Download MBBS (Bachelor of Medicine and Bachelor of Surgery) 4th Year (Final Year) ENT OTITIS Externa Handwritten Notes
CLASSIFICATION
1. INFECTIVE GROUP
2.REACTIVE GROUP
BACTERIAL
? Eczematous otitis externa
? Localized otitis externa
(Furuncle)
? Seborrhoeic otitis externa
? Diffuse otitis externa
? Neurodermatitis
? Malignant otitis externa
FUNGAL
? Otomycosis
VIRAL
? Herpes zoster oticus
? Otitis externa haemorrhagica
Furuncle (localized acute otitis
externa)
? A furuncle is a staphylococcal infection of the
hair follicle.
? cartilaginous part of the meatus.
? Usually single, the furuncles may be multiple.
? Pain,tenderness,painful movements of
pinna,jaw,enlarged lymphnodes[Periauricular
lymph nodes (anterior, posterior and inferior)]
? Treatment of Furuncle without abscess
formation, consists of systemic antibiotics,
analgesics and local heat.
? An ear pack of 10% ichthammol glycerine
provides splintage and reduces pain. Hygroscopic
action of glycerine reduces oedema, while
ichthammol is mildly antiseptic.
? If abscess has formed, incision and drainage
should be done.
? In case of recurrent furunculosis,
? diabetes should be excluded, and
? attention paid to the patient's nasal vestibules
which may harbour staphylococci and the
infection transferred by patient's fingers.
? Staphylococcal infections of the skin as a
possible source should also be excluded and
suitably treated.
Diffuse otitis externa.
? It is diffuse inflammation of meatal skin which may spread
to involve the pinna and epidermal layer of tympanic
membrane.
? Aetiology.
? Disease is commonly seen in hot and humid climate and in
swimmers.
? Excessive sweating changes the pH of meatal skin from
that of acid to alkaline which favours growth of
pathogens.
? This is by
? (i) trauma to the meatal skin and
? (ii) invasion by pathogenic organisms.
? Common organisms responsible for otitis
externa are Staphylococcus aureus,
Pseudomonas pyocyaneus, Bacil us proteus
and Escherichia coli but more often the
infection is mixed.
? Acute phase is characterized by
? hot burning sensation in the ear, followed by pain
which is aggravated by movements of jaw.
? Ear starts oozing thin serous discharge which later
becomes thick and purulent.
? Meatal lining becomes inflamed and swol en.
? Collection of debris and discharge accompanied with
meatal swel ing gives rise to conductive hearing loss.
? In severe cases, regional lymph nodes become
enlarged and tender with cel ulitis of the surrounding
tissues.
? Chronic phase is characterized by irritation and
strong desire to itch. This is responsible for acute
exacerbations and reinfection.
? Discharge is scanty and may dry up to form
crusts.
? Meatal skin which is thick and swol en may also
show scaling and fissuring.
? Rarely, the skin becomes hypertrophic leading to
meatal stenosis (chronic stenotic otitis externa).
? Treatment. Acute phase is treated as follows:
? (i) Ear toilet.
? It is the most important single factor in the
treatment of diffuse otitis externa
? anteroinferior meatal recess
? Ear toilet can be done by dry mopping, suction
clearance or irrigating the canal with warm,
sterile normal saline.
? (i ) Medicated wicks.
? After thorough toilet, a gauze wick soaked in
antibiotic steroid preparation is inserted in the
ear canal .
? Local steroid drops help to relieve oedema,
erythema and prevent itching.
? Aluminium acetate (8%) or silver nitrate (3%) are
mild astringents and can be used in the form of a
wick to form a protective coagulum to dry-up an
oozing meatus.
? (i i) Antibiotics. Broad-spectrum systemic
antibiotics are used when there is cel ulitis and
acute tender lymphadenitis.
? (iv) Analgesics. For relief of pain.
? Chronic phase. Treatment aims at
? (i) reduction of meatal swel ing so that ear toilet can
be effectively done and
? (i ) al eviation of itching so that scratching is stopped
and further recurrences controlled.
? A gauze wick soaked in 10% ichthammol glycerine and
inserted into the canal helps to reduce swel ing. This is
followed by ear toilet with particular attention to
anteroinferior meatal recess.
? Itching can be controlled by topical application of
antibiotic steroid cream.
? When the meatal skin is thickened to the point of
obstruction and resists al forms of medical treatment,
i.e. chronic stenotic otitis externa, it is surgical y
excised, bony meatus is widened with a dril and lined
by split-skin graft
Otitis externa haemorrhagica
? It is characterized by formation of haemorrhagic
bul ae on the tympanic membrane and deep meatus.
? It is probably viral in origin
? The condition causes severe pain in the ear and blood-
stained discharge when the bul ae rupture.
? Treatment with analgesics is directed to give relief
from pain.
? Antibiotics are given for secondary infection of the ear
canal, or middle ear if the bul a has ruptured into the
middle ear.
OTITIS EXTERNA (CONTD)
Otomycosis
Herpes zoster oticus
Malignant otitis externa
Otomycosis
? Otomycosis is a fungal infection of the ear
canal that often occurs due to Aspergil us
niger, A. fumigatus or Candida albicans.
? It is seen in hot and humid climate of tropical
and subtropical countries.
? Secondary fungal growth is also seen in
patients using topical antibiotics for treatment
of otitis externa or middle ear suppuration.
? The clinical features of otomycosis include
intense itching, discomfort or pain in the ear,
watery discharge with a musty odour and ear
blockage.
? The fungal mass may appear white,brown or
black and has been likened to a wet piece of filter
paper.
? Examined with an otoscope, A. niger appears as
blackheaded filamentous growth, A. fumigatus as
pale blue or green and Candida as white or
creamy deposit.
