Transcript Slide 1

OTITIS EXTERNA
A Case Report
Jennifer Johnson
Lock Haven University
SOME OF THE ABSTRACT/OVERVIEW
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Pain is the predominant complaint and the only
symptom directly related to the severity of otitis
externa.
Unlike other forms of ear infections, the pain of otitis
externa is worsened when the outer ear is touched or
pulled gently.
Patients may also experience ear discharge and
itchiness.
When enough swelling and discharge in the ear canal
is present to block the opening, otitis externa may
cause temporary conductive hearing loss.
The two most common bacterial bugs affecting the ear
canal are Pseudomonas aeruginosa and
Staphylococcus aureus. (Sander, 2001)
The characteristics of otitis externa can be
greatly overlooked for otitis media!
HISTORY
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A 7 year old, white male presented to the pediatrician
office with an overall 1 week history of right ear pain.
When he first presented to the office, his mother
stated that he had been pulling at his right ear and
had been complaining of pain and itchiness for 3 days.
The boy stated that his pain felt like a dull, stabbing
ache without any radiation into his sinuses or jaw.
The young boy rated his pain with a 7/10 on a pain
rating scale. Motrin alleviated his pain some, stated
mom. They could not think of any aggravating
factors. The young boy denied fever, chills, fatigue,
congestion or other cold related symptoms, dizziness,
headaches, nausea, vomiting, diarrhea, constipation,
shortness of breath, or chest pain.
PAST MEDICAL HISTORY, FAMILY HISTORY,
SOCIAL HISTORY, MEDICATIONS AND
ALLERGIES…
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Past medical history included a febrile seizure at the
age of 26 months.
His family history included hypertension and cancer.
Social history included being around several sick
children at school and the babysitters. Mother denied
anyone smoking around the child. Mom stated that
the child had been swimming at the YMCA after
school every Tuesday and Thursday over the past
month.
He had no known drug allergies or seasonal allergies.
Mother supplemented the young child with a
multivitamin daily.
PHYSICAL EXAMINATION
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It was noted that his right ear appeared with a
thickened, erythematous, and bulging right
tympanic membrane, but the boy had an
otherwise unremarkable physical exam.
DIAGNOSIS, TREATMENT AND FOLLOW-UP
He was diagnosed with acute otitis media of the
right ear and treated with oral amoxicillin by
mouth twice daily.
 He was told to follow-up if symptoms worsened,
such as fever greater than 101.0, increasing pain,
SOB, or follow-up on an as needed basis.
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FIRST FOLLOW-UP
He returned to the office the next day with
increased otalgia and fever.
 After looking in the ear and noting the same
findings as before, the doctor explained that the
antibiotic and OTC anti-inflammatories would
kick in and run its course.
 He reassured them to wait another day, and then
follow-up if not better for a different plan of
action.
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WORSENED PHYSICAL EXAMINATION
FINDINGS
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The child returned 2 days later with a complaint again of a
subjective fever and increasing right ear pain. His oral
temperature was 97.0°F in the office.
Physical exam revealed mild right postauricular edema
and erythema. The right cheek was edematous.
Exquisite tenderness was noted with manipulation of the
right pinna and tragus and on palpation over the right
mastoid, cheek, and neck. Otoscopic examination revealed
the right auditory canal to be erythematous, very
edematous, and tender, with a moderate amount of
mucoid drainage. The right tympanic membrane could
not be visualized because of obstructive edema of the
canal. The right postauricular node was palpable,
mobile, and tender, with no other palpable lymph nodes.
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The left ear exam was unremarkable, and the remainder of
the exam was within normal limits.
DIFFERENTIAL DIAGNOSES:
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“The most common differential diagnoses are
otitis media, chronic suppurative otitis
media, cholesteatoma, mastoiditis,
chondritis, and polychondritis.
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Less common differential diagnosis is referred pain.
It is important to keep in mind that carcinoma of the
ear canal can present as otitis externa.”
