Otitis Med 3, Chloe Saade

Acute otitis externa

Clinical Practice Guideline: Acute Otitis Externa, Otolaryngology– Head and Neck Surgery 2014,
Vol. 150(1S) S1–S24

Acute Otitis Externa: An Update, Am Fam Physician. 2012 Dec 1;86(11):1055-1061

External otitis: Pathogenesis, clinical features, and diagnosis, UpToDate

External otitis: Treatment, UpToDate

Definition
Diffuse inflammation of the external ear canal, which
may also involve the pinna or tympanic membrane.

“ Swimmer’s ear ”

Most frequent in June through August.

Affects all age groups but most visits come from children.
 Predisposing factors
Anatomical Canal Cerumen, Dermatologic Water in ear Miscellaneous
obstruction epithelial canal
integrity

Canal stenosis Cerumen Cerumen Eczema Humidity Purulent

removal otorrhea from
otitis media

Hairy ear canal Foreign body Ear plugs Psoriasis Sweating Soap

Sebaceous cyst Hearing aids Swimming Stress

++++

Instrumentation Prolonged
water exposure
Basically ask about:

previous tympanic membrane perforation,

previous ear surgery,

previous ear infections,

instrumentation,

water exposure
Etiology
Bacteria ++++
The 2 most common:
Pseudomonas aeruginosa ++
Staphylococcus aureus

Others anaerobes, aerobes

Polymicrobial in about 1/3 of cases

Fungal pathogens, primarily those of the Aspergillus and Candida species,

occur more often in tropical or subtropical environments and in patients
previously treated with antibiotics, Candida in those with hearing aids.

Inflammatory skin disorders and allergic reactions may cause

noninfectious otitis externa, which can be chronic.
Symptoms
Ear pain (otalgia)

Pruritus

Discharge (otorrhea)

Fullness

Mild fever may be present, but a temperature >38.3°C suggests extension

beyond the auditory canal

Hearing loss
Clinical examination
A hallmark sign is tenderness of the tragus, pinna, or both that is often intense and
disproportionate to what might be expected based on visual inspection.

Otoscopy

Usually ear canal edematous, erythematous.

Tympanic membrane may be erythematous and partially visible due to canal edema.

Air-fluid level along tympanic membrane: middle ear effusion, underlying otitis media.

Pneumatic otoscopy for insufflation = tympanic membrane mobile

Check for deep tissue infection: malignant otitis externa,

classic finding is granulation tissue at bony cartilaginous junction of ear canal floor.
Cultures (from cotton swab into canal)

More costly than empiric treatment, which is in itself

effective.

Reserved for severe otitis externa, recurrent, chronic,

immunosuppressed patients, infections post-aural
surgery, no response to initial therapy.
Severity
Mild
Minor discomfort and pruritus, minimal edema.

Moderate
Intermediate pain and pruritus, partial occlusion from edema.

Severe
Intense pain, complete occlusion from edema,
periauricular erythema, lymphadenopathy and fever ++
Diagnosis
Differential diagnosis
Complications
Periauricular cellulitis: erythema, edema, warmth of skin around auricle, mild pain
and no systemic symptoms.

Malignant external otitis (necrotizing external otitis),

potentially fatal, infection goes from skin to bone to marrow spaces of skull base,
severe pain and otorrhea out of proportion to examination.

Cranial nerve palsy, poor prognosis

Aided diagnosis with CT or MRI for extent of disease,

refer to ENT !

If have obstruction and aspiration is needed, refer to ENT!

Treatment
Cleaning

Consensus guidelines published by the American Academy of Otolaryngology

recommend that debris be removed to achieve optimal effectiveness of the topical
antibiotics.

However, no randomized controlled trials have examined the effectiveness of aural

toilet, and this is not typically done in most primary care settings.

Gentle lavage suctioning or dry mopping under otoscopic or microscopic

visualization.

