CASE REPORT

DIFFUSE OTITIS EXTERNA

Presentator Koas THT periode 20 January-15 February 2014 :

Geetha Balasubramaniyam

Johannes Octan Daniel 

Rizky Ajrina Meidiyana 

Zahrifa Riandani Putri 

Putri Riadhini 

Resy

Moderator : dr Akmal

Otorinolaryngology and Head Neck Surgery Departments

Medical Faculty of Gadjah Mada University

DR Sardjito Hospital Yogyakarta

2014

CHAPTER II

INTRODUCTION

Otitis externa is an infection of the external auditory canal. Otitis externa

occurs in 4 of every 1000 people annually, and the chronic form affect 3-5% of

the population. Prompt diagnosis and treatment cures the majority of cases

without complication. Otitis externa is defined as chronic when the duration of the

infection exceeds more than 1 month or when more than 4 episode occur in 1

year.

If left untreated, the infection may invade the deeper adjacent structures

and progress into malignant otitis externa. This complication is almost exclusively

seen in immunocompromised patients such as those with diabetes, AIDS patients,

those undergoing chemotherapy, and patients taking immunosuppressant

medications (eg. Organ transplantation) such as glucocorticoids. Pseudomonas

Aueroginosa is the inciting organism in the vast majority of cases. When

untreated, malignant otitis externa has a mortality rate approaching 50%. This

complication should be suspected if tenderness, otalgia, rythema, or edema of the

external ear or adjacent tissues is present on physical examination.

People in some racial groups have small ear canals, which may predispose

them to obstruction and infection. Rates of occurrence of otitis externa are equal

in males and females. Although otitis externa is seen in all age groups, the peak

incidence is in children aged 7-12 years.

ANATOMY

The external ear is composed of the auricle and external auditory canal.

Both contain elastic cartilage derived from mesoderm and a small amount of

subcutaneous tisssue, covered by skin with its adnexal appendages. There is fat

but not cartilage in the lobule.

1. Auricle

The Auricula or Pinna is of an avoid form, with its langer end directed upward. Its

lateral surface is irregularly concave, directed slightly forward, and presents

numerous eminences and depressions to which names have been assigned.The

prominent rim of the auricula is called the helix; where the helix turns downward

behind, a small tubercle, the auricular tubercle of Darwin, is frequently seen; this

tubercle is very evident about sixth month of fetal life when the whole auricula

has a close resemblance to that of some of the adult monkeys. Another curved

prominence, parallel with and in front of the helix, is called the antihelix; this

divides above into two crura, between which is a triangular depression, fossa

triangularis. The narrow-curved depression between the helix and the antihelix is

called the scapha; the antihelix describes a curve around a deep,capacious cavity,

the concha, which is partially divided into two parts by the crus or commencement

of the helix; the upper part is termed the cymba concha, the lower part the cavum

concha. In front of the concha, and projecting backward over the meatus, is a

small pointed eminence, the tragus,so called from its being generally covered in

its under surface with a turf of hair, resembling a goat’s beard. Opposite the

tragus, and separated from it by intertragic notch, is small tubercle, the antitragus.

Below this is the lobule, composed of tough areolar and adipose tissues, and

wanting the firmness and elasticity of the rest of the auricula.

2. External Auditory Canal

The External Acoustic Meatus (muatus acusticus externus; external

auditory canal or meatus) exterds from the bottom of the concha to the tympanic

membrane. It is about 4 cm in length if measured from the tragus ; from the

bottom of the concha its length is about 2,5 cm. It forms an S-shaped curve, and is

directed at first inward and backward (pars media), and lastly is carried, inward,

forward and slightly downward (pars interna). It is oval cylindrical canal, the

greatest diameter being directed downward and backward at the external orifice,

but nearly horizontally at the inner end. It present two constrictions, one near

theinner end of the cartilaginous portion, and another the isthmus, in the osseous

portion, about 2 cm from the botton of the concha. The tympanic membran, which

closes the inner end of the meatus, is obliquely directed; in consequence of this

the floor and anterior wall of the meatus are longer than the roof and posterior

wall.

The external acoustic meatus is formed partly by cartilage and membrane,

and partly by bone and lined by skin.

The Cartilaginous portion ( meatus acustiocus externus cartilageus)

The length is about 8mm in the length. It is continous with the cartilage of

the auricula, and firmly attached to the circuference of the auditory process of the

temporal bone. The cartilage is deficient at the upper and back part of the meatus,

its place being supplied by fibrous membran; two or three deep fissures are

present in the anterior part of the cartilage.

