CASE PRESENTATION

SUPERVISOR:DR. OSCAR DJAUHARI, SP. THT

PRESENTED BY:VICTOR BANDANA 2012.061 .049

GESTANO 2012.061 .054

Otitis Externa

Ear Nose Throat - Head and Neck DepartmentMedical Faculty of Unika Atma Jaya JakartaSyamsudin, S.H. Regional General Hospital,

SukabumiPeriod September 22nd 2014 – October 18th

2014

PATIENT’S IDENTITY

Name : Mr. MGender : MaleAge : 35 years oldOccupation : BussinessmanRace : JavaneseAddress : SukabumiWeight : 65 kgHeight : 170 cm

HISTORY

Chief Complaint : Severe right ear pain. Additional Complaint : Right ear fullness, fluid came out from right ear, mild

decreased hearing. History of Present Illness A 35-years-old male came to ENT clinic with a chief

complaint of rapid-onset severe right ear pain and fullness. The patient complains of otorrhea and mild decreased hearing in the right ear. He reports that his symptoms started after swimming 2 days ago. No fever is reported.

HISTORY

History of Past IllnessHistory of previous illness was denied History of Family IllnessHistory of family illness was denied

PHYSICAL EXAMINATION

General condition : Appear calmBody weight : 65 kgHeight : 170 cmBlood pressure : 120/80 mmHg Pulse : 88 beats per minuteRespiratory rate : 20 times per

minuteTemperature : 36,9 oC

ENT ExaminationEarRight earAuricle : normalExternal auditory canal :

hyperemic (+), edema (+), mass (-), laceration (-) secretion (-), cerumen (-), pain on tragus (+)

Tymphanic membrane : Can’t visualized due to the swelling

Left earAuricle : normalExternal auditory canal:

hyperemic (-), edema (-), mass (-), laceration (-) secretion (-) , cerumen (-)

Tymphanic membrane: Intact, bulging (-), light reflex (+)

Otoscopy Right Ear

NoseRight nose Mucous membrane:

hyperemic (-), edema (-), ,mass (-), laceration (-), crust (-) Inferior conchae : eutrophy Septum : no deviation Air passage : normalLeft nose Mucous membrane:

hyperemic (-), edema (-),secretion (-), mass (-), laceration (-), crust (-) Inferior conchae : eurtrophy Septum : no deviation Air passage :normal

ENT Examination

OropharynxPosterior pharynx : hyperemic (-)Palatine tonsils : T1 / T1, hyperemic (-), detritus

(-)Uvula : symmetrical Dental : no abnormatlities Maxillofacial : symmetrical Neck : no lymphadenopathy

ENT Examination

WORKING DIAGNOSIS

♂, 35 years old with Acute Otitis Eksterna AD

DIFFERENTIAL DIAGNOSISTraumaTumor

WORK-UP

Laboratory:Complete blood count

TREATMENT

Cleansing with 2% acetic acidTopical AntibioticAnalgetic Education for aural toilet

LITERATURE REVIEW

Otitis externa commonly infection (usually bacterial, occasionally fungal)

May associated noninfectious systemic or local dermatologic processes

Characteristic symptom : Discomfort, limited to the CAE Erythema and swelling of the canal with variable

discharge

Definition

Otitis externa is an infection of the outer ear canal.

Also called swimmer's ear.

Anatomy and Physiology of the External Auditory Canal

Precipitants and Etiology of Otitis ExternaMoisture

- Swimming- Perspiration- High humidity

Water contaminated with bacteria

High environmental temperatures

Mechanical removal of cerumen

Insertion of foreign objects- Cotton swabs- Fingernails- Hearing aids- Ear plugs

Other trauma to ear canalChronic dermatologic

disease- Eczema- Psoriasis

- Seborrheic dermatitis- Acne

Etiology

The most common cause OE bacterial infection

Fungal overgrowth 10 percent of cases

BACTERIAL OTITIS EXTERNAOverview

External auditory canal ↓

Normal bacterial flora ↓

Remains free of infection ↓

Defenses disrupted ↓

New pathogenic flora develops ↓

Dominated by Pseudomonas aeruginosa & Staphylococcus aureus.

BACTERIAL OTITIS EXTERNA

OE with a bacterial etiology more intense than other

Otalgia may be severe enough to require systemic analgesics such as codeine and nonsteroidal anti-inflammatory drugs (NSAIDs)

Significant swelling of the canal is common

BACTERIAL OTITIS EXTERNA

Once the external auditory canal has been cleansed as much as possible and a wick inserted if swelling is severe, topical antibacterial therapy should be started.

Topical agents acidification with 2 % acetic acid usually effective

Steroids ear drops ↓ inflammation & edema resolve symptoms more quickly

Clinical Presentation

OtalgiaOtorrheaItching Swelling in ear canalCrusting around the ear canal opening.Sometimes swelling or pus may decrease

hearing

DiagnosisCause Characteristic

Otitis Externa

Acute bacterial Scant white mucus, but occasionally thick

Chronic bacterial Bloody discharge, especially in the presence of granulation tissue

Fungal Typically fluffy and white to off-white discharge, but may be black,

gray, bluish-green or yellow; small black or white conidiophores on

white hyphae associated with Aspergillus

Otitis media with perforated tympanic membrane

Acute Purulent white to yellow mucus with deep pain

Serous Clear mucus, especially in the presence of allergies

Chronic Intermittent purulent mucus without pain

Cerebrospinal fluid

leak

Clear, thin and watery discharge

Trauma Bloody mucus

Osteomyelitis Otorrhea with odor

Treatment

Prevention of Recurrence

Avoiding precipitants

Treat any underlying chronic dermatologic disorders

Otitis Externa Maligna

Diabetes most significant risk factor (90% of patients)

50% of cases of malignant external otitis (MEO) preceded by traumatic aural irrigation in patients with diabetes.

Physical examination

Inflammatory changes The pain is out of proportion Marked tenderness is present in the soft tissue

between the mandible ramus and mastoid tipGranulation tissue is present at the floor of the

osseocartilaginous junctionOtoscopic examination may also reveal exposed

boneThe cranial nerves (V-XII) should be examinedMental status examination Fever is uncommon

Laboratory Studies

Leukocyte count

Erythrocyte sedimentation rate

Serum chemistry

Culture and sensitivities from the external auditory canal

Imaging Studies

CT scanning and MRI ↓

For evaluating the anatomic extent of soft tissue inflammation, abscess formation, and intracranial complications

Treatment

Treatment includes :meticulous glucose controlaural toiletsystemic and ototopic antimicrobial therapy