(Demetroulakos, 2007)
CLINICAL DIAGNOSIS
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Otitis externa is a clinical diagnosis.
Culture results will confirm the causative
organisms.
A CT examination can be ordered to rule out
abscesses, mastoiditis, etc.
FINAL DIAGNOSIS AND EAR WICK
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There were no any laboratory studies ordered to determine
this patient’s chief complaint and possible diagnosis.
The patient was diagnosed with otitis externa, and an ear
wick was placed in the right external auditory canal and
instilled with antibiotic otic drops.
The patient was prescribed to take amoxicillin by mouth
twice daily for 10 days, and to instill four drops of
ciprofloxacin-hydrocortisone otic solution to the right ear
canal twice daily until removal of the wick on follow-up.
Five days later he presented to the pediatric clinic. At that
time, his symptoms were greatly improved. He was
afebrile, and without otorrhea, otalgia, or edema.
The ear wick was removed revealing an intact and mobile
right tympanic membrane.
DISCUSSION
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This 7 year old male pediatric patient’s symptoms
complicated an interesting case of otitis externa.
It was first thought that the increase in ear pain was
due to otitis media. Then second guessing, thinking
that it was mastoiditis.
The physician should have done something more the
second time the child presented to the office.
As a CT scan should have been performed to rule out
a serious case; in the small rural clinic, we took the
chances to instill drops and a wick instead.
We made sure that the child followed-up with a phone
call from mother 1 day after the wick was placed
inside the right ear.
The child was feeling moderately better within those
24 hours. If he weren’t, more drastic measures would
have been taken to resolve that problem.
KEY POINT…
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“When edema, debris, and exudate are marked
enough to impede antibiotic drops from
contacting the canal skin, use an ear wick. The
wick works as a conduit to deliver the antibiotic
solutions to the ear canal. The true benefit of
wick implantation is unknown.” (Roberts, 2010)
In this case it worked just fabulously.
PREVENTION:
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Prevention of recurrence of otitis externa primarily
consists of avoiding the many precipitants that have
been discussed and treating any underlying chronic
dermatologic disorders.
“Swimmers who are prone to recurrent otitis externa may
benefit from thorough drying of the ear canals after
bathing, such as by using a hair-dryer.
 The prophylactic instillation of 2% white vinegar solution,
prescription ear preparations, or over-the-counter
swimmer's eardrops is considered; 2% acetic acid acidifies
the environment of the canal and reduces Pseudomonas
colonization.
 Effectiveness of earplugs is controversial.” (Schwartz,
2008)
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Also be sure to educate your patients against
cleaning their ears with Q-tips for this causes
trauma and abrasions to the ear canal, thus
imbedding grounds for bacteria!
REFERENCES:
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Demetroulakos, J.L. (2007). Otitis externa [First consult, an imprint
of
Elsevier Inc.]. (MD Consult), Retrieved from
http://mdconsult.com/das/pdxmd/body/2181227265/0?type=med&eid=9-u1.0_1_m
Osguthorpe, J.D., & Nielsen, D.R. (2006). Otitis externa: review
and clinical update. American Family Physician, 74(9), Retrieved
from http://www.aafp.org/afp
Roberts, J.R. (2010). Clinical procedure in emergency medicine: ear
[5th edition, an imprint of Elsevier Inc.]. (MD Consult), Retrieved
from http://www.mdconsult.com/das/book/body/21812272611/0/2083/559.html#4-u1.0-B978-1-4160-3623-4..00064-X-s0145_3100
Sander, R. (2001). Otitis externa: a practical guide to treatment
and prevention. American Family Physician, 63(5), Retrieved from
http://www.aafp.org/afp
Schwartz, R.H. (2008). Otitis externa and malignant otitis externa
[Chapter 32, Churchill Livingstone, an imprint of Elsevier, 3rd
edition]. (MD Consult), Retrieved from
http://www.mdconsult.com/das/book/body/21812272614/0/1679/36.html