OTITIS EXTERNAA Case Report

Jennifer Johnson

Lock Haven University

SOME OF THE ABSTRACT/OVERVIEW 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 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…

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

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.

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.

WORSENED PHYSICAL EXAMINATION FINDINGS 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. The left ear exam was unremarkable, and the remainder of

the exam was within normal limits.

DIFFERENTIAL DIAGNOSES:

“The most common differential diagnoses are otitis media, chronic suppurative otitis media, cholesteatoma, mastoiditis, chondritis, and polychondritis.

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

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 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 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…

“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: 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) 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: Demetroulakos, J.L. (2007). Otitis externa [First consult, an imprint of

Elsevier Inc.]. (MD Consult), Retrieved from http://mdconsult.com/das/pdxmd/body/218122726-5/0?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/218122726-11/0/2083/559.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/218122726-14/0/1679/36.html