? Meatal skin appears sodden, red and
oedematous.
? Treatment consists of thorough ear toilet.
? Specific antifungal agents can be applied.
? Nystatin (100,000 units/mL of propylene glycol) is
effective against Candida.
? Other broad-spectrum antifungal agents include
clotrimazole and povidone iodine.
? Two per cent salicylic acid in alcohol is also effective.
? Antifungal treatment should be continued for a week
even after apparent cure to avoid recurrences.
? Ear must be kept dry.
? Bacterial infections are often associated with
otomycosis and treatment with an antibiotic/steroid
preparation helps to reduce inflammation and oedema
and thus permitting better penetration of antifungal
agents.
Herpes zoster oticus.
? It is characterized by formation of vesicles on
the tympanic membrane, meatal skin, concha
and postauricular groove.
? The VI th and VI Ith cranial nerves may be
involved.
Malignant (necrotizing) otitis externa.
? It is an inflammatory condition caused by
pseudomonas infection usual y in the elderly
diabetics, or in those on immunosuppressive drugs.
? Its early manifestations resemble diffuse otitis externa
but there is excruciating pain and appearance of
granulations in the ear canal.
? Facial paralysis is common.
? Infection may spread to the skul base and jugular
foramen causing multiple cranial nerve palsies.
? Anteriorly, infection spreads to temporomandibular
fossa, posteriorly to the mastoid and medial y into the
middle ear and petrous bone.
? Diagnosis.
? Severe otalgia in an elderly diabetic patient with
granulation tissue in the external ear canal at its
cartilaginous? bony junction should alert the physician of
necrotizing otitis externa.
? CT scan may show bony destruction but is often not
helpful.
? Gal ium-67 is more useful in diagnosis and follow-up of the
patient.
? It is taken up by monocytes and reticuloendothelial cells,
and is indicative of soft tissue infection. It can be repeated
every 3 weeks to monitor the disease and response to
treatment.
? Technetium 99 bone scan reveals bone infection but test
remains positive for a year or so and cannot be used to
monitor the disease.
? Treatment. It consists of:
? (i) Control of diabetes.
? (ii) Toilet of ear canal.
? (iii) Antibiotic treatment against causative
organism, which in most ears is P. aeruginosa,
but sometimes other organisms which can be
found by culture and sensitivity.
? Antibiotic treatment is continued for 6?8
weeks, sometimes more.
? Antibiotics found effective are:
? ? Gentamicin combined with ticarcillin. They are given
intravenously. Gentamicin is both ototoxic and
nephrotoxic, and ticarcillin may produce penicillin-like
reactions.
? ? Third-generation cephalosporins, e.g. ceftriaxone 1?2
g/day i.v. or ceftazidime 1?2 g/day i.v. are usually
combined with an aminoglycoside.
? ? Quinolones (ciprofloxacin, ofloxacin and levofloxacin) are
also effective and can be given orally. They can be
combined with rifampin. Ciprofloxacin 750 mg OD orally
can be used. Oral therapy with quinolones obviates the
need for admission for i.v. injections.
? If patient is not responsive, culture and sensitivity of ear
discharge should guide the surgeon.
? Prolonged antibiotic treatment has replaced radical
surgery and resections done earlier for this condition.
OTITIS EXTERNA(CONTD)
Eczematous otitis externa
Seborrhoeic otitis externa
Neurodermatitis
Keratosis obturans
Eczematous otitis externa
? It is the result of hypersensitivity to infective
organisms or topical ear drops such as
chloromycetin or neomycin, etc.
? It is marked by intense irritation,vesicle
formation, oozing and crusting in the canal.
? Treatment is withdrawal of topical antibiotic
causing sensitivity and application of steroid
cream.
Seborrhoeic otitis externa.
? It is associated with seborrhoeic dermatitis of
the scalp.
? Itching is the main complaint. Greasy yellow
scales are seen in the external canal, over the
lobule and postauricular sulcus.
? Treatment consists of ear toilet, application of
a cream containing salicylic acid and sulfur,
and attention to the scalp for seborrhoea.
Neurodermatitis.
? It is caused by compulsive scratching due to
psychological factors.
? Patient's main complaint is intense itching.
? Otitis externa of bacterial type may fol ow
infection of raw area left by scratching.
? Treatment is sympathetic psychotherapy and
that meant for any secondary infection.
? Ear pack and bandage to the ear are helpful
toprevent compulsive scratching
Keratosis obturans
? Collection of a pearly white mass of desquamated epithelial cel s in
the deep meatus is cal ed keratosis obturans.
? This, by its pressure effect, causes absorption of bone leading to
widening of the meatus so much so that facial nerve may be
exposed and paralyzed.
? (a) Aetiology.
? It is commonly seen between 5 and 20 years
? and may affect one or both ears.
? It may sometimes be associated with bronchiectasis and chronic
sinusitis.
? Normal y, epithelium from surface of tympanic membrane
migrates onto the posterior meatal wal .
? Failure of this migration or obstruction to migration caused by wax
may lead to accumulation of the epithelial plug in the deep meatus.
Clinical features
? Presenting symptoms may be pain in the ear,
hearing loss, tinnitus and sometimes ear
discharge.
? On examination, ear canal may be full of
pearly white mass of keratin material
disposed in several layers.
? Removal of this mass may show widening of
bony meatus with ulceration and even
granuloma formation.
Treatment
? Keratotic mass is removed either by syringing or
instrumentation, similar to the techniques
employed for impacted wax.
? Secondary otitis externa may be presentand
should be treated.
? Patient should be periodical y checked and any
reaccumulations removed.
? Recurrence can be checked to some extent by
the use of keratolytic agent such as 2% salicylic
acid in alcohol
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This post was last modified on 11 August 2021