Otitis Externa

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Otitis Externa

مشاركةبواسطة دكتور كمال سيد » الأربعاء مارس 09, 2016 5:58 pm

Managing Acute Otitis Externa: The Latest Guidelines



First Case: The Diagnosis of Acute Otitis Externa

A 19-year-old college student presented to the university health clinic with a 3-day history of pain and whitish drainage from his left ear. He had gone swimming before the onset of symptoms, and neither of his two roommates had similar symptoms. The patient had no history of ear infection or ear surgery. He denied hearing loss, vertigo, or aural fullness and did not use tobacco, alcohol, or illicit drugs. He was not actively taking any medications and had no drug allergies.

On examination, the patient appeared comfortable, and his vital signs were all within normal limits. Fundoscopy and anterior rhinoscopy were unremarkable. The patient reported substantial pain when the left auricle was manipulated and when the aural speculum was placed in the left ear canal. The left mastoid process was non-tender. Otoscopy of the left ear demonstrated significant swelling of the external auditory canal with a small amount of thin white fluid. The tympanic membrane was poorly visualized but appeared to be intact. The right ear was normal on examination. The patient's oral cavity and oropharyngeal cavity were also unremarkable, with no pain around the temporomandibular joints when opening or closing the mouth. The neck was supple without lymphadenopathy.

(The patient was diagnosed with acute otitis externa (AOE .

Which of the following symptoms may be present for a diagnosis of AOE, according to American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) criteria? [select all that apply]
Otalgia
Otorrhea
Pruritus
Hearing loss
Aural fullness

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Re: Otitis Externa

مشاركةبواسطة دكتور كمال سيد » الأربعاء مارس 09, 2016 5:59 pm

Which of the following symptoms may be present for a diagnosis of AOE, according to American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) criteria? [select all that apply]

Your Colleagues Responded:
Otalgia Correct Answer 36%
Otorrhea 28%
Pruritus Correct Answer 14%
Hearing loss 7%
Aural fullness Correct Answer 15%
Diagnostic Criteria for AOE

AOE (known colloquially as "swimmer's ear") is a very common condition. In 2007, the Centers for Disease Control and Prevention estimated that more than 2.4 million ambulatory care and emergency department visits in the United States (approximately 8.1 visits per 1000 population) resulted in a diagnosis of AOE.[1] In the United Kingdom, the estimated 12-month prevalence of AOE was slightly more than 1% in 1997.[2]

AOE can present with any or all of these five symptoms: otalgia, otorrhea, pruritus, hearing loss, and aural fullness, although all five need not be present to make the diagnosis. The diagnosis of AOE requires three components, incorporating symptoms, signs, and rapidity of onset[3,4]:

Symptoms of inflammation of the external auditory canal, including otalgia, itching/pruritus, or aural fullness;

Signs of inflammation of the external auditory canal, including tenderness of the tragus, pinna, or both, or diffuse ear canal edema, erythema, or both; and

Rapid onset of symptoms (within the previous 3 weeks) and generally within 48 hours.

Similarly, patients may have such signs as mild fever, otorrhea, cervical lymphadenitis, tympanic membrane inflammation, and cellulitis of the pinna or adjacent skin on examination, but none of these findings are mandatory for the diagnosis of AOE. Pain is considered the symptom that best correlates with the severity of AOE presentation.
http://www.medscape.com/viewarticle/859468_2
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Re: Otitis Externa

مشاركةبواسطة دكتور كمال سيد » الأربعاء مارس 09, 2016 6:00 pm

Second Case: Risk Factors for AOE

A 62-year-old mechanic presented to his family physician with a 2-day history of severe right ear pain and a sensation of fullness in the right ear. He denied having any fevers, dizziness, or hearing loss. The patient's medical history was significant for diabetes controlled with metformin, hypertension, and a stroke 3 years ago. He reported no history of ear surgery but did state that he had "many" ear infections as a child. The patient has used bilateral hearing aids for about 5 years with no previous difficulties. He denied using tobacco, alcohol, or illicit drugs and has no known drug allergies.

