Otitis externa: Difference between revisions

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{{Infobox_Disease |
{{Infobox_Disease |
   Name          = Otitis externa |
   Name          = Otitis externa |
   Image          = Otitis Externa Oct2004 044 2 op .jpg|
   Image          = OtitisExterna001.jpg|
  Caption        = A severe case of Otitis Externa. Case provided by James Heilman, MD.|
}}
}}
{{Otitis externa}}
{{Otitis externa}}
'''For patient information, click [[{{PAGENAME}} (patient information)|here]]'''


{{CMG}}
{{CMG}}; {{AE}} {{LRO}}; {{TarekNafee}}


==Symptoms==
{{SK}} Swimmer's ear; external otitis; acute otitis externa; chronic otitis externa; malignant otitis externa; malignant necrotizing otitis externa; outer ear infection
[[Pain]] is the predominant complaint and the only symptom directly related to the severity of acute external otitis. Unlike other forms of ear infections, ''the pain of acute external otitis is worsened when the outer ear is touched or pulled gently''. Pushing the tragus (that tablike portion of the [[Pinna | auricle]] that projects out just in front of the ear canal opening) so typically causes pain in this condition as to be diagnostic of external otitis on physical examination. Patients may also experience ear discharge and itchiness. When enough swelling and discharge in the ear canal is present to block the opening, external otitis may cause temporary conductive hearing loss.


Due to the fact that the ear and throat are often interconnected, irritation (whether it be in inflammation or a scratching sensation) is normal.  However, excessive throat symptoms may likely point to the throat as the cause of the pain in the ear rather than the other way around.
==[[Otitis externa overview|Overview]]==


Because the symptoms of external otitis promote many people to attempt to clean out the ear canal (or scratch it) with slim implements, and self-cleaning attempts generally lead to additional trauma of the injured skin, rapid worsening of the condition often occurs. Worsening is also common in the vacationer who continues holiday swimming despite symptoms of mild external otitis.
==[[Otitis externa historical perspective|Historical Perspective]]==


==Causes, incidence, and risk factors==  
==[[Otitis externa classification|Classification]]==


[[Swimming]] in polluted water is a common way to contract swimmer's ear, but it is also possible to contract swimmer's ear from water trapped in the ear canal after a shower, especially in a humid climate.<ref>{{cite journal |author=Wang MC, Liu CY, Shiao AS, Wang T |title=Ear problems in swimmers |journal=J Chin Med Assoc |volume=68 |issue=8 |pages=347–52 |year=2005 |month=August |pmid=16138712 |doi= |url= |accessdate= }}</ref> Saturation divers have reported Otitis externa during occupational exposure.<ref>{{cite journal |author=Cobet AB, Wright DN, Warren PI |title=Tektite-I program: bacteriological aspects |journal=Aerosp Med |volume=41 |issue=6 |pages=611–6 |year=1970 |month=June |pmid=4392833 |doi= |url= |accessdate= }}</ref><ref>{{cite journal |author=Ahlén C, Mandal LH, Iversen OJ |title=Identification of infectious Pseudomonas aeruginosa strains in an occupational saturation diving environment |journal=Occup Environ Med |volume=55 |issue=7
==[[Otitis externa pathophysiology|Pathophysiology]]==
|pages=480–4 |year=1998 |month=July |pmid=9816382 |pmc=1757612 |doi= |url= |accessdate= }}</ref><ref>{{cite journal  |author=Thalmann, ED |title=A Prophylactic Program for the Prevention of Otitis Externa in Saturation Divers. |journal=US Naval Experimental Diving Unit Technical Report |volume=NEDU-RR-10-74 |date=1974 |url=http://archive.rubicon-foundation.org/3372 |accessdate=2008-07-22 }}</ref>  Even without exposure to water, the use of objects such as [[cotton swab]]s or other small objects to clear the ear canal is enough to cause breaks in the skin, and allow the condition to develop.<ref>{{cite journal |author=Zichichi L, Asta G, Noto G |title=Pseudomonas aeruginosa folliculitis after shower/bath exposure |journal=Int. J. Dermatol. |volume=39 |issue=4 |pages=270–3 |year=2000 |month=April |pmid=10809975 |doi= |url=http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0011-9059&date=2000&volume=39&issue=4&spage=270 |accessdate=2008-07-22}}</ref> Once the skin of the ear canal is inflamed, external otitis can be drastically enhanced by either scratching the ear canal with an object, or by allowing water to remain in the ear canal for any prolonged length of time.


