otitis externa

Acute Tragal Tenderness

A sign commonly associated with acute otitis externa indicating inflammation.

Necrotizing Otitis Externa (NOE)

Severe infection of the external auditory canal that can lead to bone infection.

risk factors of AOE

local injury

water exposure » bacterial build up

hearing aid, ear plug, ear protection, headphones »decrease ventilation + cerumen clearance

tortuous, narrow or collapsing canals

bony growths like exostoses

Diabetes

immunosuppression

radiotherapy » compromises the skin integrity, blood supply to the ear and bone narrowing

causative pathogens

Predominantly bacterial, AOE is commonly caused by Pseudomonas or Staph.A.

Fungal causes (otomycosis), like Aspergillus and Candida, often manifest as co-pathogens, in immunocompromised patients, or after prolonged use of topical antibacterial drops

P.E in AOE ?

erythema, edema and tenderness in pinna and tragus

periauricular cellulitis

postauricular lymphadenopathy

Otalgia can be elicited by tragal pumping and pinna retraction.

otoscopy » inflamed, erythematous, edematous and moist canal, often painful (needs prior painkiller beforehand).

diagnostic implications of otorrhea?

otorrhea or debris can give diagnostic info of the pathogen:

1-aspergillus white hyphae with black spores.

2-candida off-white sebaceous-like debris)

DX of AOE?

AOE usually involves identifiable risk factors and three key features. include:

symptoms (otalgia, pruritus and aural fullness) and

signs (tenderness, edema and erythema) of EAC inflammation

with rapid onset within 48 hours.

Acute tragal tenderness is widely accepted as a pathognomonic sign.

Both bacterial and fungal AOE have overlapping features of otalgia, otorrhoea, pruritus and erythema.

DDX of AOE?

AOM/CSOM

mastoiditis

furunculosis

perichondritis

neoplasm/ abnormal growth

contact dermatitis

atopic dermatitis

seborrheic dermatitis

psoriasis

ramsay hunt syn. (VZV)

TMJ disorder

treatment?

Treatment with topical antibiotics and ear cleaning typically lead to significant improvement within 72 hours.

analgesics : paracetamol and NSAID

antibiotic choices in AOE?

antibiotic:

Topical antibacterial ear drops, either quinolone based or non-quinolone based, are the first-line treatment for AOE and are empirically commenced without the need for swab confirmation because a significant proportion of cases are bacterial in origin. Generally, 65–90% of patients experience

Red flag symptoms to look for…

• Focal neurology (eg cranial nerve palsies)

• Periauricular cellulitis/abscess

• Systemic symptoms

» should be referred

prevention?

• Ear plugs prevent water retention in the EAC during water-based activities, and petroleum jelly applied around the ear plugs can enhance the seal.

• A hair dryer on the lowest heat setting or applying acetic acid/ethanol ear drops can dry EAC.

• Individuals who use hearing aids or similar devices should take frequent breaks for ventilation and clean the earpieces regularly.

• Cerumenolytics prevent cerumen impaction, but instrumentation (cotton buds) be avoided.

• Effective management of predisposing conditions like diabetes mellitus is crucial

referral indications?

• condition worsens despite appropriate treatment

• condition persists beyond two weeks.

• significant debris or otorrhoea impedes drug delivery and clearance is not feasible in general practice, microsuction might be necessary and warrants referral.

• severe EAC oedema precludes wick insertion,

• focal neurological signs (eg facial nerve palsy) suspicious of NOE should have imaging and an urgent consultation through the emergency department .

• systemic features indicating infection beyond the EAC (eg periauricular cellulitis) also warrant prompt evaluation and potential hospital admission