This issue of Primary Care: Clinics in Office Practice, edited by Gretchen Dickson, MD and Rick Kellerman, MD, is devoted to Primary Care ENT. Articles in this issue include Otitis Externa; Disease of the Internal Ear; Hearing Loss; Dizziness and Vertigo; Rhinitis; Sinusitis; Epistaxis; Laryngitis; Pharyngitis; Mouth Disease; and Neurological Syndromes pertaining to the Head and Neck.
Otitis Externa
Jennifer Wipperman, MD, MPHjennifer.wipperman@viachristi.org, Depertment of Family and Community Medicine, University of Kansas School of Medicine – Wichita, 1010 North Kansas, Wichita, KS 67214, USA
Acute otitis externa (AOE) is most often infectious in origin, and can be easily treated with a combination of topical antibiotic and steroid preparations. Systemic antibiotics are rarely needed for AOE. Chronic otitis externa (COE) can be more difficult to treat, but if an underlying cause can be identified this condition can often be successfully managed. In both AOE and COE, prevention is fundamental. If patients are able to avoid precipitating factors, future episodes can often be averted.
Keywords
Acute otitis externa
Chronic otitis externa
Antibiotics
Topical steroids
Key points
• Acute otitis externa most often is infectious in origin, and can be easily treated with a combination of topical antibiotic and steroid preparations.
• Systemic antibiotics are rarely needed for acute otitis externa.
• Chronic otitis externa can be more difficult to treat, but if an underlying cause can be identified this condition can often be successfully managed.
• In both acute and chronic otitis externa, prevention is fundamental. If patients are able to avoid precipitating factors, future episodes can often be averted.
Otitis externa is a common problem seen in the primary care office, and most cases are managed by primary care providers.1 Otitis externa is an inflammatory condition of the external ear canal, with or without infection. Inflammation may be localized to the ear canal, or include portions of the outer ear, such as the pinna or tragus. Acute otitis externa (AOE) is defined as lasting less than 6 weeks, and chronic otitis externa (COE) as lasting 3 months or longer. AOE, also known as swimmer's ear, is usually an infectious condition, whereas COE more often has a noninfectious, allergic cause.
Acute otitis externa
Epidemiology
The overwhelming majority (>95%) of otitis externa cases are acute.2 AOE occurs most often in the summer and in warmer, humid climates. Each year, 1 to 2.5 in 100 people are affected.1,2 Peak incidence arises among children of age 7 to 12 years, and is 5 times more common in regular swimmers.3
Risk Factors
In addition to living in warmer, humid climates and swimming, other risk factors relate to increased moisture in the ear canal, loss of protective cerumen, and trauma to the ear canal.4 Cerumen impaction can cause water retention in the ear canal and may predispose to AOE. On the other hand, removal of cerumen by excessive cleaning leads to a loss of protective waxy barrier and breakdown of the epithelial lining. Trauma to the ear canal may also occur from use of a hearing aid or ear plug. AOE is more common among those with chronic dermatologic conditions, such as psoriasis or atopic dermatitis, which causes debris and skin breakdown in the ear canal.5 Finally, those who are immunocompromised, including patients with diabetes mellitus, may have more severe and resistant cases of AOE.2
Pathophysiology
The external auditory canal is about 25 mm long and curves in an S-shape toward the tympanic membrane.4 The outer one-third of the canal base is cartilaginous whereas the inner two-thirds is bony. Hair follicles and cerumen-producing glands cover the outer one-third of the canal. Cerumen has several protective functions in the ear canal. First, it provides a waxy barrier that protects the epithelium from breakdown caused by excessive moisture exposure. Second, cerumen has a slightly acidic pH and lysozymal activity that inhibits bacterial and fungal growth.6 Disturbance in the normal acidic environment, lack of cerumen, and trauma to the epithelial lining can lead to bacterial or fungal infection of the ear canal, causing an inflammatory response. More than 98% of infectious AOE is bacterial.3 The most likely pathogens include Pseudomonas aeruginosa and Staphylococcus spp, and AOE is often a polymicrobial infection. Less often, gram-negative bacteria may be involved. Rarely, AOE may result from a fungal (Candida or Aspergillus) infection.7
Clinical Presentation
Patients with AOE present with the rapid onset of ear pain, fullness, and otorrhea. Pain that is worse with traction on the pinna or palpation of the tragus is the hallmark of AOE. In the initial stages, patients may experience mild discomfort and ear pruritus. On examination, the ear canal may be erythematous and slightly edematous, with minimal discharge. Often the severity of pain experienced by the patient is disproportionate to physical examination findings. As the condition progresses, the canal may become extremely edematous and nearly obstructed from additional otorrhea and debris. Inflammation may spread to the tympanic membrane, causing myringitis. A sensation of ear fullness may occur, as well as hearing loss if obstruction is severe. Regional lymphadenitis and surrounding cellulitis of the pinna may be present. Of importance, systemic symptoms such as fever and malaise suggest extension beyond the ear canal.