The skin of the cartilaginous canal contains many hair cells and sebaceous and

apocrine glands such as cerumen glands. Together, these three adnexal structures

provide a protective function and are termed the apopilosebaceous unit. Glandular

secretion combine with sloughed squamous epithelium to form an acidic coat of

cerumen, one of the primary barriers to infection of the canal.

The osseous portion (meatus acusticus externus osseus)

The length is about 16 mm and narrower than the cartilaginous portion. It

is directed in ward and a little forward, forming in its course a slight curve the

convexity of which is upward and backward. Its inner and smaller than the outer

and sloped the anterior wall projecting beyond the posterior for about 4 mm. It is

mark, except at its upper part, by a narrow groove, the tympanic sulcus in which

the circumference of the tympanic membrane is attached. Its outer end is dilated

and rough in the greater part of its circumference, for the attachment of the

cartilage of the auricula. The front and lower parts of the osseous portion are

formed by a curved plate of bone, the tympanic part of the temporal, which in the

fetus, exists as a separate ring (annulus tympanicus), incomplete at its upper part.

4. Vascularitation

The arteries of the auricula are the posterior auricular from the external

carotid, the anterior auricular from the superficial temporl, and a branch from the

occipital artery. The arteries supplying the meatus are branches from the posterior

auricular, internal maxillary, and temporal. The veins accompany the

corresponding arteries.

5. Innervation

The sensory nerve of the auricle are the great auricular, from the cervical

plexus the auricular branch of the vagus ; the auriculotemporal branch of the

mandibular nerve ; and the lesser occipital from the cervical plexus. The nerves of

meatus are chiefly derived from auriculotemporal branch of the mandibular nerve

and the auricular branch of the vagus.

6. Lympatic

Lympatic drainage of external ear consist of

Lnn Parotis superfisial

Receive drainage from tragus and anterior auricula

Lnn Retroauricular

Receive lymph drainage from posterior and cranial auricula

Lnn Cervical Superfisialis

Receive lymph drainge from lobulus

DIFFUSE OTITIS EXTERNA

1. Definition

Diffuse otitis externa is inflammation of the external ear canal, with or

without involment of the pinna or tympanic membrane. Diffuse otitis externa is

the most common form of otitis externa.

2. Etiology

The most common offending organisms that cause otitis externa are

Pseudomonas aeruginosa (50%), Stapylococcus aureus (23%), anaerobes and

gram-negative organisms (12,5%)

3. Risk Factor

The risk factor of diffuse otitis externa are swimming, swimming in water

where bacterial level are high, people with allergic condition, people who has

small ear canal because water can be trapped more easily, over cleaning the ear

canal, too much ear wax, making it more likely that water gets trapped.

Predisotition factors :

Moisture (swimming, perspiration, high warmth CAE

High ambient temperature

Contamination by water contaminated with bacteria

Habits take cerumen, cerumen impaction

The entry of foreign materials (cotton swab, fingernail, toys, insect, ear plugs)

Traumatic ear canal

Chronic skin diseases (eczema, psoriasis, seborrheic dermatitis, acne)

Diabetes mellitus

Immunocompromised state

Exostosis at CAE

4. Pathogenesis

Excessive cleansing and water exposure will remove the protective layer

and acid mantle from the canal, so the stratum corneum become edematous

resulting in plugging of the apopilosebaceous unit. As obstruction continues, a

sense of fullness and itching begins. The disruption of the epithelial layer due to

scratching allows invasion of bacteria that either reside in the canal or are

introduced on foreign objects inserted into the canal, such as a cotton swab or a

dirty fingernails

5. Sign and symptoms

Pain, fullness, itching, and hearing loss are the four major symptoms of

external otitis, although not every patient has each symptom. Throughout the

examination, the examiner should remember the innervation of auditory external

canal and recall that pain from other areas of the upper aerodigestive tract may be

referred to the ear.

Typically, the preinflammatoory stage begins when the stratum corneum

becomes edematous because of removal of the protective lipid layer and acid

mantle from the canal, resulting in lugging of the apopilosebaceous unit. As

obstruction continues, a sense of fullness and itching begins.

