Chapter 90

• Pseudomonas aeruginosa is the cause of almost all cases of malignant otitis externa.
• The diagnosis of otitis media is based on the rapid onset of signs and symptoms of middle ear inflammation in the presence of middle ear effusion.
• Pneumatic otoscopy is an essential component of the ear examination.
• Streptococcus pneumoniae is the most common cause of bullous myringitis.
• Worsening otitis media, while on antibiotics, may be a sign of a suppurative complication.
• Sinusitis should be considered in patients with severe rhinitis and in patients with persistent or worsening URI symptoms after 10 days.
• Hospitalization for intravenous antibiotics, sinus imaging, and subspecialty consultation are indicated in patients with sinusitis with orbital or intracranial extension.

Otalgia is a frequent presenting complaint in the emergency department. An algorithm on the conditions that can cause otalgia is presented in Figure 90–1. A large subset of these patients will have inflammatory conditions of the external ear. Most external ear infections are easy to recognize and to treat. However, it is important to differentiate a simple otitis externa from other conditions.

###### Figure 90-1.

Algorithm for otalgia.

### Pathophysiology

The external ear, consisting of the pinna and the external auditory meatus, ends as a blind sac at the tympanic membrane. The medial two-thirds, or the osseous portion, lacks subcutaneous tissue and has a thin skin that tightly covers the bone. The cartilaginous portion or lateral third contains hair follicles, subcutaneous tissue, and ceruminous glands overlying the perichondrium and cartilage.

The fragile skin of the external auditory canal is easily infected when it is disrupted by any trauma or inflammation. Aggressive removal of the protective cerumen barrier can allow the normal ear flora (Staphylococcus spp., Streptococcus spp., diptheroids, and Pseudomonas aeruginosa) to invade the tissue. In addition, heat, humidity, and moisture promote the development of infection (thus the term “swimmer's ear”). Such an infection manifests as a diffuse cellulitis affecting the skin of the external auditory canal and pinna, underlying tissue, and regional lymph nodes1 (Fig. 90–2).

###### Figure 90-2.

Picture showing otitis externa.

### Diagnosis

In acute uncomplicated cases of acute otitis externa, the diagnosis is a clinical one. A history of local trauma, swimming, and travel to a warm climate may or may not be present. Depending on the severity of the infection, most patients will present with localized ear pain and itching. The pinna should be normal in appearance; however, manipulation of the pinna or tragus or movement of the jaw usually elicits pain. Redness and edema of the ear canal can be seen along with an exudate. If the infection is due to a fungus (predominantly Aspergillus spp.), white or gray masses composed of hyphae ...

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