OTITIS

EXTERNA
DR. KARIM KABINEH
Introduction
• Otitis externa (OE) is an inflammation or infection of external
auditory canal (EAC), the auricle or both.
• It is a common disease that can be found in all age groups
• OE usually represents an acute bacterial infection of the skin of the ear
canal but can also be caused by other bacteria, viruses, or a fungal
infection.
• Several factors can contribute to EAC infection and the development
of OE, including the following:
• Absence of cerumen
• High humidity
• Retained water in ear canal
• Increased temperature
• Local trauma (eg, use of cotton swabs or hearing aids)
• Aquatic athletes are particularly prone to the development of OE
because repeated exposure to water results in removal of cerumen and
drying of the EAC.
• Retained water in the ear canal can cause maceration of the skin and a
milieu conducive to bacterial or fungal proliferation.
• Individuals with allergic conditions (eg, eczema, allergic rhinitis, and
asthma) are also at significantly higher risk for OE
• Necrotizing OE occurs in patients who are immunocompromised and
represents a true osteomyelitis of the temporal bone.
• Risk factors for OE include the following:
• Previous episodes of OE
• Swimming, diving, or participating in aquatic activities
• Use of earplugs or probing of the EAC
• Hot, humid weather
• Use of a hearing aid
• Coexistence of eczema, allergic rhinitis, or asthma
• Comorbidities such as diabetes mellitus, AIDS, leukopenia, or
malnutrition
Classification
OE may be classified as follows:
• Acute diffuse OE
• Acute localized OE
• Chronic OE
• Eczematous (eczematoid) OE
• Necrotizing (malignant) OE
• Otomycosis
Etiology
• OE is most often caused by a bacterial pathogen; other varieties
include fungal OE (otomycosis) and eczematoid (psoriatic) OE.
• The most common causative bacteria are:
• Pseudomonas species (38% of all cases),
• Staphylococcus species,
• Anaerobes,
• gram-negative organisms.
• Fungal OE may result from overtreatment with topical antibiotics or
may arise de novo from moisture trapped in the EAC.
• It is caused by Aspergillus 80-90% of the time;
• Candida and other organisms have also been isolated.
• Eczematoid (psoriatic) OE is associated with the following conditions:
• Eczema
• Seborrhea
• Neurodermatitis
• Contact dermatitis from earrings or hearing aid use
• Sensitivity to topical medications
Pathophysiology
• OE is a superficial infection of the skin in the EAC.
• The processes involved in the development of OE can be divided into
the following 4 categories:
• Obstruction (eg, cerumen buildup, surfer’s exostosis, or a narrow
or tortuous canal), resulting in water retention
• Absence of cerumen, which may occur as a result of repeated water
exposure or overcleaning the ear canal
• Trauma
• Alteration of the pH of the ear canal
• If moisture is trapped in the EAC, it may cause maceration of the skin
and provide a good breeding ground for bacteria.
• This may occur after swimming (especially in contaminated water) or
bathing—hence the common lay term “swimmer’s ear.”
• It may also occur in hot humid weather.
• Obstruction of the EAC by excessive cerumen, debris, surfer’s
exostoses, or a narrow and tortuous canal may also lead to infection by
means of moisture retention.
• Trauma to the EAC allows invasion of bacteria into the damaged skin.
• This often occurs after attempts at cleaning the ear with a cotton swab,
paper clip, or any other utensil that can fit into the ear.
• Once infection is established, an inflammatory response occurs with
skin edema.
• Exudate and pus often appear in the EAC as well.
• If severe, the infection may spread and cause a cellulitis of the face or
neck.
Acute diffuse OE
• This is the most common form of OE, typically seen in swimmers;
• it is characterized by rapid onset (generally within 48 hours) and symptoms of
EAC inflammation (e.g, otalgia, itching, or fullness, with or without hearing loss
or jaw pain) as well as:
• tenderness of the tragus or pinna or diffuse ear edema or erythema or both,
with or without otorrhea,
• regional lymphadenitis,
• tympanic membrane erythema, or
• cellulitis of the pinna
Acute localized OE
• This condition, also known as furunculosis, is associated with
infection of a hair follicle
Furunculosis: Signs
• Edema
• Erythema
• Tenderness
• Occasional fluctuance
Chronic OE
• This is the same as acute diffuse OE but is of longer duration (>6
weeks)
Eczematous (eczematoid) OE
• This encompasses various dermatologic conditions (eg, atopic
dermatitis, psoriasis, systemic lupus erythematosus, and eczema) that
may infect the EAC and cause OE
Necrotizing (malignant) OE
• This is an infection that extends into the deeper tissues adjacent to the
EAC;
• it primarily occurs in adult patients who are immunocompromised (eg,
as a result of diabetes mellitus or AIDS) and is rarely described in
children;
• it may result in cases of cellulitis and osteomyelitis
Otomycosis
• Infection of the ear canal secondary to
fungus species such as Candida or
Aspergillus
Epidemiology
• Although the infection can affect all age groups, OE appears
to be most prevalent in the older pediatric and young adult
population, with a peak incidence in children aged 7-12 years
• 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.
History
Patients with otitis externa (OE) may complain of the following:
• Otalgia, ranging from mild to severe, typically progressing over 1-2
days
• Hearing loss
• Ear fullness or pressure
• Tinnitus
• Fever (occasionally)
• Itching (especially in fungal OE or chronic OE)
• Severe deep pain – If this is experienced by a patient who is
immunocompromised or diabetic, be alerted to the possibility of
necrotizing (malignant) OE
• Discharge – Initially, the discharge may be clear and odorless, but it quickly
becomes purulent and foul-smelling
• Bilateral symptoms (rare)
• Frequently, a history of exposure to or activities in water (e.g, swimming)
• Usually, a history of preceding ear trauma (e.g, forceful ear cleaning, use of
cotton swabs, or water in the ear canal)
Physical Examination
• 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).
• Examination reveals erythema, edema, and narrowing
of the external auditory canal (EAC), and a purulent or
serous discharge may be noted.
• Conductive hearing loss may be evident.
• Cellulitis of the face or neck or lymphadenopathy of the
ipsilateral neck occurs in some patients.
Exostoses
Otomycosis
Herpes Zoster Oticus
(Ramsay Hunt Syndrome)
• Viral infection caused by varicella zoster
• Infection along one or more cranial nerve dermatomes (shingles).
- herpes zoster of the pinna with otalgia.
- facial paralysis
- sensorineural hearing loss
- A vesicular eruption of the concha of the pinna and the EAC.
Symptoms
-Early: burning pain in one ear, headache, malaise and fever
-Late (3 to 7 days): vesicles, facial paralysis
Bullous Myringitis
• Viral infection
• Confined to tympanic membrane
• Primarily involves younger children
• Bullous Myringitis: Symptoms
• Sudden onset of severe pain
• No fever
• No hearing impairment
• Bloody otorrhoea (significant) if rupture
Bullous Myringitis: Signs

