COMMON EAR INFECTIONS

DR ABRAHAM N. GYUSE , MBBCh, FMCGP

Associate Professor of Family Medicine,DEPARTMENT OF FAMILY MEDICINE, Faculty of Medicine &

Dentistry, College of Medical Sciences, University of Calabar&

UNIVERSITYOF CALABAR TEACHING HOSPITAL

OUTLINE

INTRODUCTION EPIDEMOLOGY CAUSES TYPES OF EAR INFECTIONS CLINICAL PRESENTATION OF EAR

INFECTIONS COMPLICATIONS PREVENTION CONCLUSION

INTRODUCTION

THE HUMAN EAR IS A SENSORY ORGAN WITH TWO MAIN FUNCTIONS; HEARING AND BALANCE.

THE SENSE OF HEARING IS ESSENTIAL FOR NORMAL DEVELOPMENT AND MAINTAINANCE OF SPEECH AS WELL AS THE ABILITY TO COMMUNICATE WITH OTHERS.

BALANCE ON THE OTHER HAND IS ESSENTIAL FOR MAINTAINING BODY MOVEMENT, POSITION AND CORDINATION.

LIKE WITH ORTHER ORGANS OF THE BODY THE EAR CAN BECOME INFECTED AND IF NOT DIAGNOSED AND TREATED PROMPTLY COULD LEAD TO A LOSS OF HEARING AND BALANCE.

THIS IN TURN COULD LEAD TO ADVERSE EFFECTS ON THE PATIENT, THE FAMILY AND THE COMMUNITY.

IT IS THEREFORE IMPORTANT FOR PRIMARY CARE PHYSICIANS TO KNOW HOW TO IDENTIFY AND MANAGE COMMON INFECTIONS OF THIS DELICATE ORGAN AND STRUCTURE.

THE EARS ARE LOCATED ON EITHER SIDE OF THE CRANIUM AT APPROXIMATELY THE EYE LEVEL

THE EAR HAS THREE MAIN PARTS;

-THE EXTERNAL EAR

-THE MIDDLE EAR

-THE INNER EAR

EXTERNAL EAR IT INCLUDES THE AURICLE AND

EXTERNAL AUDITORY CANAL MIDDLE EAR

AN AIR-FILLED CAVITY, INCLUDES THE TYMPANIC MEMBRANE, OTIC CAPSULE WITH A MIDDLE EAR CLEFT BETWEEN THE TWO. THE EUSTACHIAN TUBE CONNECTS THE MIDDLE EAR TO THE NASOPHARYNX.

INNER EAR THE INNER EAR IS HOUSED DEEP

WITHIN THE TEMPORAL BONE. IT CONTAINS THE ORGANS FOR

HEARING(COCHLEA) AND FOR BALANCE SEMICIRCULAR CANALS. THESE ARE HOUSED IN THE BONY LABYRINTH

OTHER CONTENTS INCLUDE FACIAL AND VESTIBULOCOCHLEAR NERVE

INFECTION CAN OCCUR IN ANY PART OF THE EAR

EPIDEMOLOGY

GLOBALLY EAR INFECTIONS AFFECT OVER 400 MILLION INDIVIDUALS. CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM) AFFECTS ABOUT 65-330 MILLION PEOPLE WITH ABOUT 60% SUFFERING FROM SIGNIFICANT HEARING IMPAIRMENT. CSOM ALSO ACCOUNTS FOR ABOUT 28,000 DEATHS ANUALLY

OTITIS MEDIA (OM) IS COMMONER AMONGST CHILDREN AND IT IS THE MAIN PREVENTABLE CAUSE OF HEARING LOSS AND ACCOUNTS FOR 90% OF HEARING LOSS IN CHILDREN.

ABOUT 2-4% OF THE NIGERIAN POPULACE SUFFER FROM OTITIS MEDIA.

THERE ARE 2.163 MILLION DISABILITY-ADJUSTED LIFE YEARS (DALY) LOST TO OM.

94% OF THESE CASES ARE FROM SUB-SAHARAN AFRICA

IT HAS ALSO BEEN SHOWN THAT EAR INFECTIONS ACCOUNT FOR ABOUT 25% OF OUT PATIENT CONSULTATIONS IN WEST AFRICA.