The two factors that are required for external otitis to develop are (1) the presence of [[Pathogen|germs]] that can infect the skin and (2) impairments in the integrity of the skin of the ear canal that allow infection to occur. If the skin is healthy and uninjured, only exposure to a high concentration of pathogens, such as submersion in a pond contaminated by sewage, is likely to set off an episode. However, if there are chronic skin conditions that affect the ear canal skin, such as [[atopic dermatitis]], seborrheic dermatitis, [[psoriasis]] or abnormalities of [[keratin]] production, or if there has been a break in the skin from trauma, even the normal bacteria found in the ear canal may cause infection and full-blown symptoms of external otitis.<ref>Kang K, Stevens SR. Pathophysiology of atopic dermatitis. Clin Dermatol 2003;21:116–121.</ref>
==[[Otitis externa causes|Causes]]==


Fungal ear canal infections, also known as [[otomycosis]], range from inconsequential to very severe.  Fungus can be saprophytic, in which there are no symptoms and the fungus simply co-exists in the ear canal in a harmless parasitic relationship with the host, in which case the only physical finding is presence of the fungus.  If for any reason the fungus begins active reproduction, the ear canal can fill with  dense fungal debris, causing pressure and ever-increasing pain that is unrelenting until the fungus is removed from the canal and anti-fungal medication is used.  Most antibacterial ear drops also contain a steroid to hasten resolution of canal edema and pain.  Unfortunately such drops make fungal infection worse.  Prolonged use of them promotes growth of fungus in the ear canal.  Antibacterial ear drops should be used a maximum of one week, but 5 days is usually enough.  Otomycosis responds more than 95% of the time to a three day course of the same over-the-counter anti-fungal solutions used for athlete's foot. 
==[[Differentiating otitis externa from other diseases|Differentiating Otitis Externa from Other Diseases]]==


The incidence of otitis externa is high. In the Netherlands, it has been estimated at 12-14 per 1000 population per year,  and has been shown to affect more than 1% of a sample of the population in the United Kingdom over a 12 month period.<ref>{{cite journal | author = van Balen F, Smit W, Zuithoff N, Verheij T | title = Clinical efficacy of three common treatments in acute otitis externa in primary care: randomised controlled trial. | journal = BMJ | volume = 327 | issue = 7425 | pages = 1201-5 | year = 2003 | id = PMID 14630756}}''[http://bmj.bmjjournals.com/cgi/content/full/327/7425/1201 Full text]''</ref>
==[[Otitis externa epidemiology and demographics|Epidemiology and Demographics]]==


===Characteristics of the external ear leading to external otitis===
==[[Otitis externa risk factors|Risk Factors]]==
The outer ear canal starts at the opening on each side of the head that allows the entry of sound; the skin-lined canal extends in as far as the tympanic membrane (ear drum). The thin topmost layer of the ear canal skin is continuous with the surface of the ear drum, forming its outermost layer. There are two distinct anatomical regions of the ear canal, the outer portion, which lines the movable cartilage portion of the ear canal that is surrounded by soft tissues of the side of the head, and the inner portion, which lines the bony ear canal that is part of the skull. The bony ear canal can be seen on preserved specimens of the skull. The skin that is most easily injured, commonly giving rise to external otitis, is the delicate skin of the inner portion, the thin closely applied skin of the bony ear canal, which is perhaps the only skin of the body that ordinarily should never be touched!


The ear canal skin is specialized and is not like skin anywhere else on the body.  The skin of the cartilaginous part of the ear canal contains glands that make wax (cerumen), which is believed to have protective function(s).  The skin of the bony portion of the canal is almost paper thin, is firmly attached to bone, is immobile, and has no sweat glands. Like skin elsewhere on the body, the surface layer of the canal skin sheds. Accumulation of shed debris is prevented by the self-cleaning mechanism of the ear canal, with the top layer of the canal skin migrating outward along the canal to the surface of the head and bringing debris with it. The outer ear canal skin has a thick layer of subcutaneous tissue cushioning it and is thus more resistant to injury than the skin of the bony canal.
==[[Otitis externa natural history, complications, and prognosis|Natural History, Complications, and Prognosis]]==


A [[folliculitis]] of one of the hairs of the outer portion of the ear canal can be the start of a bout of external otitis. Impaction of cerumen that abuts up against the delicate skin of the bony canal, or attempts to remove the impacted wax, can also be the initial event.  Other inciting factors can be foreign bodies or cysts that develop in the skin near or just inside the canal opening.
==Diagnosis==
 