Lavage should be used only if the tympanic membrane is known to be intact, and
should not be performed on patients with diabetes because of the potential risk of
causing malignant otitis externa.
Antibiotics

TOPICAL THERAPY: Clinicians should prescribe topical preparations for initial

therapy of diffuse, uncomplicated AOE.

Ophthalmic preparations may be better tolerated than otic preparations, possibly due to differences in pH
between the preparations, and may help facilitate compliance with treatment recommendations.

Commonly studied antimicrobial agents include aminoglycosides, polymyxin B, quinolones, and acetic
acid. No consistent evidence has shown that any one agent or preparation is more effective than another.

Current guidelines recommend factoring in the risk of adverse effects, adherence issues, cost, patient
preference, and physician experience.

The addition of a topical corticosteroid yields more rapid improvement in symptoms such as pain, canal
edema, and erythema.

At least a 7 days course, around 10-14 days.

Improvement in 48-72h after initiation.

NONINTACT TYMPANIC
MEMBRANE: When the patient has
a known or suspected perforation
of the tympanic membrane,
including a tympanostomy tube,
the clinician should prescribe a
non-ototoxic topical preparation.

If non intact TM or its status cannot be determined

visually.

Mild disease, no need for antibiotic.

If intact TM and no hypersensitivity to aminoglycosides,

1st line due to low cost and effectiveness.
Patient education

The patient should lie down with his or her affected side facing upward,
running the preparation along the side of the ear canal until it is full and gently moving
the pinna to relieve air pockets.
The patient should remain in this position for 3-5 minutes, after which the canal should
not be occluded, but rather left open to dry.
It may benefit the patient to have another person administer the ear drops, because only
40% of patients self-medicate appropriately.

Clinicians should advise patients with AOE to resist manipulating the ear to minimize
trauma and should discuss issues pertaining to water restrictions during treatment.
Patients with AOE should preferably abstain from water sports for 7 to 10 days during
treatment.
Inserting earplugs or cotton (with petroleum jelly) prior to showering or swimming can
reduce the introduction of moisture into the ear. The external auditory canal can be dried
after swimming or bathing with a hair dryer on the lowest heat setting.
SYSTEMIC ANTIMICROBIALS: Clinicians should not prescribe
systemic antimicrobials as initial therapy for diffuse,
uncomplicated AOE unless there is extension outside the ear
canal or the presence of specific host factors that would
indicate a need for systemic therapy.

Immunodeficiency

Diabetes

History of radiation to ear

Pain management

PAIN MANAGEMENT: The clinician should assess patients

with AOE for pain and recommend analgesic treatment
based on the severity of pain.

First-line analgesics include NSAIDs and acetaminophen.

When ongoing frequent dosing is required to control pain, medications

should be administered on a scheduled rather than as-needed basis.

Opioid combination pills may be used when symptom severity warrants.

 Acute otitis media
Otitis Media: Diagnosis and Treatment, Am Fam Physician. 2013 Oct 1;88(7):435-440

Acute otitis media in adults (suppurative and serous), UpToDate

Acute otitis media in children: Epidemiology, microbiology, clinical manifestations, and

complications, UpToDate
Definition
Infection of the middle ear.

Approximately 80% of children will have at least one

episode of acute otitis media,
and between 80% and 90% will have at least one
episode of otitis media with effusion before school
age.
Risk factors
Etiology
Usually, AOM is a complication of Eustachian tube dysfunction that occurred
during an acute viral upper respiratory tract infection.

Bacteria can be isolated from middle ear fluid cultures in 50% to 90% of cases of
AOM and OME.

Streptococcus pneumoniae, Haemophilus influenza (nontypable), and Moraxella

catarrhalis are the most common organisms.

H. influenzae has become the most prevalent organism among children with
severe or refractory AOM following the introduction of the pneumococcal
conjugate vaccine.

