chronic otitis externa 20060425
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Chronic Otitis Externa
2006/04/25
R3 張維修
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Introduction
Otitis externaMayer in 1844, a fungus infection
Chronic otitis externa1. McLaurin et al. in 1964, laryngoscope;
persistent external otitis
2. Otitis externa: clinically into acute,sub-acute, chronic, or recurrent
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Introduction
Persistent: chronic or recurrent case of otitis externa
1. An interruption of the continuity of theepithelial lining of the external auditorycanal
2. A change of the PH from the acid to
the alkaline side
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Clinical presentation F:M=2:1 Bilateral: 50% (constitutional or systemic factor) First visit of mean age: 50.5 y/oTwo clinical stage Initial stage:1. intense and persistent pruritus (most frequently); painlessness2. Otorrhea (scant, watery or milky, odorless, not very
troublesome)3. Progressive narrowing of EAC End stage1. Hearing loss (conductive hearing loss)
secondary to edema and/or debris accumulation in the EAC
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Physical examination:Initial stage Cerumen: usually absent Otorrhea: watery or milky, rarely copious Ear canal: varies (depend on the level of disease activity)
Shiny, hyperemic and/or erythematous, covered with
granulation tissue Almost any intermediate stage imaginable can be seen The lateral canal is less severely affected Lumen progressively narrows (months to years)
End stage:a shiny, cerumen-free, skin-lined blunted sac and no evidence of
active infection or ongoing inflammation (squamous epitheliumrarely becomes trapped between the blind end and TM)
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Image (Coronal CT)
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Histopathology
Consist of fibrous connective tissue,including focal areas of calcification
Some subepithelial edema area were
slightly infiltrated with lymphocytes Subepithelial mucopurulency can
coalesce to form microabscesses No evidence of neoplasm or significant
acute or specific inflammation
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Etiology
Mixed etiology; Unclear; Genetic or constitutional factor (50% bilateral)
Environmental factor: high temperature, high
humidity (hot and humid climate), waterexposure (swimming)
Traumatic
InfectiveMultifactor; Right genetic predisposition and the
right environment
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Infectious component:
Bacterial pathogens: Culture: the same as acute bacterial external
otitis
Pseudomonas spp.:30~50%Staphylococcus spp.: 10~20%
other G(-) organism
The development of antibiotic resistantorganisms with the use of ototopicalmedications?
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Microbiology of acute otitis externa.
Laryngoscope. 112(7 Pt 1):1166-77, 2002 Jul.
1998-2000, US, 2039 AOE subjects (2240 diseasedears)
Top 3 most frequent1. P. aeruginosa (38%)
2. S. epidermidis (9.1%)3. S. aureus (7.8%) Resistance S. epidermidis S. aureus1.
Neomycin 23% 6.3%2. Oxacillin 11% 2.7%3. Ofloxacin 12% 4.5% P. aeruginosa: resistant to quinolones from only
one subject
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Infectious component:Fungal organisms:
Not common in AOE; less well understood in COE
Aspergillus and Candida spp. are the most frequentlyrecovered organism
Slow-growing fungi might be missed (specialdetection techniques: immunofluorescencemicroscopy)
an id reaction: a focus of fungal infection elsewherein the body can cause an secondary inflammatoryprocess in the external auditory canal
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Allergic otitis externa
Two basic forms: A contact dermatitis
1. primary contact otitis2. secondary contact otitis
A dermatophytid reaction
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Allergic contact dermatitis:
A type IV hypersensitivity reaction; adelayed-type hypersensitivity reaction
Characterized by severe pruritis leadingto scratching by the patient causingprolongation of the inflammation
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Primary contact otitis
Not previously inflamed Contact allergen:
1. Metal: nickel (commonest contact allergen),
chrome, silver, gold2. Chemicals: cosmetics, nail polish, soaps,
detergents, shampoo, hairspray, dyes,3. Plastics, rubber, leather, or drugs
Diagnosis: history taking
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Primary contact otitis:
Earrings
Nickel (10% of woman), chrome,skin around the site of ear piercing(usually the lobule or around the helix),which spreads to the antihelix,scratching: secondary infection
Dermatitis on the neck area where theearring touches
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Primary contact otitis:
Hearing aids the components of and chemical used in the
manufacture of hearing aid moulds Methyl methacrylate is the most common sensitizer
Meding and Ringdahl, 1992, Ear Hear
-22 hearing aids users with chronic dermatitis of theear canal
-6/22(27%) contact allergy to the ear mould on
patch testing;(methyl methacrylate and ethylene glycolmethacrylate)
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Secondary contact otitis
Iatrogenic Prolong use of topical preparations in the
treatment of otitis externa
Most common: neomycin; crossover withframycetin, gentamycin; avoid systemicaminoglycoside
Diagnosis: skin patch test(gold standard; 48-72 hrs)
Tx: identify antigen and avoid contact
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Reported agents associated
with allergic otitis externa
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Dermatophytid reaction: Hematologic spread of fungi or their allergenic
products from a primary focus of fungal infection Id reaction:1. A demonstrable primary focus containing the
pathogenic fungi, remote from the id lesion2. Absence of fungi in the skin lesion at the id reaction3. Spontaneous resolution of the dermatitis when the
primary focus fungal infection has been eradicated4. A positive immediate skin test response,
demonstrating a type 1, immunoglobulin E (IgE)-mediated reaction to an intradermal test of thefungal antigen
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Dermatophytid reaction:
Common sites for the primary focus of fungal infection:
1. Nails (onchomycoses),
2. skin (chronic tinea pedis infections;athlete`s foot),
3.