[[Otitis externa history and symptoms|History and Symptoms]] | [[Otitis externa physical examination|Physical Examination]] | [[Otitis externa laboratory findings|Laboratory Findings]] | [[Otitis externa CT|CT]] | [[Otitis externa other imaging findings|Other Imaging Findings]]
The S-shape of the ear canal, the presence of hair in the outer part, and the outward migration of skin all combine to help shed water from the ear canal and keep shed skin from building up within the canal, as well as to keep water from pooling in the innermost canal.  In some minor malformations of the ear canal or auricle, the size and shape of the canal may pre-dispose allowing water that enters the ear to remain, or to inhibit the normal shedding of superficial skin and [[Earwax|cerumen]] from the ear canal. In such cases, the individual may have a predispostion to recurrent external otitis.
 
===Pathogens - The Disease-Causing Germs===  
The bacterial pathogens at the top of the list are ''[[Pseudomonas aeruginosa]]'' and ''[[Staphylococcus aureus]]'', followed by a great number of other gram-positive and gram-negative species.<ref>{{cite journal | author = Roland P, Stroman D | title = Microbiology of acute otitis externa. | journal = Laryngoscope | volume = 112 | issue = 7 Pt 1 | pages = 1166-77 | year = 2002 | id = PMID 12169893}}</ref> ''[[Candida albicans]]'' and ''[[Aspergillus]]'' species are the most common fungal pathogens responsible for the condition.
 
==Diagnosis==
 
When the physician looks in the ear, the canal appears red and swollen in well-developed cases of acute external otitis. The ear canal may also appear [[eczema]]-like, with scaly shedding of skin. Touching or moving the outer ear increases the pain, and this maneuver on physical exam is very important in establishing the clinical diagnosis. It may be difficult for the physician to see the [[eardrum]] with an [[otoscope]] at the initial examination because of narrowing of the ear canal from inflammation and the presence of drainage and debris. Sometimes the diagnosis of external otitis is presumptive and return visits are required to fully examine the ear. Culture of the drainage may identify the bacteria or fungus causing infection, but is not part of the routine diagnostic evaluation.  In severe cases of external otitis, there may be swelling of the [[lymph node]](s) directly beneath the ear.
 
The diagnosis may be missed in early cases because the examination of the ear, with the exception of pain with manipulation, is normal or nearly normal. In some cases of early external otitis, the most striking visual finding in the ear canal is the lack of cerumen. As a moderate or severe case of external otitis resolves, weeks may be required before the ear canal again shows a normal amount of cerumen.
 
===Physical Examination===
 
<div align="left">
<gallery heights="175" widths="175">
Image:Otitis Externa Oct2004 044 2 op .jpg|Boil (furuncle) occluding the right external auditory meatus<ref>http://www.ghorayeb.com</ref>.
Image:Otitis Externa GG .jpg|Otitis externa.<ref>http://www.ghorayeb.com</ref>
</gallery>
</div>
 
<div align="left">
<gallery heights="175" widths="175">
Image:Otitis Externa .jpg|Magnified picture of the furuncle. Note the complete occlusion of the external auditory meatus, the redness and the crusted exudate.<ref>http://www.ghorayeb.com</ref>
Image:Allergy to Neomycin 350 SQ.jpg|Allergic otitis externa, a reaction to Neomycin. The skin of the external auditory meatus, concha, incisura intertragica is swollen, bumpy and itchy.<ref>http://www.ghorayeb.com</ref>
</gallery>
</div>
 
<div align="left">
<gallery heights="175" widths="175">
Image:AURICLEDERMATITISG.jpg|Otitis externa and seborrheic dermatitis.<ref>http://www.ghorayeb.com</ref>
Image:Seborrheic Dermatitis and Otitis Externa op.jpg|Otitis externa and seborrheic dermatitis.<ref>http://www.ghorayeb.com</ref>
</gallery>
</div>
 
