Download - Infections of the External Ear
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Infections of the External Ear
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Anatomy and Physiology
• Consists of the auricle and EAM
• Skin-lined apparatus
• Approximately 2.5 cm in length
• Ends at tympanic membrane
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Anatomy and Physiology
• Auricle is mostly skin-lined cartilage
• External auditory meatus– Cartilage: ~40%
– Bony: ~60%
– S-shaped
– Narrowest portion at bony-cartilage junction
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Anatomy and Physiology
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Anatomy and Physiology
• EAC is related to various contiguous structures– Tympanic membrane
– Mastoid
– Glenoid fossa
– Cranial fossa
– Infratemporal fossa
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Anatomy and Physiology
• Innervation: cranial nerves V, VII, IX, X, and greater auricular nerve
• Arterial supply: superficial temporal, posterior and deep auricular branches
• Venous drainage: superficial temporal and posterior auricular veins
• Lymphatics
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Anatomy and Physiology
• Squamous epithelium• Bony skin – 0.2mm• Cartilage skin
– 0.5 to 1.0 mm
– Apopilosebaceous unit
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Otitis Externa
• Bacterial infection of external auditory canal
• Categorized by time course– Acute– Subacute– Chronic
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Acute Otitis Externa (AOE)
• “swimmer’s ear”
• Preinflammatory stage
• Acute inflammatory stage– Mild– Moderate– Severe
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AOE: Preinflammatory Stage
• Edema of stratum corneum and plugging of apopilosebaceous unit
• Symptoms: pruritus and sense of fullness
• Signs: mild edema
• Starts the itch/scratch cycle
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AOE: Mild to Moderate Stage
• Progressive infection• Symptoms
– Pain
– Increased pruritus
• Signs– Erythema
– Increasing edema
– Canal debris, discharge
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AOE: Severe Stage
• Severe pain, worse with ear movement
• Signs– Lumen obliteration
– Purulent otorrhea
– Involvement of periauricular soft tissue
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AOE: Treatment
• Most common pathogens: P. aeruginosa and S. aureus
• Four principles– Frequent canal cleaning– Topical antibiotics– Pain control– Instructions for prevention
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Chronic Otitis Externa (COE)
• Chronic inflammatory process
• Persistent symptoms (> 2 months)
• Bacterial, fungal, dermatological etiologies
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COE: Symptoms
• Unrelenting pruritus
• Mild discomfort
• Dryness of canal skin
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COE: Signs
• Asteatosis• Dry, flaky skin• Hypertrophied skin• Mucopurulent
otorrhea (occasional)
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COE: Treatment
• Similar to that of AOE
• Topical antibiotics, frequent cleanings
• Topical Steroids
• Surgical intervention– Failure of medical treatment– Goal is to enlarge and resurface the EAC
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Furunculosis
• Acute localized infection
• Lateral 1/3 of posterosuperior canal
• Obstructed apopilosebaceous unit
• Pathogen: S. aureus
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Furunculosis: Symptoms
• Localized pain
• Pruritus
• Hearing loss (if lesion occludes canal)
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Furunculosis: Signs
• Edema• Erythema• Tenderness• Occasional fluctuance
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Furunculosis: Treatment
• Local heat
• Analgesics
• Oral anti-staphylococcal antibiotics
• Incision and drainage reserved for localized abscess
• IV antibiotics for soft tissue extension
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Otomycosis
• Fungal infection of EAC skin
• Primary or secondary
• Most common organisms: Aspergillus and Candida
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Otomycosis: Symptoms
• Often indistinguishable from bacterial OE
• Pruritus deep within the ear
• Dull pain
• Hearing loss (obstructive)
• Tinnitus
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Otomycosis: Signs
• Canal erythema• Mild edema• White, gray or black
fungal debris
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Otomycosis
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Otomycosis: Treatment
• Thorough cleaning and drying of canal
• Topical antifungals
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Granular Myringitis (GM)
• Localized chronic inflammation of pars tensa with granulation tissue
• Toynbee described in 1860
• Sequela of primary acute myringitis, previous OE, perforation of TM
• Common organisms: Pseudomonas, Proteus
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GM: Symptoms
• Foul smelling discharge from one ear
• Often asymptomatic