MOST OF THESE PATIENTS ARE SEEN BY PRIMARY CARE PHYSICIANS AND GENERAL PRACTITIONERS.

CAUSES EAR INFECTIONS ARE CAUSED BY VARYING

MECHANISMS, WHICH INCLUDE BACTERIAL INFECTION MOST COMMON- STREP PNEUMONIAE, H

INFLUENZAE (ONLY 10% DUE TO TYPE B AND PREVENTABLE BY HIB VACCINE), MORAXELLA CATARRHALIS

SINUS INFECTIONS VIRAL INFECTION- MOST COMMON- RESPIRATORY SYNCYTIAL

VIRUS AND RHINOVIRUS, HIV, HERPES ZOSTER

FUNGAL CANDIDA ALBICANS, ASPERGILLUS

(responsible for 75% of cases), PHYCOMYCETES, ACTINOMYCES, RHIZOPUS

INFECTED or SWOLLEN ADENOIDS RISK FACTORS UPPER RESPIRATORY TRACT INFECTIONS CLEFT PALATE SWIMMING IN POLLUTED WATERS OVERZEALOUS CLEANING OF THE EARS

- FAILING TO DRY THE OUTER EAR PROPERLY AFTER SWIMMING OR BATHING

- SUDDEN CHANGES IN AIR PRESSURE, DURING AIR TRAVEL (ALTITUDE CHANGE)

- YOUNG AGE (BABY AND CHILDREN MORE PRONE TO EAR INFECTIONS) - Pacifier use, Bottle fed infants

- ALLERGIES- SMOKING (Active/Passive)- SENSITIVE EARS (EXCESSIVE ITCHING)- Ear Wax – especially causing obstruction

TYPES OF EAR INFECTIONSTHESE INCLUDE; OTITIS EXTERNA OTITIS MEDIA INFECTIOUS MYRINGITIS ACUTE MASTOIDITIS VESTIBULAR NEURONITIS HERPES ZOSTER OF THE EAR OTOMYCOSIS

CLINICAL MANIFESTATIONS OF EAR INFECTIONS MOST PATIENTS PRESENT WITH

SYMPTOMS DEPENDING ON THE PART OF THE EAR AFFECTED.

o PAIN/EARACHEo FEELING OF PRESSUREo FEVERo EAR DISCHARGEo HEADACHEo ITCHING OF THE OUTER EARo POOR APPETITE

o NOISES IN THE EAR (BUZZING, HUMMING)o VERTIGO (LOSS OF BALANCE)o BLISTERS ON THE OUTER EAR OR ALONG THE

CANALo MILD DEAFNESS OR THE SENSATION THAT

SOUND IS MUFFLEDo IRRITABILITY (INFANTS)o COUGH AND NASAL DISCHARGEo PUS-LIKE EARDISCHARGE

NOTE: This symptoms may occur is varying combinations, may come and go or be continuous. May be unilateral or bilateral

OTITIS EXTERNA (OE) INFLAMMATION OF EXTERNAL AUDITORY

CANAL (EAC)- LOCALISED OE: FOLLICULITIS THAT CAN

PROGRESS TO A FURUNCLE- DIFFUSE OE: MORE WIDESPREAD

INFLAMMATION E.G. SWIMMERS EAR- OE DEFINED AS ACUTE IF

EPISODE<3WEEKS; CHRONIC IF >3MONTHS

- MALIGNANT OE: EXTENDS TO MASTOID AND TEMPORAL BONES RESULTING IN OSTEITIS. TYPICALLY IN ELDERLY DIABETICS. SUSPECT IF PAIN SEEMS DISPROPORTIONATE TO CLINICAL FINDINGS

LOCALISED OE CAUSES: USUALLY INFECTED HAIR ROOT BY

STAPH AUREUS SYMPTOMS: SEVERE EAR PAIN (COMPARED

TO SIZE OF LESION); RELIEF IF FURUNCLE BURSTS; HEARING LOSS IF EAC VERY SWOLLEN

SIGNS: TINY RED SWELLING IN EAC (EARLY); LATER HAS WHITE OR YELLOW PUS-FILLED CENTRE WHICH CAN COMPLETELY OCCLUDE EAC

MANAGEMENT: ANALGESIA; HOT COMPRESS; ANTIBIOTIC ONLY IF SEVERE INFECTION OR HIGH RISK PATIENT

REFER: IF THERE IS NO RESPONSE TO ANTIBIOTIC OR CELLULITIS SPREADING OUTSIDE EAC

‘

ACUTE DIFFUSE OE CAUSES:

