OTITIS EXTERNA, OTITIS EXTERNA, CERUMEN IMPACTION, CERUMEN IMPACTION,

FOREIGN BODIESFOREIGN BODIES

NURS 542NURS 542

ByBy

Lakesha Lemons-PriceLakesha Lemons-Price

EAR ANATOMYEAR ANATOMY

OTITIS EXTERNAOTITIS EXTERNA A term encompassing a variety of A term encompassing a variety of

conditions causing inflammation and/or conditions causing inflammation and/or infection of the external auditiory canalinfection of the external auditiory canal

6 subgroups:6 subgroups:– Acute diffuse bacterial otitis externa Acute diffuse bacterial otitis externa

(swimmer’s ear)(swimmer’s ear)– Acute localized otitis externa (furunculosis)Acute localized otitis externa (furunculosis)– Chronic otitis externaChronic otitis externa– Eczematous otitis externaEczematous otitis externa– Fungal otitis externa (otomycosis)Fungal otitis externa (otomycosis)– Invasive or necrotizing (malignant) otitis externaInvasive or necrotizing (malignant) otitis externa

ETIOLOGYETIOLOGY

SwimmingSwimming Hot, humid climatesHot, humid climates Tightly fitting Tightly fitting

hearing aidshearing aids Use of ear plugsUse of ear plugs Pseudomonas Pseudomonas

aeruginosaaeruginosa S. aureusS. aureus FungusFungus

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Infection happens when there is a a Infection happens when there is a a breakdown in the skin/cerumen protective breakdown in the skin/cerumen protective barrier of the external ear canalbarrier of the external ear canal

2 most common pathogens: Pseudomonas 2 most common pathogens: Pseudomonas and Staph aureusand Staph aureus

If left untreated, the infection progresses If left untreated, the infection progresses through 3 different phases: through 3 different phases: – 1. Pre-inflammatory stage1. Pre-inflammatory stage– 2. Inflammatory stage (3 phases)2. Inflammatory stage (3 phases)– 3. Chronic stage3. Chronic stage

CLINICAL PRESENTATIONCLINICAL PRESENTATION Otalgia (ear pain)Otalgia (ear pain) Otorrhea (serous to purulent)Otorrhea (serous to purulent) PruritusPruritus Tragal manipulation painTragal manipulation pain Erythema and edemaErythema and edema Aural fullness or pressureAural fullness or pressure Partial hearing lossPartial hearing loss TM may appear dull and infectedTM may appear dull and infected Fever and chills may also be presentFever and chills may also be present DM & immunocompromised pts – suspect NOEDM & immunocompromised pts – suspect NOE

– Granulation tissue or small ulcerations of necrotic tissueGranulation tissue or small ulcerations of necrotic tissue– Facial nerve palsyFacial nerve palsy

RELEVANT HISTORYRELEVANT HISTORY

Trauma (q tip use, foreign body in ear, Trauma (q tip use, foreign body in ear, ear syringing, ear plugs, hearing aid, ear syringing, ear plugs, hearing aid, head trauma)head trauma)

Immune statusImmune status DMDM Contact dermatitis, eczema, and Contact dermatitis, eczema, and

psoriasis predispose to OEpsoriasis predispose to OE Previous hx of ear disease or ear Previous hx of ear disease or ear

surgerysurgery

DIAGNOSTICSDIAGNOSTICS

Thorough H&P examinationThorough H&P examination– OtoscopyOtoscopy– Look for several key findings:Look for several key findings:

Edema/erythema of the canalEdema/erythema of the canal Narrowing of the canalNarrowing of the canal Debris in the canalDebris in the canal Purulent secretionsPurulent secretions Also det. if TM is intact or perforated (affects Also det. if TM is intact or perforated (affects

treatment options)treatment options)

***Expert opinion supports H&P as the best ***Expert opinion supports H&P as the best means of diagnosis of OEmeans of diagnosis of OE

DIAGNOSTICSDIAGNOSTICS

LabLab– Culture: warranted after 1Culture: warranted after 1stst tx failure to identify tx failure to identify

organism and prescribe effective antibioticorganism and prescribe effective antibiotic– Leukocyte count: normal or mildly elevatedLeukocyte count: normal or mildly elevated– ESR: quite elevated in NOEESR: quite elevated in NOE

ImagingImaging– Considered if NOE suspected (CT, MRI, isotope Considered if NOE suspected (CT, MRI, isotope

bone scan)bone scan)

DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES Furunculosis Furunculosis

– occurs in the hair bearing (lateral third) portion of the occurs in the hair bearing (lateral third) portion of the EAC; it is differentiated from OE because the swelling EAC; it is differentiated from OE because the swelling assoc with it tends to be localized a single quadrant assoc with it tends to be localized a single quadrant whereas with OE it is usually concentric and involves the whereas with OE it is usually concentric and involves the entire lengh of the canalentire lengh of the canal

Acute Otitis MediaAcute Otitis Media– Must visualize the TM to differentiate from OEMust visualize the TM to differentiate from OE

Necrotizing Otitis ExternaNecrotizing Otitis Externa MastoiditisMastoiditis

– Can be diagnosed if the post-auricular fold is obliterated Can be diagnosed if the post-auricular fold is obliterated (it is preseved in OE; pain to palpation over mastoid (it is preseved in OE; pain to palpation over mastoid process process

Foreign BodyForeign Body NeoplasmsNeoplasms

TREATMENTTREATMENT Treatment of otitis externa involves Treatment of otitis externa involves

nonpharmacological measures and pharmacological nonpharmacological measures and pharmacological measures. measures.