On examination, the patient appeared to be in mild discomfort but reported no respiratory distress. His vital signs were within normal limits. A fundoscopic exam was unremarkable, and extraocular movements were intact. Anterior rhinoscopy demonstrated a small nasal septal deviation but no other notable findings. Examination of the right ear revealed mild edema and tenderness of the auricle and pinna as well as severe pain when the otoscope was introduced into the external auditory canal. There was no right-sided mastoid tenderness. Right otoscopy demonstrated significant swelling of the canal, some desquamation of the canal epithelium, and copious white otorrhea. The tympanic membrane could not be visualized owing to a foreign body wedged deeply in the canal. Under otomicroscopy, the foreign body was removed and found to be a soiled tip from a cotton swab. The tympanic membrane was inflamed but otherwise intact. Examination of the left ear was unremarkable, as were the oral and oropharyngeal cavities. The neck was supple without lymphadenopathy. Cranial nerve VII function was grossly intact bilaterally.

Upon further questioning, the patient admitted to regular use, over many years, of cotton swabs to "clean out" his ears. However, he was insistent that this was the first time he had experienced these symptoms.

In addition to blind instrumentation of the ears with cotton-tip applicators, which other known risk factors for AOE are exhibited in this patient? [select all that apply]
Diabetes
Hypertension
Age older than 60 years
Male sex
Hearing aid use
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Re: Otitis Externa

مشاركةبواسطة دكتور كمال سيد » الأربعاء مارس 09, 2016 6:01 pm

In addition to blind instrumentation of the ears with cotton-tip applicators, which other known risk factors for AOE are exhibited in this patient? [select all that apply]

Your Colleagues Responded:
Diabetes Correct Answer 42%
Hypertension 2%
Age older than 60 years 9%
Male sex 3%
Hearing aid use Correct Answer 43%
Predisposing and Complicating Factors

Many conditions predispose to the development of AOE. Among the most common risk factors is prolonged exposure to water, from swimming or other water-based activities, or through long-term exposure to high-humidity environments. Anatomic features (a narrowed ear canal, canal obstruction by cerumen or other means, and placement of such objects as earplugs, cotton swabs, or hearing aids in the ear canal) and dermatologic conditions (eczema psoriasis or contact irritation by otorrhea from otitis media, soap, and other agents) are among many other known risk factors for AOE.[4]

This patient demonstrated several risk factors, including use of cotton swabs in the ear, long-term hearing aid use, and diabetes. Age and sex are not considered to be significant risk factors for the development of AOE,[5] nor has hypertension been reported to be a risk factor for AOE.

The AAO-HNSF clinical practice guideline for AOE[3] highlights several special conditions that may modify the management of AOE. Patients with diabetes, HIV infection, or other immunocompromised states are particularly prone to necrotizing/malignant otitis externa and otomycosis.[3] Necrotizing otitis externa, an invasive infection of the external auditory canal and skull base, is classically reported in elderly patients with diabetes and almost always caused by Pseudomonas aeruginosa.[6] Cranial nerve involvement is sometimes present, and examination can reveal granulation tissue along the floor of the external auditory canal and at the bony-cartilaginous junction. Treatment of this condition includes surgical debridement and systemic antibiotic therapy.[3] Otomycosis, a fungal infection of the external auditory canal, is found not only in patients in immunocompromised states but also in those living in tropical, humid conditions. Symptoms include otorrhea (which can be many different colors) and pruritus. Aspergillus-related infections produce debris often described as having the appearance of "wet newspaper," whereas Candida-related infections usually are whitish-colored with hyphae. Debridement plus topical antifungal therapy is the usual treatment approach; topical antibiotic therapy may actually exacerbate the process by promoting fungal overgrowth.[3,4]

Radiation therapy produces substantial adverse effects on the external ear. The skin of the external ear can undergo acute reactions such as erythema, desquamation, and ulceration as well as delayed changes such as atrophy, ulceration, external otitis, and canal stenosis. Destruction of sebaceous and apocrine glands with reduced cerumen production can further alter the external auditory canal environment and contribute to ongoing chronic infections. Management of radiation therapy-induced external otitis can require anti-inflammatory and antimicrobial therapy.[7]

Finally, concurrent middle ear disease can affect how AOE is managed. A tympanic membrane perforation from otitis media, or the presence of tympanostomy tubes, can allow purulent secretions from the middle ear to enter the external auditory canal and irritate the skin.[3] Research also has demonstrated that middle ear or mastoid fluid from occult otitis media can be present during AOE.[8] Management of concurrent otitis media may require systemic antibiotic therapy, imaging, or surgical intervention; if ototopical medication is prescribed in patients with a non-intact tympanic membrane, caution to avoid compounds that are ototoxic (eg, neomycin/polymyxin B/hydrocortisone) or have a low pH (eg, alcohol, acetic acid) is advised.[3,4] Acute, uncomplicated otorrhea associated with tympanostomy tube placement should be managed with ototopical antibiotics only, without concurrent oral antibiotics.