BACTERIAL INFECTION- PSEUDOMONAS OR STAPH AUREUS

SEBORRHOEIC DERMATITIS FUNGAL INFECTION- USUALLY CANDIDA CONTACT DERMATITIS - MEDS (SUDDEN

ONSET) OR HEARING AIDS/EARPLUGS (INSIDIOUS ONSET)

SYMPTOMS: ANY COMBINATION OF EAR PAIN, ITCHING, DISCHARGE AND HEARING LOSS

DIFFUSE ÒE PATIENTS

SIGNS: EAC AND/OR EXTERNAL EAR ARE RED,

SWOLLEN OR ECZEMATOUS SEROUS/PURULENT DISCHARGE INFLAMED TM – MAY BE DIFFICULT TO

VISUALISE PAIN ON MOVING EAR OR JAW

INVESTIGATIONS: RARELY USEFUL BUT IF TREATMENT FAILS, SEND SWAB FOR BACTERIAL AND FUNGAL CULTURE

MANAGEMENT: USE TOPICAL EAR PREPARATION FOR 7 DAYS; 2% ACETIC ACID FOR MILD CASES ANTIBIOTIC PLUS STEROID (NB Not in

perforated cases)

IF WAX/DEBRIS OBSTRUCTING EAC OR EXTENSIVE SWELLING OR CELLULITIS DRY MOPPING (CHILDREN) MICROSUCTION (ENT CLINIC)

ADVISE /PREVENTION OF OE: KEEP EARS CLEAN AND DRY; TREAT UNDERLYING ECZEMA/PSORIASIS

FAILURE OF TOPICAL MEDS: REVIEW DIAGNOSIS/COMPLIANCE CONSIDER ORAL ANTIBIOTICS ?FUNGAL (SPORES IN EAC) SWAB AND REFER

CHRONIC OE CAUSES:

SECONDARY FUNGAL INFECTION- DUE TO PROLONGED USE OF TOPICAL ANTIBACTERIALS OR STEROIDS

SEBORRHOEIC DERMATITIS; CONTACT DERMATITIS

SOMETIMES NO CAUSE CAN BE FOUND FOR OE

SYMPTOMS: MILD DISCOMFORT; PAIN USUALLY MILD

SIGNS: LACK OF EAR WAX; DRY, HYPERTROPHIC

SKIN LEADING TO CANAL STENOSIS; PAIN ON EXAM

ASSESS RISK /PRECIPITATING FACTORS

• SYMPTOMS; SIGNS OF FUNGAL INFECTION- WHITISH COTTON-LIKE STRANDS IN EAC

• BLACK OR WHITE BALLS OF ASPERGILLUS. LOOK FOR SIGNS OF DERMATITIS

• EVIDENCE OF ALLERGY (EAR PLUGS ETC) OR

• FOCUS OF FUNGAL INFECTION ELSEWHERE, E.G. SKIN, NAILS, VAGINA- CAN CAUSE SECONDARY INFLAMMATION OF THE EAC

• INVESTIGATIONS: ONLY TAKE SWAB FOR CULTURE AND

SENSITIVITY IF TREATMENT FAILS AS INTERPRETATION CAN BE DIFFICULT: SENSITIVITIES ARE DETERMINED FOR SYSTEMIC USE AND MUCH HIGHER CONCENTRATIONS CAN BE ACHIEVED BY TOPICAL USE

ORGANISMS MAY BE CONTAMINANTS, USUALLY SUPPRESSED NORMAL BACTERIAL FLORAL,

FUNGAL OVERGROWTH AFTER USING ANTIBACTERIAL DROPS DUE TO DISRUPTION OF THE NORMAL FLORA

MANAGEMENT:

ADVISE GENERAL MEASURES AS FOR ACUTE DIFFUSE OE TREATMENT DEPENDS ON CAUSE - OFTEN REQUIRES MORE THAN

ONE STRATEGY: IF FUNGAL INFECTION- TOPICAL ANTIFUNGAL, REFER IF POOR

RESPONSE

SEBORRHOEIC DERMATITIS- ANTIFUNGAL AND STEROID COMBINED

IF NO CAUSE EVIDENT- 7DAYS COURSE TOPICAL STEROID +/- ACETIC ACID SPRAY. IF GOOD RESPONSE, MAY NEED TO CONTINUE STEROID BUT REDUCE POTENCY/DOSE.

