuries / direct blows
 Self-inflicted penetrating injuries account for about 25% 
due to causes that include diving & aviation barotrauma,
foreign bodies such as button batteries, insects, welding debris
& blast injury
 Associated tinnitus & vertigo

Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
 Causatic Perforation
 Most common cause  button batteries in children  non-
accidental injury
 Electrical shorting between the battery terminals from mucosal
contact, and possibly cerumen  battery leakage  become
corroded at the crimp area  permanent short  speeding up the
leakage & consequent trauma, severe burns may result
 Ear drops act as an electrolyte  enhancing the process, must not
be used
 Local inflammation & erosion may extend into surrounding structures
 deafness, facial palsy, meatal stenosis, even death
 Removal of the button battery, thorough irrigation of the meatus
with sterile water & any necessary debridement should be
performed urgently
Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
Clinical Aspects
 History of the trauma modality is required
 Examination should include the pinna and canal, with
microscopy as necessary
 Microsuction may be required to observe the tympanic
membrane in detail
 Any foreign body should be removed
 Apply cigarette paper / absorbable gelatin sponge to any
perforation  speeding up spontaneous healing
 Infection should be treated with aural toilet & topical
quinolone antibiotic drops
 Outpatient situation, if the patient is tolerant  clearance of
blood, wax and keratin debris by microsuction is appropriate
Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.
Prognosis
 Spontaneous resolution rates are high, typically 80-94%
 Poorer outcomes  increasing age & perforation size
 Mean time for spontaneous healing  1 month, a majority will
have healed within 3 months
 Slower speed of healing  if there is a middle ear infection

Scott Brown’s Otorhinolaryngology, Head and Neck Surgery. Volume 2. London: Edward Arnold Ltd, 2008.