http://www.medscape.com/viewarticle/859468_3
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Re: Otitis Externa

مشاركةبواسطة دكتور كمال سيد » الأربعاء مارس 09, 2016 6:02 pm

Third Case: Ototopical Therapy for AOE

A 17-year-old high school student presented to an urgent care clinic with severe pain and sensation of fullness of the right ear for the past week. The patient recalled noticing some yellowish drainage from the ear at the onset of symptoms but said that he had not seen any drainage in the past few days. He was otherwise healthy with no pertinent medical or surgical history. The patient denied hearing loss, tinnitus, or vertigo. He admitted to weekend consumption of beer but denied tobacco or illicit drug use. The patient had been using over-the-counter analgesics but denied using any prescribed medications or having any drug allergies. He denied antecedent trauma or swimming.

The patient was afebrile, with normal vital signs, and did not appear to be in significant distress. He reported moderate pain when the tragus of the right ear was lightly pressed. There was some difficulty examining the right ear with an otoscope owing to significant canal swelling and tenderness. The right tympanic membrane was poorly visualized, but there was a questionable presence of granulation tissue over the central portion of the eardrum. The right mastoid process was nontender. The left ear exam and the remainder of the head and neck exam were unremarkable.

The patient was diagnosed with concurrent AOE and acute otitis media with suspected tympanic membrane perforation.

Which of the following ototopical medications are safe and appropriate to use in this patient? [select all that apply]
Ciprofloxacin 0.3%/dexamethasone 0.1%
Ciprofloxacin 0.2%/hydrocortisone 1.0%
Neomycin/polymyxin B/hydrocortisone
Acetic acid 2.0%
Ofloxacin 0.3%
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Re: Otitis Externa

مشاركةبواسطة دكتور كمال سيد » الأربعاء مارس 09, 2016 6:04 pm

Which of the following ototopical medications are safe and appropriate to use in this patient? [select all that apply]

Your Colleagues Responded:
Ciprofloxacin 0.3%/dexamethasone 0.1% Correct Answer 30%
Ciprofloxacin 0.2%/hydrocortisone 1.0% Correct Answer 22%
Neomycin/polymyxin B/hydrocortisone 17%
Acetic acid 2.0% 7%
Ofloxacin 0.3% Correct Answer 24%
Topical Treatment Options

Ototopical medications are considered first-line therapy for AOE. Several classes of medications are available for use, including antibiotics (eg, fluoroquinolones, aminoglycosides, and polymyxin B), steroids (eg, dexamethasone and hydrocortisone), and antiseptics (eg, acetic acid and boric acid). Three major meta-analyses have compared the relative efficacies of these various classes of drugs for AOE. Rosenfeld and colleagues[10] and Kaushik and colleagues[5] concluded that there were few clinically meaningful differences among ototopical compounds. Mösges and colleagues[11] determined that medications containing both antibiotics and steroids were superior to those containing antibiotics alone when measuring improvement of clinical presentation and eradication of microbes; however, it should be noted that this study was funded in part by a pharmaceutical company that manufactures the drugs that were included in the meta-analysis. Because outcomes are generally similar among ototopical medications, the decision to select a particular medication may be informed heavily by such factors as patient preference, cost, treatment adherence, adverse effects, and provider experience.

For uncomplicated AOE with an intact tympanic membrane, all of the choices listed above are reasonable. Neomycin/polymyxin B/hydrocortisone is often an initial selection owing to its relatively low cost and reasonable effectiveness.[4] However, the medication has three critical features of which providers and patients should be aware. First, the AAO-HNSF clinical practice guideline on AOE, the UK Committee on Safety of Medicines, and the Medicines Control Agency recommend using a medication that is non-ototoxic for patients with non-intact tympanic membranes.[3,12] Animal models consistently demonstrate that aminoglycosides are ototoxic when instilled into the middle ear.[13-16] Furthermore, analysis of Medicaid claims data suggests that repeated use of aminoglycoside-containing eardrops may be associated with an elevated risk for sensorineural hearing loss.[17] Black box warnings exist on ototopical aminoglycoside labels about the risk for ototoxicity.[3,16] Second, 15% of patients can develop contact dermatitis after exposure to neomycin therapy,[5] which can present similarly to AOE (eg, pruritus). The rate of contact dermatitis can be as high as 30%-60% of patients with chronic or eczematous external otitis.[3] Finally, neomycin/polymyxin B/hydrocortisone is generally administered three to four times daily, a higher frequency than with fluoroquinolone formulations, which may contribute to poorer patient adherence.