IF IT CANNOT BE WITHDRAWN AFTER 2-3MONTHS REFER ENT. IF POOR RESPONSE, TRY TRIAL OF TOPCAL ANTIFUNGAL

REFER ENT IF CONTACT SENSITIVITY (RE PATCH TESTING); IF EAC OCCLUDED; IF MALIGNANT OE SUSPECTED.

ACUTE OTITIS MEDIA (AOM) DEFINITIONS

AOM: INFECTION IN MIDDLE EAR, CHARACTERISED BY PRESENCE OF MIDDLE EAR EFFUSION ASSOCIATED WITH ACUTE ONSET OF SIGNS AND SYMPTOMS OF MIDDLE EAR INFLAMMATION

RECURRENT AOM: ≥3 EPISODES IN 6MONTHS OR ≥4 IN 1YEAR WITH ABSENCE OF MIDDLE EAR DISEASE BETWEEN EPISODES

PERSISTENT AOM (TREATMENT FAILURE): SYMPTOMS PERSIST AFTER INITIAL MANAGEMENT (NO ANTIBIOTICS, DELAYED ANTIBIOTICS OR IMMEDIATE ANTIBIOTIC PRESCRIBING STRATEGY) OR SYMPTOMS WORSENING

AOM DIAGNOSIS- PRESENTS WITH EARACHE (!)

IN YOUNGER CHILDREN-NON SPECIFIC SYMPTOMS, E.G RUBBING EAR, FEVER, IRRITABILITY, CRYING, POOR FEEDING, RESTLESSNESS AT NIGHT, COUGH, OR RHINORRHOEA

AOM WITH BULGING TYMPANIC MEMBRANES

WHEN TO REFER OR ADMIT?

WITH SUSPECTED AOM BUT: CONSIDER ANTIBIOTICS IN CHILDREN <

3MONTHS, BILATERAL AOM SYSTEMICALLY UNWELL HIGH RISK OF COMPLICATIONS E.G.

IMMUNOSUPPRESSION, CF. FOR ALL ANTIBIOTIC PRESCRIBING STRATEGIES:

INFORM PATIENT AVERAGE DURATION OF ILLNESS FOR UNTREATED AOM IS 5-7 DAYS.

ADMIT: CHILDREN WITH FEVER FOR IV ANTIBIOTICS ADULTS AND CHILDREN WITH SUSPECTED

COMPLICATIONS E.G. MENINGITIS, MASTOIDITIS, OR FACIAL PARALYSIS

OTITIS MEDIA WITH EFFUSION (OME) / GLUE EAR

DEFINITION: NON-PURULENT COLLECTION OF FLUID IN MIDDLE EAR(MUST BE > 2WEEKS AFTER RECENT AOM TO BE CLASSIFIED AS GLUE EAR)

CAUSES: EUSTACHIAN TUBE DYSFUNCTION > 50% DUE TO AOM ESPECIALLY IN < 3

YEARS OTHERS: LOW GRADE BACTERIAL/VIRAL

INFECTIONS, GASTRIC REFLUX, NASAL ALLERGIES, ADENOIDS OR NASAL POLYPS, DOWN’S SYNDROME

PRESSURE CHANGES E.G. WITH FLYING OR SCUBA DIVING (ADULTS)

SYMPTOMS: HEARING LOSS ABSENCE OF EARACHE OR

SYSTEMIC UPSET CAN PRESENT WITH PROBLEMS OF

SPEECH/LANGUAGE DEVELOPMENT, BEHAVIOUR OR SOCIAL INTERACTION

INITIAL MANAGEMENT OF OME ASK ABOUT DEVELOPMENTAL DELAY OR

LANGUAGE DIFFICULTIES HEARING TEST

DRUGS NOT RECOMMENDED AS OME USUALLY SELF LIMITING.

