Approach
• Nature of pain, associated sxs, duration, fevers, hearing loss; diabetes
Otitis Externa (Swimmer’s Ear)
Definition
• Infection (Pseudomonas, S. aureus) of the outer ear due to breakdown of natural barriers
History
• Summer, water exposure, cotton swab trauma, hearing aids, pain/itching/drainage
Physical Findings
• Pain w/ movement of tragus/helix, redness/exudate in canal, white/gray debris, ±green d/c/yellow crusting, ±abscess
Treatment
• Remove debris, dry canal w/ suction, drain abscess if present
• Mild infections: Cleanse w/ 2% acetic acid OR sterile saline; no good evidence for these
• Severe infections: Topical antibiotic (eg, ofloxacin) + steroid × 7 d
• Use wick (cotton, gauze, or cellulose) 10–12 mm into canal × 2–3 d to allow med delivery
• No swimming × 48 h, keep ear dry in shower × 1 wk (ear plugs or Vaseline gauze seal)
Disposition
• Home. Diabetics w/ simple OE should get close f/u.
Malignant (Necrotizing) Otitis Externa
Definition: Aggressive infection (95% Pseudomonas) of the outer ear canal to skull base/bony structures, usually in diabetics/immunocompromised
History: Ear pain extending to TMJ (pain w/ chewing), swelling, otorrhea
Physical Findings: Granulation tissue, severe inflammation, may have CN palsy
Evaluation: CT scan to eval extent & intracranial cx
Treatment
• IV ciprofloxacin. 2nd line: Ceftazidime, imipenem, OR piperacillin/tazobactam.
• Consider amphotericin B for aspergillus in HIV/immunocompromised
Disposition: Admission for IV abx ± operative débridement
Pearls
• 10% mortality
• Cx: Cerebral/epidural abscess, dural sinus thrombophlebitis, meningitis
Otitis Media
Definition
• Inflammation of the middle ear
• Acute OM: Infection (50% S. pneumoniae, 20% H. influenzae, 10% M. catarrhalis, viral 50–70%) + effusion <3 wk
• Chronic OM: Effusion w/o infection
History: Unilateral ear pain, fever (25%), winter/spring, 2–10 y/o, URI
Physical Findings: Bulging TM, loss of light reflex/TM mobility (most sens), effusion, erythema (not sufficient alone to diagnose OM), purulent drainage
Treatment
• Majority improve w/ no abx w/o cx
• Pain control: Acetaminophen/ibuprofen, auralgan (topical)
• Nonsevere acute OM: Amoxicillin to start in 2–3 d if sxs do not improve
• Severe (<6 mo, bilateral, bulging TM, otorrhea, fever > 39, systemically ill) = immediate abx
• Pediatric: Amoxicillin 80–90 mg/kg/d (1st line) 7–10 d, amoxicillin/clavulanate if recent abx or concurrent conjunctivitis (Pediatrics 2010;125(2):384)
• Adult: Cefpodoxime OR cefuroxime
Disposition: Home, PCP f/u 2–3 d
Pearls
• Cx (rare): Meningitis, mastoiditis, persistent effusion → hearing loss
• TM perforation does not require any change in management
Mastoiditis
Definition: Extension of infection from the middle ear into the mastoid air cells
History: Unilateral ear pain, fever, HA
Physical Findings: Tenderness, erythema, fluctuance over mastoid, outward bulging pinna
Evaluation: CT scan to eval extent/destruction of the septa of the air cells, ENT consult
Treatment
• Abx: Nafcillin/cefuroxime/ceftriaxone
• ±Myringotomy/tympanostomy; mastoidectomy (if 50% of air cells involved)
Disposition: Admission, possible operative débridement
Pearl: Cx include meningitis, dural sinus thrombosis, brain abscess, hearing loss