Otitis Externa

ETIOLOGY
• Otitis externa, also known as swimmer's ear, is
defined by inflammation and exudation in the
external auditory canal in the absence of other
disorders, such as otitis media or mastoiditis.
• It results from the interaction of host,
environmental, and microbial factors.
• The most common bacterial pathogen is P.
aeruginosa, especially in association with
swimming in pools or lakes.
• Other common pathogens may be associated with
tympanostomy tubes. Otitis externa develops in
approximately 20% of children with tympanostomy tubes,
associated with S. aureus, S. pneumoniae, M. catarrhalis,
Proteus, Klebsiella, and occasionally anaerobes.
• Coagulase-negative staphylococci and Corynebacterium
are isolated frequently from cultures of the external canal
but represent normal flora.
• Malignant otitis externa is caused by P. aeruginosa in
immuno-compromised persons and adults with diabetes.
EPIDEMIOLOGY
• Otitis externa is a frequent complaint in summer,
in contrast to otitis media, which occurs primarily
in colder seasons in association with viral upper
respiratory tract infections.
• Disruption of the integrity of the cutaneous lining
of the ear canal and local defenses, as occurs with
cleaning of the auditory canal, swimming, and, in
particular, diving, predisposes to otitis externa.
CLINICAL MANIFESTATIONS
• Pain, tenderness, and aural discharge are the characteristic
clinical findings of otitis externa.
• Fever is notably absent, and hearing is unaffected.
• Tenderness with movement of the pinnae, especially the
tragus, and with chewing is particularly typical. This is not
present in otitis media, and is a valuable diagnostic criterion.
• The most common symptoms of malignant otitis externa are
o severe ear pain,
o tenderness on movement of the pinna,
o drainage from the canal,
o and occasionally facial nerve palsy.
• Inspection usually reveals that the lining of the
auditory canal is inflamed with mild to severe
erythema and edema.
• There may be a scant to copious discharge from the
auditory canal, often obscuring the tympanic
membrane.
• In malignant otitis externa, the most common
physical findings are swelling and granulation tissue
in the canal, usually with a discharge from the
external auditory canal.
LABORATORY AND IMAGING STUDIES
• The diagnosis of uncomplicated otitis externa usually is
established solely on the basis of the clinical symptoms and
physical examination findings without the need for additional
laboratory or microbiologic evaluation.
• In malignant otitis externa, an elevated ESR is a constant
finding.
• The diagnosis requires documentation of the extent of
involvement with diagnostic imaging studies, such as CT or MRI.
• Cultures are required to identify the etiologic agent, which is
usually P. aeruginosa, and the antimicrobial susceptibility.
DIFFERENTIAL DIAGNOSIS
• Otitis media with tympanic perforation and discharge into the
auditory canal may be confused with otitis externa, particularly in
infants in whom it may be difficult to clear the discharge.
• Pain on movement of the pinnae or the tragus, which is typical of
otitis externa, is not present.
• Local and systemic signs of mastoiditis, of swelling and tenderness
over the mastoid, indicate a process more extensive than otitis
externa.
• Tuberculous otitis media is marked by a chronic, painless aural
discharge, further suggested by skin testing and chest x-ray.
• Malignancies presenting in the auditory canal are rare in children,
but may occur with discharge, unusual pain, or hearing loss.
TREATMENT
• The most widely used topical otic preparations contain
a combination of an aminoglycoside, such as neomycin
and polymyxin B, with a topical corticosteroid.
• Topical quinolone antibiotic drops (ciprofloxacin,
ofloxacin) are more popular despite the cost.
• They are active against S. aureus and most gram-
negative bacteria, including P. aeruginosa.
• None of these antibiotics has any antifungal activity.
• Local therapy with acetic acid preparations (2%)
designed to restore the acid pH of the auditory canal is
usually effective.
• It may be necessary to remove the aural exudate
with a swab or with suction to permit instillation
of the solution.
• The predisposing activity, such as swimming or
diving, that produced the condition should be
avoided until the inflammation has resolved.
• Topical acetic acid preparations have indirect
antibacterial and antifungal effects by
acidification.
• Otic solutions containing corticosteroids are
used frequently and reduce local inflammation
when there is no infection.
• Solutions that combine antibiotics and
corticosteroids are a reasonable choice in
severe cases and when therapy with acetic
acid preparations has not been effective.
• Treatment with topical otic analgesics and
ceruminolytics is usually unnecessary.
• Fungi such as Aspergillus, Candida, and
dermatophytes occasionally are isolated from
the external ear.
• It may be difficult to determine whether they
represent normal flora or are the cause of
inflammation.
• In most cases, local therapy and restoration of
normal pH as recommended for bacterial otitis
externa are sufficient.
• Tympanostomy tube otorrhea is best treated with
quinolone otic drugs because they are considered less
likely to be ototoxic.
• There are theoretical risks of ototoxicity with neomycin and
polymyxin B, which should be avoided in the presence of
tympanic perforation.
• Malignant otitis externa is treated by parenteral
antimicrobials with activity against P. aeruginosa, such as
an expanded-spectrum penicillin (mezlocillin, piperacillin-
tazobactam) or a cephalosporin with activity against P.
aeruginosa (ceftazidime, cefepime) plus an aminoglycoside.
COMPLICATIONS AND PROGNOSIS
• Acute otitis externa usually resolves promptly without
complications within 1 to 2 days of initiating treatment.
• Persistent pain, especially if severe or if accompanied by other
symptoms, such as fever, should prompt re-evaluation for other
conditions.
• Malignant otitis externa frequently is accompanied by
complications.
• Invasion of the bones of the base of the skull may cause cranial
nerve palsies, such as facial nerve palsy.
• A mortality of 15% to 20% occurs in adults with malignant otitis
media.
• Relapses within the first year after treatment are common.
PREVENTION
• Overly vigorous cleaning of an asymptomatic auditory
canal should be avoided. Drying the auditory canals with
acetic acid (2%), Burow solution, or diluted isopropyl
alcohol (rubbing alcohol) after swimming may be used
prophylactically to help prevent the maceration that
may facilitate bacterial invasion. Often underwater gear,
such as earplugs or diving equipment, must be avoided
to prevent recurrent disease. There is no role for
prophylactic otic antibiotics.