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THE EAR

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INFECTIONS OF THE EAR

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1. Otitis Externa
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ESSENTIALS OF DIAGNOSIS

  • Rapid onset of symptoms in the past three weeks AND

  • Symptoms of ear canal inflammation, including otalgia, itching, or fullness, with or without hearing loss or jaw pain AND

  • Signs of ear canal inflammation, including tenderness of the tragus and/or pinna, ear canal edema and/or erythema, otorrhea, regional lymphadenitis, tympanic membrane (TM) erythema, or cellulitis of the pinna and adjacent skin.

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Differential Diagnosis
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Acute otitis media with TM rupture, furunculosis of the ear canal, herpes zoster oticus, mastoiditis.

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Pathogenesis
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Otitis externa (OE) is a cellulitis of the soft tissues of the EAC, which can extend to surrounding structures such as the pinna, tragus, and lymph nodes., Humidity, heat, and moisture in the ear are known to contribute to the development of OE, along with localized trauma to the ear canal skin. Sources of trauma may include digital trauma, earplugs, ear irrigations, and the use of cotton-tipped swabs to clean or scratch the ear canal. Cerumen actually serves as a protective barrier to the underlying skin and its acidic pH inhibits bacterial and fungal growth. The most common organisms in OE are Staphylococcus aureus and Pseudomonas aeruginosa.

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Clinical Findings
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Symptoms include acute onset of pain, aural fullness, decreased hearing, and sometimes itching in the ear. Symptoms tend to peak within three days. Manipulation of the pinna or tragus causes considerable pain. Discharge may start out as clear then become purulent and may also cause secondary eczema of the auricle. The ear canal is typically swollen and narrowed, and the patient may resist any attempt to insert an otoscope. Debris is present in the canal, and it is usually very difficult to visualize the tympanic membrane (TM) due to canal edema.

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Complications
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If untreated, facial cellulitis may result. Immunocompromised individuals can develop malignant OE, which is a spread of the infection to the skull base with resultant osteomyelitis. This is a life-threatening condition and should be evaluated with a fine-cut temporal bone CT scan.

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Treatment
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Management of OE includes pain control, removal of debris from the canal, topical antimicrobial therapy, and avoidance of causative factors. Fluoroquinolone eardrops are first-line therapy for OE. In the absence of systemic symptoms, children with OE should be treated with antibiotic eardrops only. The topical therapy chosen must be nonototoxic because a perforation or patent tube may be present; if the TM cannot be visualized, then a perforation should be presumed to exist. If the ear canal is too edematous to allow entry of the eardrops, a Pope ear wick (expandable sponge) should be placed to ensure antibiotic delivery. Oral antibiotics are indicated for any signs of invasive infection, such as fever, cellulitis of ...

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