Journal Reading
OTITIS
EXTERNA
By
Amalia Zahrina
Deny Fasla
M Ali Alvin
Rizka Fadilah
OTITIS EXTERNA
Otitis externa is an inflammatory condition of
the external ear canal, with or without
infection
ACUTE OTITS
EXTERNA
EPIDEMIOLOGY
>95% cases of otitis externa are acute
Each year, 1 to 2.5 in 100 people are affected.
Peak incidence arises among children of age 7
to 12 years
RISK FACTOR
Living in warmer, humid climates
and swimming
Risk factors relate to Removal of cerumen by excessive
increased moisture in
cleaning
the ear canal, loss of
protective cerumen,
and trauma to the ear
canal
Trauma to the ear canal
People with chronic dermatologic
conditions and
immunocompromised
PATOPHYSIOLOGY
The external auditory canal is about 25 mm long and
curves in an S-shape toward the tympanic membrane.
The outer one-third of the canal base is cartilaginous
covered by cerumen glands and hair follicles, the inner
two-thirds is bony
Provides a waxy barrier that protects the epithelium from
breakdown caused by excessive moisture exposure
Cerumen
Cerumen has a slightly acidic pH and lysozymal activity that
inhibits bacterial and fungal growth
Disturbance in the normal acidic environment, lack of cerumen, and trauma to the
epithelial lining can lead to bacterial or fungal infection of the ear canal, causing an
inflammatory response
CLINICAL MANIFESTATION
Rapid onset of ear pain, fullness, and
otorrhea. Pain is worse with traction on the
pinna or palpation of the tragus
On initial stages, patients may experience mild
discomfort and ear pruritus. The ear canal may
be erythematous and slightly edematous, with
minimal discharge
Inflammation may spread to the tympanic
membrane. A sensation of ear fullness, as
well as hearing loss
Regional lymphadenitis and surrounding
cellulitis of the pinna. Systemic symptoms
suggest extension beyond the ear canal.
DIAGNOSIS
TREATMENT
Aural Toilet A topical antibiotic
Topical steroid Over-the-counter oral
pain medication
If needed
Choice of antibiotic should be based on factors such as risk of ototoxicity, contact
sensitivity, availability, cost, dosing schedules, and patient compliance
Because topical antibiotics reach a high concentration in the ear canal, even bacterial strains
considered resistant to systemic antibiotics (ie, methicillin resistant Staphylococcus aureus) are
susceptible to topical antibiotic preparations
Finally, patients with AOE should avoid precipitating factors. In general,
swimming should be avoided until the infection is resolved, although
swimming may be allowed as long as patients do not submerge their
head
MONITORING
AOE patients will experience
significant improvement within
24 hours
If patients do not
improve within 48
to 72 hours, they Referral is indicated in cases of
should be suspected malignant otitis
reevaluated externa, lack of improvement, or
an inability to remove obstructing
debris or a foreign body
PREVENTION
Limiting Avoid the sources of
predisposing factor ear trauma
Minimize the Adequately treat the
moisture retention underlying
in the ear canal dermatologic
conditions
In addition, acidifying
drops, such as acetic acid
Maintain the healthy 2% may be placed in the
skin barrier ear after water exposure to
dry the ear canal
COMPLICATIONS
Auricular or facial cellulitis,
perichondritis, or chondritis
Canal stenosis and
hearing loss
Malignant
(necrotizing) otitis
externa
Meningitis, dural sinus
thrombosis, cranial abscess,
and cranial nerve palsies
CHRONIC OTITS
EXTERNA
Chronic otitis externa (COE) is more often attributed to
allergic or autoimmune causes than infectious etiology
CLINICAL PRESENTATION
Itching of the ear, clear or mucoid otorrhea,
and aural fullness
Ear pain or discomfort and hearing loss
Waxing and waning course over years with
intermittent exacerbations
At times patients may also experience AOE
PHYSICAL EXAMINATION
Depending on the cause
Patients with
contact dermatitis
may exhibit a COE has also resulted
maculopapular rash from chronic otitis
with excoriations on media with tympanic
the skin of the membrane perforation
conchal bowel and
ear canal
The ear canal in
Patients with chronic patients with fungal
dermatologic infection (otomycosis)
conditions such as may show fluffy,
psoriasis and atopic cotton-like debris
dermatitis may show
eczema- tous
changes,
hyperkeratosis, and
lichenification of the
ear canal epithelium
DIAGNOSIS
Diagnosis of COE is made clinically at least
3 months’ duration
Culture for bacteria and fungi is
often prudent if chronic infection is
suspected
Skin-patch testing in cases of contact
dermatitis may be useful to elucidate
the cause
Chronic dermatologic disorders such as
psoriasis should be suspected when a
typical exanthem is visualized elsewhere
on the skin
TREATMENT
Treatment of COE is aimed at identifying the underlying
cause and managing accordingly
Aural toilet Patients with chronic
bacterial infection should be
Preventive precautions as treated with topical
for AOE antibiotics, as for AOE
Topical steroid therapy with medium- For fungal otitis externa,
potency (triamcinolone 0.1% cream) and antifungal creams such as
high-potency (desoximetasone 0.05% clotrimazole 1% may be
cream) agents is often effec- tive for used
patients with contact dermatitis or
chronic dermatologic conditions
COMPLICATIONS
The tympanic
Perforation of membrane may
tympanic appear to be
membrane oriented laterally
and have fibrotic
changes
Fibrosis of the Conductive hearing
medial canal loss
CONCLUSION
Otitis externa is a common
condition seen by primary care
clinicians. AOE most often is
infectious in origin, and can be easily
treated with a combination of
topical antibiotic and steroid
preparations. Systemic antibiotics
are rarely needed. In both AOE and
COE, prevention is fundamental
Thank you