OME GENERAL ADVICE: GOOD PROGNOSIS, SELF-LIMITING

AND >90% GET RESOLUTION WITHIN 6MONTHS, WITH LIMITED PROVEN BENEFIT FROM DRUGS.

OME IN ADULTS IS UNUSUAL AND NEED REFERRAL TO ENT (UNILATERAL COULD MEAN NASOPHARYNGEAL CA)

GROMMETS - GENERAL POINTS: USUALLY STOP FUNCTIONING AFTER 10MONTHS APPROX 50% REQUIRE REINSERTION WITHIN

5YEARS CONDUCTIVE DEAFNESS AFTER EXTRUSION

IMPROVES SLOWLY COMPLICATIONS ARE OTORRHOEA, MAY NEED

SPECIALIST INPUT. MOST ACTIVITIES UNAFFECTED, I.E. CAN FLY AND

SWIM BUT AVOID IMMERSION, RISK OF HEARING LOSS, SHOULD FACE CHILD WHEN SPEAKING

ADENOIDECTOMY: IS USUALLY SECOND LINE TREATMENT FOR OME WITH LITTLE BENEFIT

NO EVIDENCE FOR TONSILLECTOMY IN OME

CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM)

SYMPTOMS PERSISTENT PAINLESS OTORRHOEA >2WEEKS MAY BE PRECEDED BY AOM, TRAUMA

DIFFERENTIALS OE, FOREIGN BODY, WAX

ASSESSMENT EXCLUDE INTRACRANIAL INVOLVEMENT,

FACIAL PARALYSIS OR MASTOIDITIS- NEEDS ADMISSION

OTHERWISE ROUTINE REFERRAL

OTOMYCOSIS(FUNGAL EAR INFECTIONS)

Incidence not known – but common among aquatic sports

Prevalence around 10% of OE 1 in 8 of OE is fungal with 90% due to

Aspergillus spp and the rest due to Candida spp

Common in warm/hot climate (American study – peak during summer)

PREDISPOSING FACTORS

ABSENT CERUMEN AQUATIC SPORT HIGH HUMIDIDY INCREASED TEMPERATURE LOCAL TRAUMA Hx OR PREVIOUS INVASIVE

PROCEDURES

PRESENTTATION AND MANAGEMENT

Very similar to other otitis externa However Otomycosis typically

Inflammation Pruritus (very severe compared to bacterial OE) Scaling and Severe discomfort Superficial epithelial exfoliation, masses of debris

containing fungal hyphae and suppuration Suspicion is usually after failure to respond to

antibiotics Investigation: bacteeriology/mycology. Debris

placed in 10% KOH

PRESENTATION AND MANAGEMENT

Management: Clear ear of debris and discharge. Suction could be used.

Repeated cleaning several times in a week Analgesia, Keep ear dry and avoid scratching it Keep ear canal patent Use Burrow’s 5% Aluminum solution to wash and reduce

swelling Antifungal ear drops could be used. No consensus on the

use of 1% Clotrimazole and other antifungal ear drops. But they have been used.

Prognosis is generally good once appropriate treatment has been started in an immunocompetent person. Recurrence is however very high!!

COMPLICATIONS OF EAR INFECTIONS

HEARING LOSS CHRONIC PERFORATION AND OTORRHOEA, CSOM CHOLESTEATOMA INTRACRANIAL

COMPLICATIONS(MENINGITIS) OTOTIC TETANUS POOR ACADEMIC PERFORMANCE LOW SELF ESTEEM/STIGMATISATION FAMILY DICORDANCE MASTOIDITIS

LABYRINTHITIS VERTIGO FACIAL PARALYSIS BRAIN ABCESS SPEECH/DEVELOPMENTAL DELAYS

PREVENTION

MOST EAR INFECTIONS CAN BE PREVENTED. THE USE OF ANTIBIOTICS FOR TREATMENT

WHICH HAS DECREASE THE RATE OF INFECTION HAS ALSO LED TO THE DEVELOPMENT OF RESISTANT OTITIC BACTERIA IN RECENT TIMES.