Antiseptic and alcohol-containing compounds also are not recommended by the AAO-HNSF if patients have tympanic membrane perforations, owing to the risk for pain and potential ototoxicity. However, fluoroquinolone-containing medications are approved by the US Food and Drug Administration for middle ear use. Moreover, they are administered once to twice daily, which may be more tolerable to patients. Thus, fluoroquinolone eardrops are ideal selections for use in patients with AOE and non-intact tympanic membranes. Their primary drawback is the relatively high cost: more than $100 per bottle for most formulations.[3,4]

Delivery of ototopical medications is enhanced by aural toilet of the obstructed ear canal, using suction or blotting with a cotton-tip applicator, under direct visualization with an otoscope or binocular microscope. Gentle lavage with saline, distilled water, or hydrogen peroxide may be considered only if the patient has an intact tympanic membrane; this should be avoided in patients with diabetes because of the risk of inducing malignant otitis externa.[3,4,18-20] Use of a wick (eg, cellulose or ribbon gauze) can help expand an edematous canal and facilitate delivery of medication. Patient education on the proper techniques for instilling ototopical medications is also critical to successful treatment. Patients should avoid water sports and limit the use of devices placed in the ear, such as hearing aids and earphones, during therapy. Patients should also be instructed on how to safely dry their ears (ie, using a hair dryer set on the lowest power setting)

http://www.medscape.com/viewarticle/859468_4
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Re: Otitis Externa

مشاركةبواسطة دكتور كمال سيد » الأربعاء مارس 09, 2016 6:06 pm

Fourth Case: Systemic Therapy for AOE

A 21-year-old college student visited her college health center with a 5-day history of bilateral ear itchiness and drainage during and after a trip with friends for spring break. She stated that the symptoms began a day or so after swimming in a resort pool. The patient admitted to using cotton-tip applicators to help dry her ears out after swimming. The patient reported no other symptoms. Her examination demonstrated tenderness of both auricles and tragi and bilateral external auditory canal edema and erythema. The tympanic membranes were intact. The patient was diagnosed with bilateral AOE, and ototopical therapy was initiated.

Which of the following conditions would be an indication for concurrent systemic antibiotic therapy in the treatment of AOE? [select all that apply]
Diabetes
HIV infection
Gastroesophageal reflux
Current smoking status
None of the above
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Re: Otitis Externa

مشاركةبواسطة دكتور كمال سيد » الأربعاء مارس 09, 2016 6:07 pm

Which of the following conditions would be an indication for concurrent systemic antibiotic therapy in the treatment of AOE? [select all that apply]

Your Colleagues Responded:
Diabetes Correct Answer 37%
HIV infection Correct Answer 40%
Gastroesophageal reflux 1%
Current smoking status 2%
None of the above 20%
When to Use Oral Antibiotics

The AAO-HNSF clinical practice guideline on AOE unequivocally states that ototopical medications, and not systemic antibiotics, should be initial therapy for uncomplicated AOE.[3] Two randomized controlled trials demonstrated no additional clinical benefit with the addition of an oral antibiotic to an ototopical therapeutic regimen for AOE.[21,22] Oral antibiotics have numerous well-documented adverse effects, ranging from rashes and allergic reactions to development of bacterial resistance. The AAO-HNSF guidelines on AOE also mention that the efficacy of numerous non-antibiotic ototopical medications was another argument against the use of oral antibiotics for routine, uncomplicated AOE.[3] Of interest, in spite of the evidence against the use of oral antibiotics for uncomplicated AOE, the rate of oral antibiotic use in US ambulatory care centers actually increased from 21.7% to 30.5% after publication of the initial version of the AAO-HNSF guideline on AOE in 2006.[23]

There are several specific situations in which systemic antibiotic therapy can serve as an effective adjunct to ototopical therapy for AOE.[3,4,24] If prescribed, systemic antibiotics should adequately cover such common AOE pathogens as P aeruginosa and Staphylococcus aureus. These specific situations include the following:

Uncontrolled diabetes;

HIV infection, AIDS, or other conditions that can impair immune responses;

History of localized radiation therapy;

Infection extending outside the external auditory canal;

Active otologic complications such as osteitis, localized abscess, middle ear disease, or recurrent, persistent infections; and

Inability to effectively deliver topical antibiotics.

http://www.medscape.com/viewarticle/859468_5
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Re: Otitis Externa

مشاركةبواسطة دكتور كمال سيد » الأربعاء مارس 09, 2016 6:10 pm

Otitis externa (OE) is an inflammation or infection of the external auditory canal (EAC), the auricle, or both.[1, 2, 3] This condition can be found in all age groups.[4] See the image below.