vagina (monilial vaginitis; recurrent vaginitis) The most common fungus: Trichophyton
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Dermatophytid reaction:
Treatment:1. identification and treatment of the
primary focus of fungal infection
2. desensitization with allergic extract of the infecting fungus to lessen the
allergic component3. control of any complicating secondary
bacterial infections
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Foot and Ear Disease- The DermatophytidReaction in Otology Laryngoscope 106:181-6, 1996
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Results
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Regional PH in EAC
1938, Dermatologist Marchionini & Hausknetch:
The bactericidal and fungicial functions of
skin are reinforced by superficial skin acidity. Martinez Devesa P. Willis CM. Capper JW.
External auditory canal pH in chronic otitisexterna. [Journal Article] Clinical Otolaryngology & Allied Sciences. 28(4):320-4,
2003 Aug.
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External auditory canal PH in
chronic otitis externa
A prospective age/sex-matched controlstudy
Chronic otitis externa: more than4weeks of duration and/or four or moreepisodes per year
18 patients (F:M=11:7); mean age:51.4 y/o
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Results
External auditory canal pH in chronic otitis externa pH=6.61; Normal controlpH=5.90 (P<0.004)
Forearm PH in chronic otitis externa pH=5.7; Normal control pH=5.66
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Results
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Results
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Results
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Results
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Dermatologic conditions: Pre-existing dermatologic processes are being
found with increasing frequency in patientwith chronic external otitis.
Seborrheic dermatitis (most common):positive family history, associated scalp andretroauricular area involvement, flexorsurfaces of the extremities
Psoriasis
Neurodermatitis
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Differential diagnosis
Carcinoma of the EAC Dermatomycosis
Psoriasis Seborrhetic dermatitis
Contact eczematoid dermatitis (e.g., tohearing aid ear mold or eye glasses)
A dermatophytid reaction
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Treatment
Restoration of the external auditorycanal to its normal anatomic andphysiologic state
Early stage: medical treatment
Surgery; clinically significant conductive
hearing loss (media fibrosis)
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Medical treatment
Cleansing: aural toilet Trauma exacerbate the disease process
As atraumatic as possible; a“
no touch”
technique
Ear wick: corticosteroid neomycin
ointment (foreign body, more irritatingthan helpful)
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Medical treatmentSteroid (the most critical component) Only one well-controlled study
Jacobsson et al. Clinical efficacy of
budesonide in the treatment of eczematous external otitis. Eur ArchOtorhinolaryngol 1991, 248; 246-9
1. A double-blind, placebo-controlled,crossover trial of budesonide2. Decreased pruritus and otorrhea
significant
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Medical treatment
The more potent steroids are moreeffective
Systemic steroid, impractical (longterm nature of the disease)
Steroid injections into the
subepithelial tissues of the EAC(anecdotally, no evidence based)
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Medical treatment
Antibiotics (for infectious component) Used cautiously and probably sparingly,
Intermittent use
Powders antibiotics mixed withpowdered dexamethasone (adhere to
wet surfaces; more consistent level of drug delivery than topical drops)
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Medical treatment
Acidic solutions for the treatment of acuteand chronic otitis externa:
Aluminium acetate (Lambert, 1981)
97% alcohol + 3% acetic acid (Strauss& Dierker, 1987)
Acetic acid 1-3% (Thorp et al. 1998)
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Medical treatment
Emgard P. Hellstrom S. Holm S.External otitis caused by infection withPseudomonas aeruginosa or Candida
albicans cured by use of a topical groupIII steroid, without any antibiotics.
[Journal Article] Acta Oto-Laryngologica.125(4):346-52, 2005 Apr.
