Otitis Externa, Emergency Medicine

Basics

Description

Inflammation or infection of the auricle, auditory canal, or external surface of the tympanic membrane (TM):
- Spares the middle ear
- Affects 4/1,000 persons in US
Also called "swimmers ear " due to the usual history of recent swimming:
- Occasional cases after normal bathing
Necrotizing (malignant) otitis externa:
- Infection starts at the ear canal and progresses through periauricular tissue toward the base of the skull
- Occurs in elderly, diabetic, or other immunocompromised patients
- Caused by Pseudomonas aeruginosa
- Can lead to cellulitis, chondritis, and osteomyelitis
- Associated with 20% mortality

Etiology

Often precipitated by an abrasion of the ear canal or maceration of the skin from persisting water or excessive dryness
Predisposing factors include:
- History of ear surgery or TM perforation
- Narrow or abnormal canal
- Humidity
- Allergy
- Eczema
- Trauma
- Abnormal cerumen production
P. aeruginosa, Staphylococcus aureus, streptococcal species, and rarely fungi

Diagnosis

Signs and Symptoms

History

Recent swimming or prolonged water exposure
History of diabetes
History of chemotherapy, prolonged steroid use, HIV/AIDS, or other processes that compromises immune system
Itching of the external ear canal is usually the 1st symptom
1 " 2 day history of progressive pain
Ear drainage
Decreased auditory acuity
Clogged sensation in ear

Physical Exam

Pain in ear or with motion of pinna/tragus
Swollen, erythematous external ear canal
Ear drainage
Decreased auditory acuity
Pain/swelling in preauricular area
Necrotizing (malignant) otitis externa:
- Pain, tenderness, swelling in periauricular area
- Headache
- Otorrhea
- Cranial nerve palsy:
  - Facial nerve most affected

Essential Workup

Clinical diagnosis with typical signs/symptoms:

Pain in ear or with motion of pinna/tragus
Otoscopic exam
Swollen, erythematous external ear canal
Ear drainage
Cheesy white or gray-green exudate

Diagnosis Tests & Interpretation

Lab

None usually indicated, except when possibility of necrotizing otitis externa:
- Signs of systemic toxicity or local spread of infection should be checked
WBC count
ESR
Glucose (check for diabetes)
Cultures

Imaging
CT/MRI to exclude mastoiditis if the patient has signs of toxicity or bone involvement
Diagnostic Procedures/Surgery

Remove debris with a soft plastic curette or gentle irrigation with peroxide/water mix
Wick placement may be needed to facilitate medication delivery

Differential Diagnosis

Necrotizing otitis externa
Otitis media
Folliculitis from obstruction of sebaceous glands
Otic foreign bodies
Herpes zoster infection of the geniculate ganglion
Parotitis
Periauricular adenitis
Mastoiditis
Dental abscess
Sinusitis
Tonsillitis
Pharyngitis
Temporomandibular joint pain
Viral exanthems

Consider ear canal foreign bodies in children with purulent drainage from edematous, painful ear canals

Treatment

Ed Treatment/Procedures

Clean external ear canal:
- Remove the inflammatory debris by gentle curettage with a cotton-tipped wire applicator
- Occasional suction with a Frazier suction tip may be necessary
Insert a cotton or gauze wick 10 " 12 mm into the canal after cleansing if the ear canal is very edematous
Management of otitis externa focuses on pain control, eradication of infection, and prevention of reoccurrence