Acute otitis externa. Ear canal is red and edematous, and discharge is present.
Classification
OE may be classified as follows:

Acute diffuse OE - Most common form of OE, typically seen in swimmers
Acute localized OE (furunculosis) - Associated with infection of a hair follicle
Chronic OE - Same as acute diffuse OE but is of longer duration (>6 weeks)
Eczematous (eczematoid) OE - Encompasses various dermatologic conditions (eg, atopic dermatitis, psoriasis, systemic lupus erythematosus, and eczema) that may infect the EAC and cause OE
Necrotizing (malignant) OE - Infection that extends into the deeper tissues adjacent to the EAC; occurs primarily in immunocompromised adults (eg, diabetics, patients with AIDS)
Otomycosis - Infection of the ear canal from a fungal species (eg, Candida, Aspergillus)
Signs and symptoms
The key physical finding of OE is pain upon palpation of the tragus (anterior to ear canal) or application of traction to the pinna (the hallmark of OE). Patients may also have the following signs and symptoms:

Otalgia - Ranges from mild to severe, typically progressing over 1-2 days
Hearing loss
Ear fullness or pressure
Erythema, edema, and narrowing of the EAC
Tinnitus
Fever (occasionally)
Itching (especially in fungal OE or chronic OE)
Severe deep pain - Immunocompromised patients may have necrotizing (malignant) OE
Discharge - Initially, clear; quickly becomes purulent and foul-smelling
Cellulitis of the face or neck or lymphadenopathy of the ipsilateral neck (occasionally)
Bilateral symptoms (rare)
History of exposure to or activities in water (frequently) (eg, swimming, surfing, kayaking)
History of preceding ear trauma (usually) (eg, forceful ear cleaning, use of cotton swabs, or water in the ear canal)
See Clinical Presentation for more detail.

Diagnosis
The patient’s history and physical examination, including otoscopy, usually provide sufficient information for the clinician to make the diagnosis of OE. Note that a patient who is diabetic or immunocompromised with severe pain in the ear should have necrotizing OE excluded by an otolaryngologist.

Laboratory testing

Typically, laboratory studies are not needed, but they may be helpful if the patient is immunocompromised, if the usual treatment measures are ineffective, or if a fungal cause is suspected. Tests may include the following:

Gram stain and culture of any discharge from the auditory canal
Blood glucose level
Urine dipstick
Imaging studies

Imaging studies are not required for most cases of OE. However, radiologic investigation may be helpful if an invasive infection such as necrotizing (malignant) OE is suspected or if the diagnosis of mastoiditis is being considered.

Imaging modalities may include the following:

High-resolution computed tomography (CT) - Preferred; better depicts bony erosion [5]
Radionucleotide bone scanning
Gallium scanning
Magnetic resonance imaging (MRI) - Not used as often as the other modalities; may be considered secondarily or if soft-tissue extension is the predominant concern [6]
See Workup for more detail.

Management
Most persons with OE are treated empirically. Primary treatment involves the following:

Pain management
Removal of debris from the EAC
Administration of topical medications to control edema and infection
Avoidance of contributing factors
Pharmacotherapy

Topical medications (eg, acetic acid in aluminum acetate, hydrocortisone and acetic acid otic solution, alcohol vinegar otic mix)
Analgesic agents (eg, acetaminophen, acetaminophen and codeine)
Antibiotics (eg, hydrocortisone/neomycin/polymyxin B, otic ofloxacin, otic ciprofloxacin, otic finafloxacin, gentamicin 0.3%/prednisolone 1% ophthalmic, dexamethasone/tobramycin, otic ciprofloxacin and dexamethasone, otic ciprofloxacin and hydrocortisone suspension)
Oral antibiotics (eg, ciprofloxacin)
Antifungal agents (eg, otic clotrimazole 1% solution, nystatin powder)
Surgery

Surgical debridement of the ear canal - Usually reserved for necrotizing OE or for complications of OE (eg, external canal stenosis); often necessary in more severe cases of OE or in cases where a significant amount of discharge is present in the ear; mainstay of treatment for fungal infections
Incision and drainage of an abscess
http://emedicine.medscape.com/article/994550-overview
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