Cleansing and debridement of the ear canal with Cleansing and debridement of the ear canal with cotton swabs and hydrogen peroxide or other cotton swabs and hydrogen peroxide or other antiseptic solution allows a more thorough antiseptic solution allows a more thorough examination of the ear. examination of the ear.

If the canal lumen is edematous and too narrow to If the canal lumen is edematous and too narrow to allow adequate cleansing, a cotton wick or gauze allow adequate cleansing, a cotton wick or gauze strip inserted into the canal serves as a conduit for strip inserted into the canal serves as a conduit for topical medications to be drawn into the canal. topical medications to be drawn into the canal. Usually wick is removed after two days. Usually wick is removed after two days.

TREATMENTTREATMENT Topical Antibiotic Treatment:Topical Antibiotic Treatment:

– AminoglycosidesAminoglycosides First line tx of OE during 1970’s thru late 1990’sFirst line tx of OE during 1970’s thru late 1990’s Drawbacks: hypersensitivity, ototoxicity (if TM perforated), Drawbacks: hypersensitivity, ototoxicity (if TM perforated),

require QID dosingrequire QID dosing– QuinolonesQuinolones

Current first line therapy for OE: Ciprodex, CiproHC, Floxin OticCurrent first line therapy for OE: Ciprodex, CiproHC, Floxin Otic Advantages: Advantages:

– Cover both gram + and – organismsCover both gram + and – organisms– BID dosing BID dosing – Can be used in pediatric population (small systemic absorption)Can be used in pediatric population (small systemic absorption)– No known ototoxicityNo known ototoxicity– Floxin Otic and Ciprodex FDA approved to treat OE with perf. TMFloxin Otic and Ciprodex FDA approved to treat OE with perf. TM

Disadvantages: costlyDisadvantages: costly

TREATMENTTREATMENT Topical AntifungalsTopical Antifungals

– Lotrimin and tinactinLotrimin and tinactin– Many tx algorithms add antifungal coverage if suspected Many tx algorithms add antifungal coverage if suspected

upon initial presentation and/or after 1upon initial presentation and/or after 1stst treatment treatment failure with abxfailure with abx

Non-antibiotic Topical Acidifying Agents Non-antibiotic Topical Acidifying Agents – Boric acid, acetic acid (Vosol HC), and alcoholsBoric acid, acetic acid (Vosol HC), and alcohols– Creates an acidic or toxic environment that is not Creates an acidic or toxic environment that is not

conducive for bacterial/fungal growthconducive for bacterial/fungal growth– InexpensiveInexpensive– Disadvantages:Disadvantages:

Work well when used early in disease processWork well when used early in disease process Can be painful to useCan be painful to use Require multiple tx per day for a long tx period (up to 3 Require multiple tx per day for a long tx period (up to 3

weeks)weeks) Ototoxic if they get into the middle earOtotoxic if they get into the middle ear

TREATMENTTREATMENT Oral AntibioticsOral Antibiotics

– Systemic antibiotics are reserved for severe cases Systemic antibiotics are reserved for severe cases (Pseudomonas, s. aureus)(Pseudomonas, s. aureus)

– Fever and systemic symptoms are presentFever and systemic symptoms are present– Ciprofloxacin is usually used BID for 10 daysCiprofloxacin is usually used BID for 10 days– Treatment for necrotizing otitis externa requires Treatment for necrotizing otitis externa requires

prolonged therapy up to three months. prolonged therapy up to three months. – Intravenous antipseudomonals with or without Intravenous antipseudomonals with or without

aminoglycosides are also appropriate.aminoglycosides are also appropriate. NSAIDs or OpioidsNSAIDs or Opioids

– May be required for painMay be required for pain Topical CorticosteroidsTopical Corticosteroids

Reduce swelling and inflammationReduce swelling and inflammation

STUDYSTUDY Late 1990’s a significant percentage of Late 1990’s a significant percentage of

primary care physicians were prescribing primary care physicians were prescribing topical antibiotics and oral antibiotics to topical antibiotics and oral antibiotics to treat OEtreat OE

Roland et al performed a study in 2008Roland et al performed a study in 2008– Topical quinolones were compared with topical Topical quinolones were compared with topical

aminoglycosides plus oral amoxicillinaminoglycosides plus oral amoxicillin– The study showed equivalent outcomes in both The study showed equivalent outcomes in both

groupsgroups– These findings provide evidence These findings provide evidence

that topical quinolines are as effective as topical that topical quinolines are as effective as topical aminoglycosides aminoglycosides