The disruption of the epithelial layer allows invasion of bacteria that either

reside introduced on foreign objects inserted into the canal, such as a cotton swab

or a dirty fingernails,. This produces the acute inflammatory stage, which is

accompanied by pain and tenderness of the auricle. In the earliest stage, the skin

of the external auditory canal shows mild erythema and minimal edema. A small

amount of clear or slightly cloudy secretion may be seen in the canal.

As pain and itching increase, the patient progresses to the moderate stage

in which the canal shows more edema and a thicker more profuse exudates.

Further progression of the inflammation in the absence of treatment the severe

inflammatory stage characterized by increased pain and obliteration of the lumen

of the canal. A profuse, purulent exudate and edema of the canal skin may obscure

the tympanic membrane. In addition, small white papules are often visible on the

surface of the canal skin. P. aeruginosa or another gram-negative bacillus can

almost always be cultured at this stage.

In the severe stage, the physician often sees evidence of extension of

infection beyond the canal to involve the adjacent soft tissue and cervical lymph

nodes. In the chronic inflammatory stage, patient experience less pain but more

profound itching. The skin of the external canal is thickened, and superficial

ulceration. This condition is likened to eczema and may range from mild drying

and thickening of the canal to complete obliteration of the external canal by

chronically infected hypertropic skin.

6. Diagnosis

Diagnosis of diffuse otitis externa is made based on the history and

physical examination. History of pain. Fullness, itching, and discharge is the

common symptom of diffuse otitis externa. From physical examination, we may

find various condition depends on its stage. In preinflammatory stage we will find

mild erythema and tenderness. In acute inflammatory, there are auricular

tenderness, erythema, edema, and discharge. And in chronic inflammatory stage,

we will find thickening or flaking of canal skin, eczematization, ulceration.

7. Management

The four fundamental principles in the treatment of external otitis in all

stages are frequent and thorough cleaning, judicious use of appropriate antibiotics,

treatment of associated inflammation and pain, and recommendation regarding the

prevention of future infection. In any stage of infection, thorough cleaning is a

priority. Meticulous debridement of exfoliated debris, purulence, and cerumen

will do as much if not more than simply placing the patient on ear drops. In the

preinflammatory stage, a complete cleaning may be all that is required. In the

absence of purulence, a brief course of an acidifying drop such as aluminum

sulfate or calcium sulfate (Domeboro) is efficacious in discouraging bacterial or

fungal growth.

Treatment of the acute inflammatory stage varies with the extent of

disease. In mildest form, cleaning as described previously is indicated. An

antibiotic drop is recommended to cover what is probably a Pseudomonas

infection. There is an emerging body of evidence that the fluoroquinolone

preparations with or without steroids (ciprofloxacin, ofloxacin, dexamethasone,

hydrocortisone (Cipro HC, Ciprodex, Floxin)) may have advantages over the

neomycin/polymyxin.hydrocortisone preparation (Cortisporin or Coly-Mycin S

Otic). At this time, no significant antibiotic resistance has been shown to emerge

due to the use of the fluoroquinolone ototopic medications. At this stage, edema

of the external auditory canal should not be severe, and the patient should be able

to instill drops into the ear by tilting the head to the side or by lying down with he

involved ear upright.

In the moderate stage of inflammation, edema of the canal may interfere

with the instillation of drops. The physician should then insert a wick into the

canal and instill drops on it. Often the canal may accommodate two or even three

wicks. As the wicks expands, it presses the soft tissues and periosteum toward the

nondistended position; this alone may relieve pain. All instrumentation of the ear

is best done under the microscope. The wick is removed by the physician at the

times of reexamination. If the edema has not significantly reduced, repacking is

indicated. Antibiotic drops should be continued for at least 2 to 3 days after the

cesation of pain, itching, and drainage, so that complete eradication of infection

may be ensured.

In the moderate stage, an oral analgesic is often prescribed because pain

can be pronounced. Caution the patient to avoid manipulation of the canal. Teach

swimmers to towel dry the concha and lateral canal, to shake water out of the

canal, or to instill an acidifying drop after swimming. If the infection has not

spread beyond the boundaries of the external canal, the use of oral antibiotics will

be of little if any value. A final office visit is important to ensure that the infection

has completely resolved and the canal is back to its normal state.

In the severe stage, infection usually extends beyond the limit of the canal.

