Otitis externa, media and other ear conditions

Otitis externa

inflammation of ear canal

also known as swimmer's ear due to water increasing risk of infection

Acute (

Risk factors of otitis externa

Skin conditions — eczema, psoriasis, and seborrhoeic dermatitis may produce debris and skin breakdown in the ear canal which can encourage infection 

Acute otitis media - if the ear drum is peforated secretions may enter ear canal

contact dermatitis

trauma to ear

foreign bodies in ear

frequent water in ear

allergies

Complications of otitis externa

### __generally rare but include:__

Chronic otitis externa

Regional spread of infection causing cellulitis etc.

Fibrosis and stenosis of the ear canal, and fibrosis of the tympanic membrane with potential conductive hearing loss

Myringitis (inflammation of the tympanic membrane) and perforation of the tympanic membrane

Malignant otitis externa is life threatening can cause facial nerve palsy (early sign); osteomyelitis involving the mastoid, and may lead to sepsis

Diagnosis of acute otitis externa

## suspect if:

### __1 typical symptom within 48 hrs__:

* itch in the ear canal
* ear pain/discharge
* not so commonly hearing loss

### __at least 2 typical signs__

* tenderness
* ear canal red/oedema
* tympanic membrane erythema
* Cellulitis of the pinna and adjacent skin

Diagnosis of chronic otitis externa

* **Typical symptoms:**
* Constant itch in the ear.
* Mild discomfort or pain (rare).
* **Typical signs:**
* Lack of ear wax in the external ear canal.
* Dry scaly skin in the ear canal, which varies in thickness but often results in at least partial canal stenosis; or red, moist skin in the ear canal.
* Fluffy, cotton-like debris, hyphae, or dots of black debris may be seen in the ear canal if there is fungal infection.
* Conductive hearing loss.

Differential diagnosis of otitis externa

\
* Foreign body in the ear (especially in children) may present with purulent ear discharge and pain.
* Impacted ear wax — may cause pain and hearing loss.
* Skin conditions
* Referred pain — may originate from the teeth, sphenoidal sinus, neck, or throat.
* Cholesteatoma — causes persistent or recurrent ear discharge and fullness, but is typically painless. There may be a perforated tympanic membrane, retraction pocket in the tympanic membrane, and granulation tissue, which may mimic malignant otitis externa.
* Mastoiditis — may present with systemic illness, fever, marked hearing loss, and mastoid tenderness or swelling.
* Ramsay Hunt syndrome — a form of herpes zoster affecting the facial nerve, which may present with severe pain, vesicles on the external ear canal and posterior pinna, facial paralysis, loss of taste on the anterior two-thirds of the tongue, and decreased lacrimation on the involved side

Non pharmacological management of acute otitis externa

self care: avoid damage

keep ears clean and dry: avoid water sport 7-10 days

keep shampoo etc. out of ear

consider cleaning aural toilet

Pharmacological management of otitis externa

use OTC acetic acid 2% ear drops/ spray every morning/evening and after contact with water for max 7 days

paracetamol/ibuprofen simple analgesia

prescribe topical antibiotic with or without topical corticosteroid for 7-14 days

oral antibiotic ciprofloxacin if immunocompromised of severe infection or spread to other tissues

ear drop preparations for otitis externa

Otomize \n Sofradex \n Gentamicin/HC \n FML drops \n Clotrimazole Drops \n Betnesol/N

management of chronic otitis externa

reinforce self care analgesia ear swab cleaning aura toilet

topical ear preparation if fungal infection: clotrimazole 1% 2-3 q day

at least 14 days after infection resolved prescribe clioquinol + corticosteroid 2-3 drops BD for 7-10 days

if bacteria prednisolone ear drops 2-3 drops q 2-3 hrs until symptoms improve

or betamethasone ear drops 2-3 drops 3-4 q day if symptoms improve lower potency and or frequency of application

Following up and referral for otitis externa

**Arrange follow up to reassess the person if:**

* Symptoms are not improving within 48–72 hours of starting initial treatment.
* Symptoms have not fully resolved after 2 weeks of starting initial treatment.
* Symptoms are severe and/or there is cellulitis spreading beyond the external ear canal

if symptoms recurring or infection not responding despite optimal management then refer

Otitis media

infection in the middle ear that is characterised by redness, swelling and fluid build up

acute is associated with symptoms and signs of an acute ear infection

otitis media with effusion is not associated with signs and symptoms

Acute otitis media

symptoms develop rapidly and include: \n  Earache and /or fever. \n  Sense of being unwell and lacking energy. \n  Slight hearing loss – if the middle ear becomes filled with fluid, hearing loss may be a sign of glue \n ear (OME). \n  pus coming from perforated ear drum

Risk factors for otitis media

* Young age.
* Male sex.
* Smoking and/or passive smoking.
* Frequent contact with other children such as daycare or nursery attendance or having siblings (increases exposure to viral illnesses).
* Formula feeding — breastfeeding has a protective effect.
* Craniofacial abnormalities (such as cleft palate).
* Use of a dummy.
* Prolonged bottle feeding in the supine position.
* Family history of otitis media.
* Lack of pneumococcal vaccination.
* Gastro-oesophageal reflux.
* Prematurity.
* Recurrent upper respiratory tract infection.
* Immunodeficiency.


* Cleft palate (causing impaired function of the eustachian tube) or other craniofacial malformation.
* Down's syndrome (impaired immunity and mucosal abnormality increasing susceptibility to infection).
* Primary ciliary dyskinesia.
* Allergic rhinitis.

Diagnosing acute otitis media

acute onset: earache if younger may have more non-specific symps

on otoscope: distinct red, yellow or cloudy tympanic membrane, moderate to sever bulging perforation tympanic membrane

Management of acute otitis media

mostly self limiting and clear in 3-5 days

regular dose paracetamol or ibuprofen

if antibiotic required 5-7 day course amoxicillin (clarithromycin/ erythromycin)

2nd line co amoxiclav

review if symptoms not improve within 7 days

referral and red flags

severe systemic infection

suspected acute complications

younger than 3 months of age with a temperature of 38°C or more

protective factors

Keeping the child up-to-date with their routine vaccinations. \n  Avoid exposing the child to smoky environments (passive smoking). \n  Not giving the child a dummy once they are older than six to 12 months old (the sucking \n mechanism can increase the chance of blocking the eustachian tube). \n  Not feed your child while they're lying flat on their back (can cause milk to flow from throat into \n the eustachian tube). \n  Feed baby with breast milk rather than formula milk. \n  Avoiding contact with other children who are infected can also help reduce a child's chances of \n catching an infection that could lead to a middle ear infection