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Material and methods
A rat model (Male Sprague-Dawley rats) Right EAC was mechanically irritated by
exposure to 400 rotations of a plasticcone (80 rev/min) under microscope
Left ear: control
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Groups Group A: P. aeruginosa 0.1ml within 1 min1. A1: untreated2. A2: 0.1ml of 0.05% BD (betamethasone
dipropionate)3. A3: 0.1ml of HCPB (hydrocortisone +
oxytetracycline + polymyxin B)4. A4: 0.1ml of saline, pH:5.0 Group B: C. albicans 0.1ml within 1 min
B1, B2, B3, B4 Group C: not infected; 0.1 ml pH:5.0 saline
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Results
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Results
Results
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Results
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Medical treatment Relief of pain or discomfort
Through cleansing of the aural canal
The judicious, limited use of specific
medication Termination of therapy, particularly specific
therapy, as promptly as possible
Elimination or control of predisposing causeFabricant`s dictum: a maximum of inspection
and a minimum of therapy
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Medical treatment
Goal: arrest the disease completely,prevent the development of stenosis
Result: disappointed; Only slow the
progression (No long-term outcomesdata)
Tradition and opinion and that no long-term outcomes data are available
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Surgical treatment Indication: a significant conductive
hearing loss
Goal: remove the stenotic segment of
the external auditory canal Recreate a physiologically functioning
tympanic membrane
Success: all of the involved skin mustbe removed
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Surgical treatmentReconstruction:
local flaps (preconchal and postauricularflap);
advantage:1. less scaring because of increased
vascularity;
2. the contractural forces that develop duringhealing tend to pull the canal open
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Surgical treatment Full-thickness grafts
1. Provide greater resistance to trauma2. contain glandular elements that provide lubrication;
3. less likely to contract than split-thickness grafts;
4. hair follicles (make postoperative managementmore difficult)
Split-thickness grafts
1. Easier to obtain;2. harder to place
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Surgical treatmentSelesnick et al. Surgical treatment of acquired
external auditory canal atresia. Am J Otol1998;19.123-30
Three requirements of the successful
surgical repair of medial canal stenosis1. Complete removal of the cicatrix2. Performance of a bony canaloplasty
3. Resurfacing of the bony canal withepithelium Success: >80%
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Surgical treatmentFollow-up
Slattery and Saadat`s series of 24patients; (3.6 years follow-up)
mean pre-op ABG: 25dB;
post-op ABG:15dB
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Surgical treatmentRecurrence: Slattery and Saadat`s series of 14 surgical
procedures;1. recurrence rate: 3/14 (21.4%);2. earliest: more than 3 years following surgery Becker and Tos`s series:1. recurrence rate: 11/47 (23%);2. 3 patient recurrent within 6 months (an
insufficient removal of fibrous tissue duringthe primary operation)
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References McLaurin JW. Raggio TP. Simmons M. Persistent external otitis.
[Journal Article] Laryngoscope. 75(11):1699-707, 1965 Nov. Roland PS. Chronic external otitis.[see comment]. [Review] [17
refs] [Journal Article. Review] Ear, Nose, & Throat Journal. 80(6 Suppl):12-6, 2001 Jun.
Slattery WH 3rd. Saadat P. Postinflammatory medial canal
fibrosis. [Journal Article] American Journal of Otology.18(3):294-7, 1997 May.
Sood S. Strachan DR. Tsikoudas A. Stables GI. Allergic otitisexterna . [Review] [26 refs] [Journal Article. Review] Clinical Otolaryngology & Allied Sciences. 27(4):233-6, 2002 Aug.
Derebery J, Berliner KI. Foot and ear disease--thedermatophytid reaction in otology.Laryngoscope. 1996 Feb;106(2 Pt 1):181-6.
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References Martinez Devesa P. Willis CM. Capper JW. Externa l auditory
canal pH in chronic otitis externa . [Journal Article] Clinical Otolaryngology & Allied Sciences. 28(4):320-4, 2003 Aug.
Goodman WS. Middleton WC. The management of chronicexternal otitis . [Case Reports. Journal Article] Journal of Otolaryngology. 13(3):183-6, 1984 Jun.
Emgard P. Hellstrom S. Holm S. External otitis caused byinfection with Pseudomonas aeruginosa or Candida albicanscured by use of a topical group III steroid, without anyantibiotics. [Journal Article] Acta Oto-Laryngologica.125(4):346-52, 2005 Apr.
Roland PS. Stroman DW. Microbiology of acute otitis externa.[Journal Article] Laryngoscope. 112(7 Pt 1):1166-77, 2002 Jul.
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