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Infections of the External Ear

Infections of the External Ear. Prof. Cummings. Bastaninejad Shahin, MD, Otolaryngologist. Otitis Externa. Bacterial infection of external auditory canal Categorized by time course Acute Chronic. Acute Otitis Externa (AOE). Swimmer’s ear Preinflammatory stage: first stage starts with:

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Infections of the External Ear

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  1. Infections of the External Ear Prof. Cummings Bastaninejad Shahin, MD, Otolaryngologist

  2. Otitis Externa • Bacterial infection of external auditory canal • Categorized by time course • Acute • Chronic

  3. Acute Otitis Externa (AOE) • Swimmer’s ear • Preinflammatory stage: first stage starts with: • Symptoms: pruritus and sense of fullness • Signs: mild edema

  4. AOE: Mild to Moderate Stage • Progressive infection • Symptoms • Pain • Increased pruritus • Signs • Erythema • Increasing edema • Canal debris, discharge

  5. AOE: Severe Stage • Severe pain, worse with ear movement • Signs • Lumen obliteration • Purulent otorrhea • Involvement of periauricular soft tissue

  6. AOE: Treatment • Most common pathogens: P. aeruginosa and S. aureus • Four principles • Frequent canal cleaning • Topical antibiotics • Pain control • Instructions for prevention

  7. Chronic Otitis Externa (COE) • It’s a chronic inflammatory process • Persistent symptoms (> 2 months) • Bacterial, fungal, dermatological etiologies

  8. COE: Symptoms • Unrelenting pruritus • Mild discomfort • Dryness of canal skin

  9. COE: Signs • Dry, flaky skin

  10. COE: Treatment • Similar to that of AOE • Topical antibiotics, frequent cleanings • Topical Steroids • Surgical intervention

  11. Furunculosis • Acute localized infection • Lateral 1/3 canal • Obstructed apopilosebaceous unit • Pathogen: S. aureus

  12. Furunculosis • Symptoms: pain and diminished hearing level • Signs: • Edema • Erythema • Tenderness • Occasional fluctuance

  13. Furunculosis: Treatment • Local heat • Analgesics • Oral anti-staphylococcal antibiotics • Incision and drainage reserved for localized abscess • IV antibiotics for soft tissue extension

  14. Otomycosis • Fungal infection of EAC skin • Primary or secondary • Most common organisms: Aspergillus and Candida

  15. Otomycosis: Symptoms • Often indistinguishable from bacterial OE • Pruritus deep within the ear • Dull pain • Hearing loss (obstructive)

  16. Otomycosis: Signs • Canal erythema • Mild edema • White, gray or black fungal debris (wet newspaper)

  17. Otomycosis

  18. Otomycosis: Treatment • Thorough cleaning and drying of canal • Topical antifungals • Canal Acidification • Treat coexisted bacterial superinfection

  19. Granular Myringitis (GM) • Localized chronic inflammation of pars tensa with granulation tissue • Sequela of primary acute myringitis, previous OE, perforation of TM • Common organisms: Pseudomonas, Proteus

  20. GM: Symptoms • Foul smelling discharge from one ear • Often asymptomatic • Slight irritation or fullness • No hearing loss or significant pain

  21. GM: Signs • TM obscured by pus • Granulations • No TM perforations

  22. GM: Treatment • Careful and frequent debridement • Topical anti-pseudomonal antibiotics • Occasionally combined with steroids • At least 2 weeks of therapy • May warrant careful destruction of granulation tissue if no response

  23. Bullous Myringitis • Due to the Virus or Mycoplasma • Confined to tympanic membrane • Primarily involves younger children

  24. Bullous Myringitis: Symptoms • Sudden onset of severe pain • No fever • No hearing impairment • Bloody otorrhea (significant) if rupture

  25. Bullous Myringitis: Signs • Inflammation limited to TM & nearby canal • Multiple reddened, inflamed blebs • Hemorrhagic vesicles

  26. Bullous Myringitis: Treatment • Self-limiting • Analgesics • Topical antibiotics to prevent secondary infection • Incision of blebs is unnecessary • Azithromycin or AOM antimicrobial therapy

  27. Necrotizing External Otitis(NEO) • Potentially lethal infection of EAC and surrounding structures • Typically seen in diabetics and immunocompromised patients • Pseudomonas aeruginosa is the usual culprit

  28. NEO: Symptoms • Poorly controlled diabetic with OE • Deep-seated aural pain • Chronic otorrhea • Aural fullness

  29. NEO: Signs • Inflammation and granulation • Purulent secretions • Occluded canal and obscured TM • Cranial nerve involvement

  30. NEO: Imaging • Plain films • Computerized tomography – most used • Technetium-99 – reveals osteomyelitis • Gallium scan – useful for evaluating Rx • Magnetic Resonance Imaging

  31. NEO: Diagnosis • Clinical findings • Laboratory evidence • Imaging • Physician’s suspicion

  32. NEO: Treatment • Intravenous antibiotics for at least 4 weeks (Ceftazidim) – with serial gallium scans monthly • Local canal debridement until healed • Pain control • Use of topical agents • Surgical debridement for refractory cases

  33. NEO: Mortality • Death rate essentially unchanged despite newer antibiotics (37% to 23%) • Higher with multiple cranial neuropathies (60%)

  34. Herpes Zoster Oticus • Viral infection caused by varicella zoster • Infection along one or more cranial nerve dermatomes (shingles) • Ramsey Hunt syndrome: herpes zoster of the pinna with otalgia and facial paralysis

  35. Herpes Zoster Oticus: Symptoms • Early: burning pain in one ear, headache, malaise and fever • Late (3 to 7 days): vesicles, facial paralysis

  36. Herpes Zoster Oticus: Treatment • Oral steroid taper (10 to 14 days) • Antivirals

  37. Thank You!

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