In addition to the cleaning, packing, and use of antibiotic drops as discussed

previously, attend to any soft tissue involvement by using an oral antibiotic with

broad spectrum coverage. Successive generations of the cephalosporins widen

gram negative coverage at the expense of gram positive coverage. In addition to

anti Pseudomonas eardrops, common choices of oral antibiotics are

antistaphylococcal penicillins, first-generation cephalosporins, or one of the

antipseudomonal fluoroquinolones such as ciprofloxacin or levofloxacin. The

fluoroquinolone antibiotics are effective against Pseudomonas species but at

present are not approved for use in patients under age 18 because of the risk of

arthropathy formation. Multiple reports over the last 10 years have indicated the

safe use of ciprofloxacin in the pediatric patient with little if any increased

development of arthropathy over adults. The fluoroquinolones remain contra-

indicate, however, except in extraordinary circumstances, such as in the treatment

of respiratory disease in children with cystic fibrosis. Warm soaks (normal saline

or diluted aluminum sulfate calcium sulfate solution) are also useful in the

treatment of the crusting and edema involving the auricle and surrounding skin.

Culture of the canal is indicated only for severe stage or for patients who have

previously been treated without resolution. Treatment is generally continued for

10 to 14 days if there is a good response. In rare patients who do not respond to

this regime, hospitalization, vigorous daily local care, repeat culturing, and

intravenous antibiotics are indicated.

In chronic phase, treatment aims at reduction of meatal swelling so that ear

toilet can be effectively done, and alleviation of itching so that scratching is

stopped and further recurrences controlled . A gauze wick soaked in 10%

ichthammol glycerine and inserted into the canal helps to reduce .swelling. This is

followed by ear toilet with particular attention to anteroinferior meatal recess.

Itching can be controlled by topical application of antibiotic steroid cream. When

the meatal skin is thickened to the point of obstruction and resists all forms of

medical treatment, i.e. chronic stenotic otitis externa, it is surgically excised, bony

meatus is widened with a drill and lined by split-skin graft.

In all cases of acute or chronic external otitis, instruct the patient to avoid

future infections by not placing any objects or instrument into the canal. These

often excoriate the canal skin and push debris further into the canal rather than

remove it. Patients who have repeated infections despite adhering to these

measures are best advised to use an acidifying drop composed of equal measures

of vinegar and water, or ethyl alcohol and water, when exposed to high humidity.

Alternatively, an acidifying power such as boric acid may be used. Custom-made

ear molds are useful for these patients.

CHAPTER III

CASE REPORT

A. Identity

• Name : Mrs. J

• Age : 30 years old

• Gender : Female

• Religion : Moslem

• Adress : Mandungan RT 2/RW 5, Manis Renggo

• Date of visit : Januari 28th 2014

• Med.Record : 664555

B. Anamnesis

Chief complaint : Continous pain in the right ear

History of Present Illness:

• 3 days before patient came to the polyclinic, patient complaint about

continuous pain in the right ear although there was no contact to the ear. The pain

felt was accompanied with a heat sensation that affected the patient’s daily

activities. The patient felt that the complaint worsen day by day.The patient also

felt a sensation of aural fullness in the right ear which decrease her hearing ability.

No blood was present but the patient did admit that there was a little bit of serous

discharge seen on the cotton bud that she used to clean her ear. The patient had no

complaint regarding her left ear. The patient has a history of routinely using

cotton bud ( every 3 days once). Patient denied the entrance of water or any other

foreign objects into the ear. There was no tinnitus, dizziness and fever present.

The patient had no complaints regarding nose, mouth and throat.

History of Past Illness

• Previous history regarding her right ear in which she went to the ENT

polyclinic on the 13th February 2013 with complaint of yellow discharge present

in the right ear and was diagnosed as Chronic Suppurative Otitis Media.

Medication given was Tarivid ear drops 2x4, Aldesa 2x1 and Ambroxol 3x1. The

patient failed to show up for her follow up session.

• History of allergy denied

• History of flu (-)

• History of hypertension (-)

• History of DM (-)

• History of admitted to the hospital (-)

• History of smoking (-)

History of Illness in Family Members

• History of the same complaints (-)

History of medication : Patient has never bought any ear drop medication

unprescribed

Nutritional status : Good, eats 3x a day, home cooked meals

Psychological status : Good

Socioeconomic status : Well off

Anamnesis Summary

• Pain in the right ear

• Heat sensation in the right ear

• Sensation of aural fullness in the right ear

• Serous discharge from the right ear

• History of right ear infection

C. Physical Examination

• General status: well conscious, adequatly nourished

• Vital sign:

Blood Pressure : 120/80 mmHg

Respiratory Rate : 88 x/minute

Heart rate : 20x/minute

Temperature : 37 0C

• Head and neck : Normal

• Conjungtiva anemia (-), enlargement of lymph node (-)

D. ENT Examination

Ear

Dextra Sinistra

Outer Inspection Auricular deformity

(-), Hyperemis (-),

swelling (-)

Auricular deformity

(-), Hyperemis (-),

swelling (-)

Palpation Tenderness (+) Tenderness (-)

Otoscopy EAC hyperemis (+),

swelling (+),minimal

discharge (+)

Tympanic membrane

can’t be asseseed

Normal EAC,

hyperemis (-),

swelling (-), normal

cerumen.