Medication

Most cases respond well to topical treatment:
- Antiseptic, anti-inflammatory, and drying otic drops eliminate the pathogenic bacteria and allow for rapid healing of the canal
- Acetic acid solutions such as Domeboro otic (2% acetic acid): 4 " 6 drops q4 " 6h
- Corticosporin otic (hydrocortisone 1%, polymyxin + neomycin) suspension: 4 drops to ear canal QID (use suspensions and not solutions with suspected TM perforation)
- Ofloxacin: 5 drops BID (drug of choice in perforated TM)
Oral antibiotics:
- Administer to patients with cellulitis of the face or neck, severe edema of the ear canal, concurrent otitis media, or when the TM cannot be visualized
- Treat diabetics and other immunocompromised patients with oral ciprofloxacin and follow closely for symptoms of malignant otitis externa
- Amoxicillin: 500 mg (peds: 40 mg/kg/d) PO TID
- Ciprofloxacin: 500 mg PO BID
IV antibiotics for patients with necrotizing otitis externa, severe cellulitis, or septic appearing
Prophylaxis:
- Apply rubbing alcohol or acetic acid (2%) to keep the external ear canal dry and prevent recurrence of infection
Pain management with acetaminophen or NSAID. Consider opioids if severe pain
Surgical debridement of granulation tissue and bone sequestration or drainage of associated abscess may be necessary in necrotizing otitis externa

Complications

Mastoiditis
Chondritis of the auricle
Necrotizing otitis externa
Osteomyelitis of the base of the skull
CNS infections

Follow-Up

Disposition

Admission Criteria

Necrotizing otitis externa
Significant involvement of the pinna
Signs of systemic illness

Discharge Criteria

Most patients
Close follow-up for patients at risk of otitis externa
Patient instructions:
- Avoid swimming and keep ears completely dry for 3 " 4 wk
- Apply medications as directed
- Return if worse pain, fever, hearing loss develops, or there is any change in mental or neurologic status
- Follow up if symptoms are not improved within 2 " 3 days

Issues for Referral
Ear " nose " throat follow-up for:

Perforated TM
Worsening of symptoms
Conductive hearing loss
Failure of initial management

Followup Recommendations

Follow up with primary care physician or a return ED visit within 2 " 3 days for removal of the wick or if symptoms are worse.

Pearls and Pitfalls

Concomitant and often erroneous diagnoses of acute otitis externa and otitis media are common because the TM in acute otitis externa is erythematous.
Avoid ear canal lavage until tympanic integrity is documented.
Regardless of the topical medications, penetration to the epithelium is key to therapy; any obstruction should be cleared.
Recurrence can be largely prevented by counseling the patient and explaining how it can be avoided by minimizing ear canal moisture, trauma, or exposure to material that incites local irritation or contact dermatitis.
Necrotizing otitis externa should be suspected in immunocompromised patients and diabetics who have severe otalgia, purulent otorrhea, and granulation tissue or exposed bone in the external auditory canal.

Additional Reading

Birchall JP. Managing otitis externa. Practitioner. 2006;250:78 " 82.
Carfrae MJ, Kesser BW. Malignant otitis externa. Otolaryngol Clin North Am. 2008;41:537 " 549.
Collier SA, Hlavsa MC,
Piercefield EW, et al. Antimicrobial and analgesic prescribing patterns for acute otitis externa, 2004 " 2010.
Otolaryngol Head Neck Surg.
2013;148:128 " 134.
Osguthorpe JD, Nielsen DR. Otitis externa: Review and clinical update. Am Fam Physician. 2006;74:1510 " 1516.
Stone KE. Otitis externa. Pediatr Rev. 2007;28:77 " 78.

Codes

ICD9

380.10 Infective otitis externa, unspecified
380.14 Malignant otitis externa

ICD10

H60.10 Cellulitis of external ear, unspecified ear
H60.20 Malignant otitis externa, unspecified ear
H60.90 Unspecified otitis externa, unspecified ear
H60.11 Cellulitis of right external ear
H60.12 Cellulitis of left external ear
H60.13 Cellulitis of external ear, bilateral
H60.1 Cellulitis of external ear
H60.21 Malignant otitis externa, right ear
H60.22 Malignant otitis externa, left ear
H60.23 Malignant otitis externa, bilateral
H60.2 Malignant otitis externa
H60.91 Unspecified otitis externa, right ear
H60.92 Unspecified otitis externa, left ear
H60.93 Unspecified otitis externa, bilateral
H60.9 Unspecified otitis externa

SNOMED

3135009 Otitis externa (disorder)
94146005 Malignant otitis externa
95806007 cellulitis of external ear (disorder)
232228007 Necrotizing otitis externa

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