On examination the external ear was swollen with honey-crusts. The external auditory canal (EAC) was narrowed and contained purulent discharge Ear, nose, and throat (ENT) was consulted and she was admitted to the hospital for the presumptive diagnosis of malignant otitis externa. She was started on IV ciprofloxacin and the ear culture grew out Pseudomonas aeruginosa sensitive to ciprofloxacin. The patient responded well to treatment and was able to go home on oral ciprofloxacin 5 days later.
Case Discussion:
Otitis Externa:
Otitis externa (OE) is a common condition and is defined as inflammation, often with infection, of the external auditary canal.
It occurs more commonly in adults than in children.
Etiology: Common pathogens, which are part of normal EAC flora, include aerobic organisms predominantly (P. aeruginosa and Staphylococcus aureus) and, to a lesser extent, anaerobes (Bacteroides and Peptostreptococcus). Up to a third of infections are polymicrobial. A small proportion (2% to 10%) of OE is caused by fungal overgrowth.
Pathogenesis: Pathogenesis of OE includes the following:
~ Trauma, the usual inciting event, leads to breech in the integrity of EAC skin.
~ Skin inflammation and edema ensue, which, in turn, leads to pruritus and obstruction of adnexal structures (e.g., cerumen glands, sebaceous glands, and hair follicles).
~ Pruritus leads to scratching, which results in further skin injury.
~ Consequently, the milieu of the EAC is altered (i.e., change in quality and quantity of cerumen, increase in pH of EAC, and dysfunctional epithelial migration).
~ Finally, the EAC becomes a warm, alkaline, and moist environment—ideal for growth of different pathogens.
Risk factors; include:
- Moisture along with high governmental temperatures.
- Trauma
- Chronic dermatologic diseases like atopic dermatitits , seborrhic dermatitis and psoariasis.
- Long standing poorly controlled diabetes.
- Chemotherapy
- Immunocompromised states like AIDS.
Clinical features:
Otitis Externa can either be localized, like a furuncle, or generalized. The latter is known as “diffuse Otitis externa.
~ Necrotizing or malignant form—Defined by destruction of the temporal bone, usually in diabetics or immunocompromised people; often life-threatening
Important clinical features include:
- Otalgia ( ear pain), including pruritus.
- Otorrhea ( ear discharge)
- Mild hearing loss.
- Pain with tragal pressure or pain when the auricle is pulled superiorly; this may be absent in very mild cases.
- Signs of EAC inflammation (edema, erythema, aural discharge)
- Fever
- Periauricular erythema,
- Lymphadenopathy
- Complete obstruction of EAC occurs in advanced OE.
• Establishing the integrity of the tympanic membrane (TM) (through direct visualization) and the absence of middle-ear effusion (through pneumatic otoscopy) is crucial in differentiating OE from
other diagnoses (e.g., suppurative otitis media, cholesteatoma).
Management: depends upon the severity of the infection.
1. Topical treatments alone are effective for uncomplicated acute OE.
2. Severe cases like malignant otitis externa needs oral or parentral antibiotics to prevent serious complications.
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