Diagnosis
AOE is a clinical diagnosis, the criteria of which are listed in Box 1. Diagnosis requires a history of rapid onset (within the last 48 hours) occurring in the last 3 weeks with signs and symptoms of ear canal inflammation.2 Symptoms include otalgia, itching, or fullness, with or without hearing loss. Signs include tenderness of the outer ear or diffuse ear-canal edema or erythema with or without otorrhea, regional lymphadenopathy, tympanic membrane erythema, or surrounding cellulitis. Several other conditions can mimic AOE, and should be differentiated (Table 1).
Box 1 Diagnostic criteria for acute otitis externa
1. Rapid onset (generally within 48 hours) in the past 3 weeks, AND
2. Symptoms of ear canal inflammation that include:
• Otalgia (often severe), itching, or fullness
• WITH OR WITHOUT hearing loss or jaw pain, AND
3. Signs of ear canal inflammation that include:
• Tenderness of the tragus, pinna, or both
• OR diffuse ear canal edema, erythema, or both
• WITH OR WITHOUT otorrhea, regional lymphadenitis, tympanic membrane erythema, or cellulitis of the pinna and adjacent skin
Data from Rosenfeld RM, Brown L, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg 2006;134(Suppl 4):S4–23.
Table 1
Differential diagnosis of acute otitis externa
| Condition | Clinical Characteristics |
| Carcinoma of the ear canal | May be indistinguishable from otitis externa. Consider if abnormal tissue growth in ear canal, or patients with mild pain, bloody otorrhea, and lack of response to treatment of otitis externa |
| Chronic suppurative otitis media | Develops after tympanic membrane rupture in acute otitis media. Chronic drainage leads to otalgia, otorrhea, and, possibly, eczematous changes |
| Contact dermatitis | Often develops after exposure to topical agents such as neomycin, anesthetics, or commercial products. Itching usually present. May see maculopapular rash on conchal bowel and edematous ear canal |
| Eczema or psoriasis | Patients with history of disorder and/or typical rash present elsewhere on the body. May have ear canal pruritus, hyperkeratosis, and lichenification |
| Furunculosis | Infection of hair follicle in ear canal manifested by a tender, erythematous papule or pustule |
| Herpes zoster oticus | Causes vesicles on external ear canal, posterior auricle, and, possibly, tympanic membrane. Patients often have severe otalgia and facial nerve palsy |
| Malignant otitis externa | Consider in patients with findings of severe otitis externa unresponsive to treatment, granulation tissue in ear canal, and systemic signs such as temperature >38°C |
| Otomycosis | Patients often experience itching more than otalgia. Fluffy, cotton-like debris may be noted in the ear canal, possibly with hyphae and otorrhea |
| Seborrheic dermatitis | May see typical seborrhea on face, hairline, and scalp. Ear canal often with minimal cerumen and is flaky,... |
| Erscheint lt. Verlag | 28.3.2014 |
|---|---|
| Sprache | englisch |
| Themenwelt | Medizin / Pharmazie ► Gesundheitswesen |
| Medizin / Pharmazie ► Medizinische Fachgebiete ► Allgemeinmedizin | |
| Medizin / Pharmazie ► Medizinische Fachgebiete ► HNO-Heilkunde | |
| ISBN-10 | 0-323-28717-4 / 0323287174 |
| ISBN-13 | 978-0-323-28717-3 / 9780323287173 |
| Haben Sie eine Frage zum Produkt? |
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