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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.| |
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| {{Otitis externa}} | | {{Otitis externa}} |
| | '''For patient information, click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{CMG}} | | {{CMG}}; {{AE}} {{LRO}}; {{TarekNafee}} |
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| ==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.
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| 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]]== |
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| 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]]== |
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| ==Diagnosis== | | ==[[Otitis externa classification|Classification]]== |
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| 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.
| | ==[[Otitis externa pathophysiology|Pathophysiology]]== |
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| 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.
| | ==[[Otitis externa causes|Causes]]== |
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| ===Physical Examination=== | | ==[[Differentiating otitis externa from other diseases|Differentiating Otitis Externa from Other Diseases]]== |
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| <div align="left">
| | ==[[Otitis externa epidemiology and demographics|Epidemiology and Demographics]]== |
| <gallery heights="175" widths="175">
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| Image:Otitis Externa Oct2004 044 2 op .jpg|Boil (furuncle) occluding the right external auditory meatus<ref>http://www.ghorayeb.com</ref>.
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| Image:Otitis Externa GG .jpg|Otitis externa.<ref>http://www.ghorayeb.com</ref>
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| </gallery>
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| </div>
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| <div align="left">
| | ==[[Otitis externa risk factors|Risk Factors]]== |
| <gallery heights="175" widths="175">
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| 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>
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| 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>
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| </gallery>
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| </div>
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| <div align="left">
| | ==[[Otitis externa natural history, complications, and prognosis|Natural History, Complications, and Prognosis]]== |
| <gallery heights="175" widths="175">
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| Image:AURICLEDERMATITISG.jpg|Otitis externa and seborrheic dermatitis.<ref>http://www.ghorayeb.com</ref>
| | ==Diagnosis== |
| Image:Seborrheic Dermatitis and Otitis Externa op.jpg|Otitis externa and seborrheic dermatitis.<ref>http://www.ghorayeb.com</ref>
| | [[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]] |
| </gallery>
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| </div>
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| ==Treatment== | | ==Treatment== |
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| | [[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.
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| 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.
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| 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.
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| 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.
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| 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.
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| 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.
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| ===Non-prescription remedies===
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| 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.
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| 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.
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| [[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> | |
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| ===Prevention===
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| 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.
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| 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.
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| [[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>
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| ==Prognosis==
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| 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.
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| ==Complications==
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| * Chronic otitis externa
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| * Spread of infection to other areas of the body
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| * Necrotizing External Otitis
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| ===Necrotizing External Otitis (Malignant otitis externa)===
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| 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.
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| 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.
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| 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>.
| | ==Case Studies== |
| | [[Otitis externa case study one|Case #1]] |
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| 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.
| | ==Related Chapters== |
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| 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.
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| 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.
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| ==References== | |
| {{Reflist|2}}
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| == See also ==
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| * [[Waterborne diseases]] | | * [[Waterborne diseases]] |
| | | * [[Otitis media]] |
| ==External links==
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| *[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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| {{Diseases of the ear and mastoid process}} | | {{Diseases of the ear and mastoid process}} |
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| [[de:Otitis externa]] | | [[de:Otitis externa]] |
| [[fr:Otite externe]] | | [[fr:Otite externe]] |
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| [[tr:Otitis eksterna]] | | [[tr:Otitis eksterna]] |
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