Intact tympanic

membrane, pearl-

white coloured,

perforation (-), cone

of light (+)

Nose

Dextra Sinistra

Inspection Deformity (-),

hyperemis (-),

swelling (-) discharge

Deformity (-),

hyperemis (-),

swelling (-) discharge

(-) (-)

Palpation Tenderness (-)

Anterior

Rhinoscopy

Septum deviation(-),

hyperemis (-),

swelling (-), massa(-),

discharge (-)

Septum deviation(-),

hyperemis (-),

swelling (-), massa(-),

discharge (-)

Posterior

rhinoscopy

(Not performed)

Paranasal sinus

examination

Maxilla and frontal tenderness (-)

Throat

Structure Finding

Lip Normal color

Buccal mucose Hiperemic (-)

Tongue and palate Hiperemic (-) stomatitis (-)

Dental and gingiva oedema (-), hiperemis (-), caries

(-)

Uvula Deviation (-)

Tonsil and pharyng T1-T1, hyperemic (-)

Indirect Laryngoscopy Not perfomed

E. Supporting examination : Not performed

F. Diagnosis

Otitis externa diffusa auris dextra

G. Therapy

Tampon sofratule

Natrium Diklofenak 2x 50 mg

H. Education

•The patient should meet the doctor for follow-up to know the progress of the

disease.

•Take care of the ear cleanliness and hygiene, prevent the entrance of water or any

foreign objects into the ear.

I. Problem

Management of Otitis Externa Diffusa (preferences between Ear wick or

Antibiotic Otic Drop)

J. Plan

Control every two until three days to reapply tampon (2 weeks)

K. Prognosis

Dubia ad bonam

CHAPTER IV

DISCUSSION

Diffuse otitis externa is an inflammation that affect whole externa ear

canal, with or without involvement of the pinna or tympanic membrane. The main

clinical features of diffuse otitis externa are pain, fullness, itching, hearing loss.

The severity of each symptoms depend on the severity of infection (mild,

moderate, severe). In this case, we conclude that patient suffers from acute

inflammatory stage (moderate severity) because the main complaint of this patient

was continuous pain in her right ear. The canal shows edema so that we could not

see the tympanic membrane. But the inflammation is not spreading to adjacent

soft tissue as in the severe stage.

In this case, patient complains about feeling continuous pain in the right

ear although there was no contact to the ear. The pain felt was accompanied with a

heat sensation that affected the patient’s routine activities. The patient felt that the

complaint worsen day by day.The patient also felt a sensation of aural fullness in

the right ear which affected her hearing in which she presumed that the sound

heard was from a distant source but in reality it is from a near source. The patient

has a history of routinely using cotton bud ( every 3 days once). From the

anamnesis and physical examination, the patient was diagnosed with diffuse otitis

externa auris dextra

Whether patient needs wick or otic drop depends on the severity of oedema.

In mild inflammatory stage, edema of the external auditory canal should not be

severe, and the patient should be able to instill drops into the ear by tilting the

head to the side or by lying down with the involved ear upright. Starting from

moderate stage, edema of the canal may interfere with the instillation of drops.

Hence the physician should then insert a wick into the canal. We chose sofratule

because of its functions as wick and antibiotic (framycetin). Antibiotic drops are

still be used for at least 2 to 3 days after the cesation of pain, itching, and

drainage, so that complete eradication of infection may be ensured. In severe

stage, the oral antibiotic is needed in addition of ear wicks and antibiotic otic

drops because the inflammation has spread to the surrounding tissue.

CHAPTER V

CONCLUSION

A female patient of age 30 years old being diagnosed with Otitis externa

diffusa auris dextra has been reported. This patient was tamponed with sofratule

wick and given natrium diclofenac 2x50mg as well as education. The patient is

adviced to control every two until three days to reapply tampon (2 weeks)

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