And that oral antibiotics are not necessary in the And that oral antibiotics are not necessary in the treatment of routine OE treatment of routine OE

PEARLSPEARLS

May evolve into osteomyelitis of the May evolve into osteomyelitis of the skull base often called malignant skull base often called malignant otitis externaotitis externa

Do not miss severe malignant otitis Do not miss severe malignant otitis externa in patients who are diabetic externa in patients who are diabetic or immunocompromisedor immunocompromised

SUBJECTIVESUBJECTIVE CC: right ear painCC: right ear pain HPI: 18 y/o WM who is on the swim team at ULM, presents HPI: 18 y/o WM who is on the swim team at ULM, presents

with constant pain in right ear for 2 days. Associated with constant pain in right ear for 2 days. Associated symptoms: fever, itching, ear fullness with decreased symptoms: fever, itching, ear fullness with decreased hearing, and purulent discharge. States he uses q-tips to hearing, and purulent discharge. States he uses q-tips to clean his ears. Also states “it hurts really bad to touch front clean his ears. Also states “it hurts really bad to touch front part of my ear” part of my ear”

Allergies: noneAllergies: none PMHx: None, Tonsillectomy, immunizations UTDPMHx: None, Tonsillectomy, immunizations UTD FMHx: positive for DMFMHx: positive for DM Social Hx: smokes 1 pack cig/daySocial Hx: smokes 1 pack cig/day Medications: NoneMedications: None ROS: fever, itching, pain, ear fullness (dec. hearing), ROS: fever, itching, pain, ear fullness (dec. hearing),

dischargedischarge

OBJECTIVEOBJECTIVE

VS: BP- 132/84, T- VS: BP- 132/84, T- 99.5, P- 89, R- 2099.5, P- 89, R- 20

Ht: 6’1Ht: 6’1 Wt: 185Wt: 185 BMI: 24.4BMI: 24.4 Physical exam- Physical exam-

Inspect (otoscope), Inspect (otoscope), palpate palpate

DiagnosticsDiagnostics

ASSESSMENTASSESSMENT

Medical diagnosis: Acute otitis externaMedical diagnosis: Acute otitis externa

Differential diagnosisDifferential diagnosis– NOENOE– AOMAOM– MastoiditisMastoiditis– FurunculosisFurunculosis– Foreign bodyForeign body– NeoplasmsNeoplasms

PLANPLAN Pharmacotherapeutic approachPharmacotherapeutic approach

– NSAIDNSAID– Ciprodex Ciprodex – Would not consider oral antibiotics with this patient at this timeWould not consider oral antibiotics with this patient at this time

Non-pharmacologic approach/interventionsNon-pharmacologic approach/interventions– Cleansing and debridement of the ear (cotton swabs/peroxide)Cleansing and debridement of the ear (cotton swabs/peroxide)

Patient educationPatient education– Prevention of OEPrevention of OE– How to take prescribed meds How to take prescribed meds – Smoking cessationSmoking cessation

ReferralReferral– Don’t supect NOEDon’t supect NOE– No evidence of treatment failure yetNo evidence of treatment failure yet– Severe pain (pt reports pain with tragal manipulation)Severe pain (pt reports pain with tragal manipulation)– No referral for this pt todayNo referral for this pt today

EVALUATIONEVALUATION

Follow up plansFollow up plans– If condition worsens, return to officeIf condition worsens, return to office

REFERENCESREFERENCES Ferri, F.F. (2012). Ferri’s clinical advisor 2012: 5 Ferri, F.F. (2012). Ferri’s clinical advisor 2012: 5

books in 1. Philadelphia, PA: Mosby.books in 1. Philadelphia, PA: Mosby. Lustig, L.R., & Schindler, J.S. (2012). Ear, nose, & Lustig, L.R., & Schindler, J.S. (2012). Ear, nose, &

throat disorders. In S.J. McPhee & M.A. Papadakis throat disorders. In S.J. McPhee & M.A. Papadakis (Eds.), (Eds.), Current medical diagnosis & treatment Current medical diagnosis & treatment 20122012 (pp. 197-198). New York: McGraw-Hill. (pp. 197-198). New York: McGraw-Hill.

Roland, P.S., Belcher, B.P., Bettis, R., Makabale, Roland, P.S., Belcher, B.P., Bettis, R., Makabale, R.L., Conroy, P.J., Wall, G.M., . . . Dupre, S. (2008). R.L., Conroy, P.J., Wall, G.M., . . . Dupre, S. (2008). A single topical agent is clinically equivalent to A single topical agent is clinically equivalent to the combination of topical and oral antibiotic the combination of topical and oral antibiotic treatment for otitis externa. treatment for otitis externa. American Journal of American Journal of Otolaryngology, 29Otolaryngology, 29(4), 255-261.(4), 255-261.