THIS CAN BE EXPLAINED BY THE ABUSE OF MEDICATIONS BY PATIENTS AND POOR COMPLIANCE TO TREATMENT.

ANTIBIOTICS ARE PURCHASED WITHOUT PRESCRIPTIONS OR PROPER INVESTIGATIONS

PATENT MEDICINE VENDORS AND PHARMACY OUTLETS PROVIDE ANTIBIOTICS TO PATIENTS AS THE DEMAND FOR IT.

THERE IS ALSO THE PROBLEM OF LOW QUALITY ANTIBIOTICS IN CIRCULATION

VACCINATION WITH PNEUMOCOCCAL CONJUGATE VACCINES DURING INFANCY DECREASE THE RATES OF OM BY 6-7% AND SHOULD BE ENCOURAGED

INFLUENZA VACCINE IS ALSO RECOMMENDED ANNUALY

RISK FACTORS SHOULD BE AVOIDED AND DISCOURAGED LIKE

SWIMMING IN POORLY TREATED POOLS

AVOID TOBACCO USE BREAST FEEDING SHOULD BE

ENCOURAGED BECAUSE IT HAS BEEN SHOWN TO REDUCE THE NUMBER AND DURATION OM.

KEEPING POTENTIAL FOREIGN BODY OBJECTS OUT OFF THE SITE OF CHILDREN

THOSE WITH HIGH ALLERGY PREDISPOSITION SHOULD AVOID SUCH ALLERGENS

- HEALTH EDUCATION OF THE POPULACE

- PROVISION OF QUALITY HEALTHCARE TO ALL MEMBERS OF THE COMMUNITY

CONCLUSION THE AIM OF THIS LECTURE WAS TO

REMIND US OF THE BURDEN OF EAR INFECTIONS

COMMON EAR INFECTIONS AND THEIR PRESENTATION

IT IS IN THE DOMAIN OF THE FAMILY PHYSICIAN TO KNOW HOW TO ASSESS AND MANAGE COMMON ENT PROBLEMS

PRIMARY CARE PHYSICIANS SHOULD KNOW HOW AND WHEN TO REFER TO AN ENT SPECIALIST

THANK YOU FOR LISTENING

REFERENCES1 OUTER EAR INFECTIONS. C-HEALTH

MEDIRESOURCES.ACCESSED FROM www.chealth.canoe.ca/channel_condition_info_details_asp ON THE 19TH OF JANUARY, 2015

2 AMUSA YB, IJADUNOLA IK, ONAYADE OO. EPIDEMIOLOGY OF OTITIS MEDIA IN A TROPICAL AFRICAN POPULATION. WAJM 2006; 24(3):227-230

3 CHRONIC SUPPURATIVE OTITIS MEDIA: BURDEN OF ILLNESS AND MANAGEMENT OPTIONS.CHILD AND ADOLESCENT HEALTH AND DEVELOPMENT, PREVENTION OF BLINDNESS AND DEAFNESS, WHO 2004 MANUAL. ACCESSED FROM www.who.intl/pbd/publications/chronicsuppurativeotitis.media.pdf ON THE 19TH OF JANUARY 2015

4 EAR INFECTIONS AN OVERVIEW BY KRUCIK G.FOR HEALTHLINE PUBLICATIONS. ACCESSED FROM www.healthline.com/health/ear-infection#overview1 ON THE 19TH OF JANUARY

5 ADEYEMO AA. KNOWLEDGE OF CAREGIVERS ON THE RISK FACTORS OF OTITIS MEDIA. INDIAN JOURNAL OF OTOLOGY. 2012; 18(4): 184 -188

6 OVERVIEW OF OTITIS MEDIA. ACCESSED FROM www.en.m.wikipedia.org/wiki/otitis_media ON THE 19TH OF JANUARY 2015

7 GIDLEY PW. COMMON EAR PROBLEMS. AMERICAN ACADEMY OF OTOLARYNGOLOGY-HEAD AND NECK SURGERY. ACCESSED FROM www.scribd.com/mobile/doc/251114263 ON THE19TH OF JANUARY 2015.