===Differentiating between otitis externa and otitis media===
 
The second type of common "earache" is [[otitis media]], and this inflammation of the [[tympanic membrane]] and [[middle ear]] space is usually clinically distinct from otitis externa. In a person with no history of chronic ear disease, acute otitis media seldom occurs in the absence of a recent viral upper respiratory infection (URI), a common cold or flu.  Most earaches are caused by either acute otitis externa or by acute otitis media; it is very unusual to see both in the same ear at the same time. Importantly, persistent earache without the physical findings of ear infection can be due to more serious, even lifethreatening, conditions, and should always be investigated by an ear, nose, and throat physician (otolaryngologist).  Acute otitis media and acute otitis externa are easily confused because both can cause earache and drainage from the ear ([[otorrhea]]). In middle ear infections, drainage only occurs if the tympanic membrane has a perforation or severe retraction pocket. When there is chronic suppurative [[otitis media]], with or without [[cholesteatoma]], the drainage in the ear canal may appear identical to drainage from external otitis. The primary distinction between acute otitis media and acute otitis externa is that otitis externa is characterized by swelling of the ear canal skin, and there is increased pain on any pushing or pulling of the ear.
 
Monocular otoscopy, the most common means used by family physicians and pediatricians to examine ears, has the severe limitation of providing no depth perception for the examiner.  Uncertainty of the exact diagnosis can lead to unnecessarily excessive prescribing to cover treatment for both otitis media and otitis externa.  Differentiating external otitis from otitis media is readily accomplished using a binocular microscope, which allows comfortable and safe cleaning of any wax or debris in the ear canal, yielding a complete view of the visble parts of the ear canal and eardrum.  Most otolaryngologists (ear, nose, & throat physicians) have binocular microscopes in their offices and are trained to quickly accomplish this task, increasing the likelihood of a correct, definitive diagnosis, which can then be treated appropriately. Cleaning of an infected ear canal promotes better contact of the topical antibiotic drops and shortens recovery time.  Children with surgically inserted ear tubes who fail to keep water out of their ears often develop painless drainage from resulting bacterial otitis media. This is not external otitis, but otitis media.  It is painless because the opening maintained by the tube, assuming no obstructing crusts or blood clot, prevents pressure from building up within the middle ear.  This problem typically clears with antibiotic drops only and does not require oral antibiotics.
 
Quinolone antibiotics in topical form (ear drops) have been shown to be of benefit in stopping discharge from otitis media through an open eardrum, and so some treatments for otitis  externa may be of benefit to otitis media.<ref> Macfadyen CA. Acuin JM. Gamble C. Topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations. [Review] [157 refs] [Journal Article. Meta-Analysis. Review] Cochrane Database of Systematic Reviews. (4):CD004618, 2005.</ref> The main pitfall of having a case of otitis media misdiagnosed as otitis externa is that a serious infection of the middle-ear may have complications and sequelae over time. Additionally, many types of topical ear drops that are safe and effective for use in the ear canal can be irritating and even damaging if allowed past the ear drum into the more delicate internal membranes of the middle-ear, prompting the warning that such topical preparations ''should not be used unless the tympanic membrane is known to be intact''. For both reasons, caution is given against self-treatment of "earache" without proper medical evaluation.
 
If there is prolonged drainage of noxious substances from the middle ear through the ear drum, then the skin of the ear canal may become secondarily inflamed. In this situation, one that occurs only in individuals with severe chronic otitis media, ''both'' external otitis and otitis media are present at that same time.  Prolonged care by a qualified specialist is generally required.


==Treatment==
==Treatment==
[[Otitis externa medical therapy|Medical Therapy]] | [[Otitis externa prevention|Prevention]] | [[Otitis externa cost-effectiveness of therapy|Cost-Effectiveness of Therapy]]
The goal of treatment is to cure the infection and to return the ear canal skin to a healthy condition. When external otitis is very mild, in its initial stages, simply refraining from swimming or washing hair for a few days, and keeping all implements out of the ear, usually results in cure. For this reason, external otitis is called a self-limiting condition. However, if the infection is moderate to severe, or if the climate is humid enough that the skin of the ear remains moist, spontaneous improvement may not occur.
 
Topical solutions or suspensions in the form of ear drops are the mainstays of treatment for external otitis. Some contain antibiotics, either antibacterial or antifungal, and others are simply designed to mildly acidify the ear canal environment to discourage bacterial growth. Some prescription drops also contain anti-inflammatory steroids, which help to resolve swelling and itching. Although there is evidence that steroids are effective at reducing the length of treatment time required, fungal otitis externa (also called otomycosis) may be caused or aggravated by overly prolonged use of  steroid-containing drops. In addition to topical antibiotics, oral anti-pseudomonal antibiotics can be used in case of severe soft tissue swelling extending into the face and neck and may hasten recovery.
 
