OTITIS EXTERNA, CERUMEN IMPACTION, FOREIGN BODIES

NURS 542 By Lakesha Lemons-Price

EAR ANATOMY

OTITIS EXTERNA
A term encompassing a variety of conditions causing inflammation and/or infection of the external auditiory canal 6 subgroups:

Acute diffuse bacterial otitis externa (swimmers ear) Acute localized otitis externa (furunculosis) Chronic otitis externa Eczematous otitis externa Fungal otitis externa (otomycosis) Invasive or necrotizing (malignant) otitis externa

ETIOLOGY

Swimming Hot, humid climates Tightly fitting hearing aids Use of ear plugs Pseudomonas aeruginosa S. aureus Fungus

PATHOPHYSIOLOGY
Infection happens when there is a a breakdown in the skin/cerumen protective barrier of the external ear canal 2 most common pathogens: Pseudomonas and Staph aureus If left untreated, the infection progresses through 3 different phases:

1. Pre-inflammatory stage 2. Inflammatory stage (3 phases) 3. Chronic stage

CLINICAL PRESENTATION
Otalgia (ear pain) Otorrhea (serous to purulent) Pruritus Tragal manipulation pain Erythema and edema Aural fullness or pressure Partial hearing loss TM may appear dull and infected Fever and chills may also be present DM & immunocompromised pts suspect NOE

Granulation tissue or small ulcerations of necrotic tissue Facial nerve palsy

RELEVANT HISTORY
Trauma (q tip use, foreign body in ear, ear syringing, ear plugs, hearing aid, head trauma) Immune status DM Contact dermatitis, eczema, and psoriasis predispose to OE Previous hx of ear disease or ear surgery

DIAGNOSTICS

Thorough H&P examination

Otoscopy Look for several key findings:
Edema/erythema of the canal Narrowing of the canal Debris in the canal Purulent secretions Also det. if TM is intact or perforated (affects treatment options)

***Expert opinion supports H&P as the best means of diagnosis of OE

DIAGNOSTICS

Lab
Culture: warranted after 1st tx failure to identify organism and prescribe effective antibiotic Leukocyte count: normal or mildly elevated ESR: quite elevated in NOE

Imaging
Considered if NOE suspected (CT, MRI, isotope bone scan)

DIFFERENTIAL DIAGNOSES

Furunculosis

Acute Otitis Media

occurs in the hair bearing (lateral third) portion of the EAC; it is differentiated from OE because the swelling assoc with it tends to be localized a single quadrant whereas with OE it is usually concentric and involves the entire lengh of the canal Must visualize the TM to differentiate from OE

Necrotizing Otitis Externa Mastoiditis

Foreign Body Neoplasms

Can be diagnosed if the post-auricular fold is obliterated (it is preseved in OE; pain to palpation over mastoid process

TREATMENT

Treatment of otitis externa involves nonpharmacological measures and pharmacological measures. Cleansing and debridement of the ear canal with cotton swabs and hydrogen peroxide or other antiseptic solution allows a more thorough examination of the ear. If the canal lumen is edematous and too narrow to allow adequate cleansing, a cotton wick or gauze strip inserted into the canal serves as a conduit for topical medications to be drawn into the canal. Usually wick is removed after two days.

TREATMENT

Topical Antibiotic Treatment:

Aminoglycosides
First line tx of OE during 1970s thru late 1990s Drawbacks: hypersensitivity, ototoxicity (if TM perforated), require QID dosing

Quinolones
Current first line therapy for OE: Ciprodex, CiproHC, Floxin Otic Advantages:
Cover both gram + and organisms BID dosing Can be used in pediatric population (small systemic absorption) No known ototoxicity Floxin Otic and Ciprodex FDA approved to treat OE with perf. TM

Disadvantages: costly

TREATMENT

Topical Antifungals

Non-antibiotic Topical Acidifying Agents

Lotrimin and tinactin Many tx algorithms add antifungal coverage if suspected upon initial presentation and/or after 1st treatment failure with abx Boric acid, acetic acid (Vosol HC), and alcohols Creates an acidic or toxic environment that is not conducive for bacterial/fungal growth Inexpensive Disadvantages:
Work well when used early in disease process Can be painful to use Require multiple tx per day for a long tx period (up to 3 weeks) Ototoxic if they get into the middle ear

TREATMENT

Oral Antibiotics

NSAIDs or Opioids

Systemic antibiotics are reserved for severe cases (Pseudomonas, s. aureus) Fever and systemic symptoms are present Ciprofloxacin is usually used BID for 10 days Treatment for necrotizing otitis externa requires prolonged therapy up to three months. Intravenous antipseudomonals with or without aminoglycosides are also appropriate. May be required for pain
Reduce swelling and inflammation

Topical Corticosteroids

STUDY
Late 1990s a significant percentage of primary care physicians were prescribing topical antibiotics and oral antibiotics to treat OE Roland et al performed a study in 2008

Topical quinolones were compared with topical aminoglycosides plus oral amoxicillin The study showed equivalent outcomes in both groups These findings provide evidence

that topical quinolines are as effective as topical aminoglycosides And that oral antibiotics are not necessary in the treatment of routine OE

PEARLS
May evolve into osteomyelitis of the skull base often called malignant otitis externa Do not miss severe malignant otitis externa in patients who are diabetic or immunocompromised

SUBJECTIVE

CC: right ear pain HPI: 18 y/o WM who is on the swim team at ULM, presents with constant pain in right ear for 2 days. Associated symptoms: fever, itching, ear fullness with decreased hearing, and purulent discharge. States he uses q-tips to clean his ears. Also states it hurts really bad to touch front part of my ear Allergies: none PMHx: None, Tonsillectomy, immunizations UTD FMHx: positive for DM Social Hx: smokes 1 pack cig/day Medications: None ROS: fever, itching, pain, ear fullness (dec. hearing), discharge

OBJECTIVE

VS: BP- 132/84, T99.5, P- 89, R- 20 Ht: 61 Wt: 185 BMI: 24.4 Physical examInspect (otoscope), palpate Diagnostics

ASSESSMENT
Medical diagnosis: Acute otitis externa Differential diagnosis

NOE AOM Mastoiditis Furunculosis Foreign body Neoplasms

PLAN

Pharmacotherapeutic approach

Non-pharmacologic approach/interventions Patient education

Prevention of OE How to take prescribed meds Smoking cessation

NSAID Ciprodex Would not consider oral antibiotics with this patient at this time Cleansing and debridement of the ear (cotton swabs/peroxide)

Referral

Dont supect NOE No evidence of treatment failure yet Severe pain (pt reports pain with tragal manipulation) No referral for this pt today

EVALUATION

Follow up plans
If condition worsens, return to office

REFERENCES

Ferri, F.F. (2012). Ferris clinical advisor 2012: 5 books in 1. Philadelphia, PA: Mosby. Lustig, L.R., & Schindler, J.S. (2012). Ear, nose, & throat disorders. In S.J. McPhee & M.A. Papadakis (Eds.), Current medical diagnosis & treatment 2012 (pp. 197198). New York: McGraw-Hill. Roland, P.S., Belcher, B.P., Bettis, R., Makabale, R.L., Conroy, P.J., Wall, G.M., . . . Dupre, S. (2008). A single topical agent is clinically equivalent to the combination of topical and oral antibiotic treatment for otitis externa. American Journal of Otolaryngology, 29(4), 255-261.