• Slight irritation or fullness
• No hearing loss or significant pain
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GM: Signs
• TM obscured by pus • “peeping”
granulations• No TM perforations
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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
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Bullous Myringitis
• Viral infection
• Confined to tympanic membrane
• Primarily involves younger children
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Bullous Myringitis: Symptoms
• Sudden onset of severe pain
• No fever
• No hearing impairment
• Bloody otorrhea (significant) if rupture
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Bullous Myringitis: Signs
• Inflammation limited to TM & nearby canal
• Multiple reddened, inflamed blebs
• Hemorrhagic vesicles
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Bullous Myringitis: Treatment
• Self-limiting
• Analgesics
• Topical antibiotics to prevent secondary infection
• Incision of blebs is unnecessary
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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
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NEO: History
• Meltzer and Kelemen, 1959
• Chandler, 1968 – credited with naming
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NEO: Symptoms
• Poorly controlled diabetic with h/o OE
• Deep-seated aural pain
• Chronic otorrhea
• Aural fullness
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NEO: Signs
• Inflammation and granulation
• Purulent secretions• Occluded canal and
obscured TM• Cranial nerve
involvement
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NEO: Imaging
• Plain films
• Computerized tomography – most used
• Technetium-99 – reveals osteomyelitis
• Gallium scan – useful for evaluating Rx
• Magnetic Resonance Imaging
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NEO: Diagnosis
• Clinical findings
• Laboratory evidence
• Imaging
• Physician’s suspicion
• Cohen and Friedman – criteria from review
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NEO: Treatment
• Intravenous antibiotics for at least 4 weeks – with serial gallium scans monthly
• Local canal debridement until healed
• Pain control
• Use of topical agents controversial
• Hyperbaric oxygen experimental
• Surgical debridement for refractory cases
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NEO: Mortality
• Death rate essentially unchanged despite newer antibiotics (37% to 23%)
• Higher with multiple cranial neuropathies (60%)
• Recurrence not uncommon (9% to 27%)
• May recur up to 12 months after treatment
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Perichondritis/Chondritis
• Infection of perichondrium/cartilage
• Result of trauma to auricle
• May be spontaneous (overt diabetes)
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Perichondritis: Symptoms
• Pain over auricle and deep in canal
• Pruritus
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Perichondritis: Signs
• Tender auricle• Induration• Edema• Advanced cases
– Crusting & weeping
– Involvement of soft tissues
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Relapsing Polychondritis
• Episodic and progressive inflammation of cartilages
• Autoimmune etiology?
• External ear, larynx, trachea, bronchi, and nose may be involved
• Involvement of larynx and trachea causes increasing respiratory obstruction
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Relapsing Polychondritis
• Fever, pain• Swelling, erythema• Anemia, elevated ESR• Treat with oral
corticosteroids
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Herpes Zoster Oticus
• J. Ramsay Hunt described in 1907
• 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
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Herpes Zoster Oticus: Symptoms
• Early: burning pain in one ear, headache, malaise and fever
• Late (3 to 7 days): vesicles, facial paralysis
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Herpes Zoster Oticus: Treatment
• Corneal protection
• Oral steroid taper (10 to 14 days)
• Antivirals
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Erysipelas
• Acute superficial cellulitis
• Group A, beta hemolytic streptococci
• Skin: bright red; well-demarcated, advancing margin
• Rapid treatment with oral or IV antibiotics if insufficient response
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Perichondritis: Treatment
• Mild: debridement, topical & oral antibiotic
• Advanced: hospitalization, IV antibiotics
• Chronic: surgical intervention with excision of necrotic tissue and skin coverage
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Radiation-Induced Otitis Externa
• OE occurring after radiotherapy
• Often difficult to treat• Limited infection
treated like COE• Involvement of bone
requires surgical debridement and skin coverage
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Conclusions
• Careful History
• Thorough physical exam
• Understanding of various disease processes common to this area
• Vigilant treatment and patience