Removal of debris (wax, shed skin, and pus) from the ear canal promotes direct contact of the prescribed medication with the infected skin and shortens recovery time. This is best accomplished using a binocular microscope. When canal swelling has progressed to the point where the ear canal is blocked, topical drops may not penetrate far enough into the ear canal to be effective. The physician may need to carefully insert a wick of cotton or other commercially available, pre-fashioned, absorbent material called an ear wick and then saturate that with the medication. The wick is kept saturated with medication until the canal opens enough that the drops will penetrate the canal without it. Removal of the wick does not require a health professional. Antibiotic ear drops should be dosed in a quantity that allows coating of most of the ear canal and used for no more than 4 to 7 days. The ear should be left open. Do note that it is imperative that there is visualization of an intact [[tympanic membrane]]. Use of certain medications with a ruptured tympanic membrane can cause tinnitus, vertigo, dizziness and hearing loss in some cases.
 
Although the acute external otitis generally resolves in a few days with topical washes and antibiotics, complete return of hearing and cerumen gland function may take a few more days. Once healed completely, the ear canal is again self-cleaning. Until it recovers fully, it may be more prone to repeat infection from further physical or chemical insult.
 
Effective medications include [[ear drop]]s containing [[antibiotic]]s to fight infection, and [[corticosteroid]]s to reduce itching and inflammation. In painful cases a topical solution of antibiotics such as aminoglycoside, polymyxin or fluoroquinolone is usually prescribed. Antifungal solutions are used in the case of fungal infections. External otitis is almost always predominantly bacterial or predominantly fungal, so that only one type of medication is necessary and indicated.
 
The pain of acute otitis externa is often severe enough to interfere with sleep. Topical analgesic drops often prescribed by primary care providers for pain relief are almost never adequate and should not be relied upon. A brief course of oral narcotic pain medication is often necessary to maintain comfort while the antibiotic drops are working. Improvement with appropriate initial treatment (cleaning of the canal, wick insertion if necessary, and antibiotic drops in adequate amount) is fairly rapid, with pain improvement occurring within one day and resolution within 2-4 days. Heat application using a heating pad, can also aid in pain relief.
 
===Non-prescription remedies===
 
Provided it is not too severe, recurrent otitis externa can often be successfully treated by non-prescription means, at low cost. ''When symptoms recur in an individual who has had a previous diagnosis made'', the use of non-prescription drops along with precautions to keep water out of the ear is generally effective. Self-treatment with non-prescription remedies is dangerous in individuals who have not been previously evaluated for the condition, because the [[tympanic membrane]] may not be intact, and because the true condition may be otitis media with drainage. Drops and water precautions may actually resolve otitis media with drainage for a period of time, while allowing an undiagnosed [[cholesteatoma]] to progress, or complications of otitis media to develop.
 
Effective solutions for the ear canal include acidifying and drying agents, used either singly or in combination. When the ear canal skin is inflamed from the acute otitis externa, the use of dilute [[acetic acid]] may be painful.
 
[[Burow's solution]] is an effective remedy against both bacterial and fungal external otitis. This is a buffered mixture of [[aluminum sulfate]] and [[acetic acid]], and is available without prescription in the United States.<ref>Kashiwamura M. Chida E. Matsumura M. Nakamaru Y. Suda N. Terayama Y. Fukuda S. The efficacy of Burow's solution as an ear preparation for the treatment of chronic ear infections. [Clinical Trial. Journal Article] Otology & Neurotology. 25(1):9-13, 2004 </ref>


===Prevention===
==Case Studies==
[[Otitis externa case study one|Case #1]]


Provided it is not too severe, recurrent otitis externa can often be successfully treated by non-prescription means, at low cost. ''When symptoms recur in an individual who has had a previous diagnosis made'', the use of non-prescription drops along with precautions to keep water out of the ear is generally effective. Self-treatment with non-prescription remedies is dangerous in individuals who have not been previously evaluated for the condition, because the [[tympanic membrane]] may not be intact, and because the true condition may be otitis media with drainage. Drops and water precautions may actually resolve otitis media with drainage for a period of time, while allowing an undiagnosed [[cholesteatoma]] to progress, or complications of otitis media to develop.
==Related Chapters==
 
Effective solutions for the ear canal include acidifying and drying agents, used either singly or in combination.<ref>{{cite journal |author=Doc Vikingo |title=Swimmers Ear - Additional Advice About A Pesky and Sometimes Painful Problem |journal=Diver's Alert Network: Alert Diver Magazine |volume= |issue= |pages= |year=2007 |month= March/April |pmid= |doi= |url=http://www.awoosh.com/DocVikingo/Preventing_Swimmers_Ear.htm |accessdate=2008-07-22}}</ref> When the ear canal skin is inflamed from the acute otitis externa, the use of dilute [[acetic acid]] may be painful.
 
