Chapter 18

### THE EAR

#### INFECTIONS OF THE EAR

##### Otitis Externa

ESSENTIALS OF DIAGNOSIS

• Edema and erythema of the external auditory canal (EAC) with debris or thick, purulent discharge.

• Severe ear pain, worsened by manipulation of the pinna.

• Periauricular and cervical lymphadenopathy may be present.

##### Differential Diagnosis

Acute otitis media (AOM) with tympanic membrane (TM) rupture, furunculosis of the ear canal, and mastoiditis.

##### Pathogenesis

Otitis externa (OE) is a cellulitis of the soft tissues of the EAC, which can extend to surrounding structures such as the pinna, tragus, and lymph nodes. Also known as "swimmer's ear," humidity, heat, and moisture in the ear are known to contribute to the development of OE, along with localized trauma to the ear canal skin. Sources of trauma may include digital trauma, earplugs, ear irrigations, and the use of cotton-tipped swabs to clean or scratch the ear canal. Keeping the ear "too clean" can also contribute to the development of OE, since cerumen actually serves as a protective barrier to the underlying skin and its acidic pH inhibits bacterial and fungal growth. The most common organisms in OE are Staphylococcus aureus and Pseudomonas aeruginosa.

##### Clinical Findings

Symptoms include pain, aural fullness, decreased hearing, and sometimes itching in the ear. Manipulation of the pinna or tragus causes considerable pain. Discharge may start out as clear then become purulent. It may also cause secondary eczema of the auricle. The ear canal is typically swollen and narrowed, and the patient may resist any attempt to insert an otoscope. Debris is present in the canal and it is usually very difficult to visualize the TM due to canal edema.

##### Complications

If untreated, facial cellulitis may result. Immunocompromised individuals can develop malignant OE, which is a spread of the infection to the skull base with resultant osteomyelitis. This is a life-threatening condition.

##### Treatment

Management includes pain control, removal of debris from the canal, topical antimicrobial therapy, and avoidance of causative factors. Fluoroquinolone eardrops are first-line therapy for OE. In the absence of systemic symptoms, children with OE should be treated with antibiotic eardrops only. The topical therapy chosen must be nonototoxic because a perforation or patent tube may be present; if the TM cannot be visualized, then a perforation should be presumed to exist. If the ear canal is too edematous to allow entry of the eardrops, a Pope ear wick (expandable sponge) should be placed to ensure antibiotic delivery. Oral antibiotics are indicated for any signs of invasive infection, such as fever, cellulitis of the face or auricle, or tender periauricular or cervical lymphadenopathy. In such cases, in addition to the ototopical therapy, cultures of the ear canal discharge should be sent, and an antistaphylococcal antibiotic prescribed while awaiting culture ...

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