• Inflammation limited to TM & nearby canal

• Multiple reddened, inflamed blebs.
• Hemorrhagic vesicles
Otoscopy
• In cases of external ear infection,
otoscopic examination must be
performed in conjunction with
evaluation of related structures
(eg, the external ear and the head
and neck).
• The tympanic membrane may be difficult to visualize and may be mildly
inflamed, but it should be normally mobile on insufflation.
• Eczema of the pinna may be present.
• Fungal OE results in severe itching but typically causes less pain than bacterial
OE does. A thick discharge that may be white or gray is often present.
• pseudomonal infection produces purulent otorrhea that may be green or yellow,
• Aspergillus otomycosis looks like a fine white mat topped by black spheres. Upon
close examination, the discharge may contain visible fungal elements (eg, spores
or hyphae) or have a fuzzy appearance.
Investigations
• The patient’s history and physical examination usually provide
sufficient information to allow the clinician to make the diagnosis of
otitis externa (OE). Most persons with OE are treated empirically.
• Thus, laboratory studies typically are not needed. However, Gram
staining and culture of any discharge from the auditory canal may be
helpful if the patient is immunocompromised, if the usual treatment
measures are ineffective, or if a fungal cause is suspected.
Lab studies
• Gram staining and culture of the canal discharge
• Blood glucose check/urine dipstick test
CT, MRI, Bone Scan, and Gallium Scan
• 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.

• High-resolution computed tomography (CT) is preferred and better

depicts bony erosion.
TREATMENT
Primary treatment of otitis externa (OE) involves:
• management of pain,
• removal of debris from the external auditory canal (EAC),
• administration of topical medications to control edema and infection,
and
• avoidance of contributing factors.
• Treat underlying course if it known.
• Preparations with steroids help to reduce edema and otalgia.
• Systemic antibiotics are indicated for infections that spread beyond the
EAC.
• Fungal infections need antifungal agents such as nystatin or
clotrimazole (topical vs systemic)
• Eczematous reactions of the pinna require application of anti allergic
creams or ointments
• Antivirals( e.g valacyclovir)
Surgical Debridement
• Surgical debridement of the ear canal is usually reserved for
necrotizing OE or for complications of OE (eg, external canal
stenosis).
Complications
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
• Central nervous system (CNS) infection
• Cellulitis or lymphadenitis
Differential diagnosis
• Ear canal trauma
• Otitis media
• Hearing loss
• Intracranial abscess
• Furuncle
• Preauricular cyst and fistula
• Lacerations
• Atopic dermatitis
• Cerumen impaction
• Foreign body
Questions/Comments?