[[Burow's solution]] is an effective remedy against both bacterial and fungal external otitis. This is a buffered mixture of [[aluminium sulfate]] and [[acetic acid]], and is available without prescription in the United States.<ref>Kashiwamura M. Chida E. Matsumura M. Nakamaru Y. Suda N. Terayama Y. Fukuda S. The efficacy of Burow's solution as an ear preparation for the treatment of chronic ear infections. [Clinical Trial. Journal Article] Otology & Neurotology. 25(1):9-13, 2004 </ref>
 
==Prognosis==
Otitis externa responds well to treatment, but complications may occur if it is not treated. Individuals with underlying [[diabetes]] or disorders of the immune system are more likely to get complications, including malignant otitis externa. In these individuals, rapid examination by an otolaryngologist (ear, nose, and throat physician) is very important.
 
==Complications==
* Chronic otitis externa
* Spread of infection to other areas of the body
* Necrotizing External Otitis
 
===Necrotizing External Otitis  (Malignant otitis externa)===
 
This uncommon form of external otitis occurs mainly in an elderly diabetics, being somewhat more likely and more severe when the diabetes is poorly controlled. Even less commonly, it can develop due to a severely compromised immune system.  Beginning as infection of the external ear canal, there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal. 
 
The hallmark of malignant otitis externa (MOE) is unrelenting pain that interferes with sleep and persists even after swelling of the external ear canal may have resolved with topical antibiotic treatment. MOE follows a more chronic course than ordinary acute otitis externa. There may be granulation involving the floor of the external ear canal, most often at the bony-cartilaginous junction.  Paradoxically, the physical findings of MOE, at least in its early stages, are often much less dramatic than those of ordinary acute otitis externa. In later stages there can be soft tissue swelling around the ear, even in the absence of significant canal swelling.  Unlike ordinary otitis externa, MOE requires oral or intravenous antibiotics for cure. Diabetes control is also an essential part of treatment. 
 
When MOE goes unrecognized and untreated, the infection continues to smolder and over weeks or months can spread deeper into the head and involve the bones of the skull base, constituting skull base osteomyelitis <nowiki>(SBO)</nowiki>. 
 
The infecting organism is almost always pseudomonas aeruginosa, but it can instead be fungal (aspergillus or mucor). MOE and SBO are not amenable to surgery, but exploratory surgery may facilitate culture of unusual organism(s) that are not responding to empirically used anti-pseudomonal antibiotics. 
 
The usual surgical finding is diffuse cellulitis without localized abscess formation. SBO can extend into the petrous apex of the temporal bone or more inferiorly into the opposite side of the skull base. As the skull base is progressively involved, the adjacent exiting cranial nerves and their branches, especially the facial nerve and the vagus nerve, may be affected, resulting in facial paralysis and hoarseness, respectively. 
 
If both of the recurrent laryngeal nerves are paralyzed, shortness of breath may develop and necessitate tracheotomy.  Profound deafness can occur, usually later in the disease course due to relative resistance of the inner ear structures. Gallium scans are sometimes used to document the extent of the infection but are not essential to disease management. Skull base osteomyelitis is a chronic disease that can require months of IV antibiotic treatment, tends to recur, and has a significant mortality rate.
 
 
==References==
{{Reflist|2}}
 
== See also ==
* [[Waterborne diseases]]
* [[Waterborne diseases]]
 
* [[Otitis media]]
==External links==
 
*[http://www.seattlechildrens.org/child_health_safety/health_advice/swimmers_ear.asp What to do if your child has swimmer's ear] from Seattle Children's Hospital
*[http://www.drtbalu.com/Malignantotitisexterna.html /drtbalu otolaryngology online]
 


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Latest revision as of 23:29, 29 July 2020

Otitis externa
A severe case of Otitis Externa. Case provided by James Heilman, MD.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Luke Rusowicz-Orazem, B.S.; Tarek Nafee, M.D. [2]

Synonyms and keywords: Swimmer's ear; external otitis; acute otitis externa; chronic otitis externa; malignant otitis externa; malignant necrotizing otitis externa; outer ear infection

Overview

Historical Perspective

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Pathophysiology

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