Others such as group A Streptococcus, Staphylococcus aureus…

Symptoms
Ear pain (otalgia)

Ear rubbing in children

Fever
Unusual to have it >40°C unless bacteremia or other infectious focus

Irritability

Headache

Disturbed sleep, poor feeding, vomiting, diarrhea in children

Eye findings- otitis-conjunctivitis syndrome

Clinical examination
No pain with movement of tragus/pinna

Otoscopy
Bulging of TM

Erythematous TM

Air-fluid level

Opacification of TM

Perforation of TM

Pneumatic otoscope for insufflation = decreased mobility of TM

Tympanometry and acoustic reflectometry are valuable
adjuncts to otoscopy or pneumatic otoscopy.

Tympanocentesis is the preferred method for detecting the

presence of middle ear effusion and documenting bacterial
etiology,
done when patient is toxic, immunosuppressed, no response
to previous treatment.
Diagnosis
• Moderate to severe bulging of TM
or

• New onset of otorrhea not caused by otitis externa

or

• Mild bulging of the TM associated with recent onset of ear pain (<48 hours)
or

• Mild bulging of the TM associated with intense erythema of TM

AOM should not be diagnosed in children who do not have objective evidence
of middle ear effusion.
Adults with new-onset unilateral,

recurrent AOM (>2 episodes per year),

or persistent OME (>6 weeks),

should receive additional evaluation to rule out a serious

underlying condition, such as mechanical obstruction, which
in rare cases is caused by nasopharyngeal carcinoma.

Refer to ENT!
Differential diagnosis
Mainly

Otitis media with effusion:

the presence of fluid in the middle ear without signs
or symptoms of acute ear infection
Figure 2.Comparison of otitis media with
effusion (top) and acute otitis media
(bottom). The left images show the
appearance of the eardrum on otoscopy,
and the right images depict the middle
ear space. For otitis media with effusion,
the middle ear space is filled with mucus
or liquid (top right). For acute otitis media,
the middle ear space is filled with pus,
and the pressure causes the eardrum to
bulge outward (bottom right). With
permission from Rosenfeld 2005.
Retracted, neutral position of TM vs bulging

Bluish TM vs white, pale yellow

Fluid-level, bubbles vs possible visualization of pus

behind TM
OME may occur during an upper respiratory infection,
spontaneously because of poor Eustachian tube function, or
as an inflammatory response following AOM.

Management of OME
In adults, seasonal allergic rhinitis or nasopharyngeal
swelling from URTI can induce Eustachian tube
dysfunction.

Tend to be treated with decongestants,

antihistamines, nasal steroids despite lack of data.
Other differentials …

Ex.
Red TM can be seen with crying, high fever, URTI
Complications
Hearing loss

Balance problems

TM perforation

Chronic suppurative otitis media children ++

Cholesteatoma: abnormal skin growth in the middle ear behind the

eardrum

Tympanosclerosis: asymptomatic whitish plaques

Middle ear atelectasis (due to chronic or recurrent decreased pressure in
middle ear)

Extension to adjacent structures, mastoiditis, petrositis, labyrinthitis, facial

paralysis

Meningitis

Abscesses

Other intracranial complications

Treatment
Pain management

Analgesics are recommended for symptoms of ear pain,

fever, and irritability.

Ibuprofen and acetaminophen have been shown to be

effective.

Topical analgesics, such as benzocaine, can also be

helpful.
Antibiotics

Mild to moderate 5-7 days course

More severe 10 days course

Little evidence regarding optimal duration of therapy in adults.

IM or IV ceftriaxone (Rocephin) should be reserved for
episodes of treatment failure or when a serious comorbid
bacterial infection is suspected.

One dose of ceftriaxone may be used in children who cannot

tolerate oral antibiotics because it has been shown to have
similar effectiveness as high-dose amoxicillin.
Tympanostomy tubes

Tympanostomy tubes are appropriate for children six months to 12 years

of age who have had bilateral OME for three months or longer with
documented hearing difficulties,

or for children with recurrent AOM who have evidence of middle ear
effusion at the time of assessment for tube candidacy.

Otherwise tubes are not indicated in children.

Recurrent AOM:

AOM >14 days after finishing successful antibiotic

treatment,
in this case assume that new AOM is unrelated to
previous AOM.