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OTITIS EXTERNA

© Bruce Black MD

OTITIS EXTERNA Classification

Infection Bacterial Otomycoses Chronic myringitis Viral

Seborrhoeic Allergic Neurodermatitis EAC Osteitis

© Bruce Black MD

Bacterial Otitis Externa Clinical Features

Ache, pruritis, pain Semisolid debris in EAC Blockage, deafness due to debris Gurgling in ear

© Bruce Black MD

Bacterial otitis externa. Mixed cerumen and purulent exudate. Thorough cleaning is essential to clear infection

and spores to prevent recurrent disease. © Bruce Black MD

Bacterial O. Ext.

Treatment

Clean by suction or wool carrier Wet mopping, re-clean Antibiotic ointment (neomycin, gentamicin, ciprofloxacin) Antibiotic drops (only after cleaning; ineffective without)

© Bruce Black MD

Pseudomonal otitis externa with the green debris characteristic of this infection. Clean, then use gentamicin

or ciprofloxacin topically for optimal effect. © Bruce Black MD

Severe aural furunculosis. Scattered pustules and severe oedema. Micro-suction essential. Follow with a

betamethasone and ciprofloxacin wick, together with anti-staphylococcal antibiotics © Bruce Black MD

Aural Furunculosis Clinical Features

Severe pain, distressing Scanty purulent debris Deaf; severe canal oedema Gurgling noise Pain may be disorientating

© Bruce Black MD

Erythema and oedema secondary to furunculosis. Resembles mastoiditis, but is behind and below the ear rather than the

postero-superior location of a mastoid abscess. © Bruce Black MD

Furunculosis Treatment

Immediate strong pain relief Micro-suction (EAC oedema) Ciprofloxacin-betamethasone wick,

then ciprofloxacin drops Dicloxacillin Review and re-clean EAC

© Bruce Black MD

Aspergillus nigra otomycosis. The black spores are typical. Requires meticulous toilet then prolonged topical

clotrimazole for best outcomes. © Bruce Black MD

Otomycoses Fungal Otitis Externa

Pruritic, pain if drum perforated Semisolid dirty discoloured debris Blocked and deaf Gurgling, possible ringing Resistant to treatment, micro-suction

optimal © Bruce Black MD

Aspergillus flavum mycelium and typical yellow spores. Treat as for A. nigra and follow-up to check for recurrence.

© Bruce Black MD

Candida albicans, causing intense itch and blockage. Treat as for other otomycoses with serial suction toilet and wet

mopping to eliminate infected debris. © Bruce Black MD

Otomycoses Treatment

Thorough micro-suction and wet mopping

Clotrimazole and antibiotic wick Clotrimazole drops (if no drum

perforation) 2/52 Review 2/52, re-clean

© Bruce Black MD

Chronic Myringitis Chronic Drum / EAC Ulceration

Minor ache, itch Minor accumulated debris Intermittent blockage Little tinnitus or unsteadiness Reddened, granular or fibrosing

ulceration © Bruce Black MD

Chronic myringitis surrounding a small defect in the pars tensa. This is difficult to eradicate and often hinders

spontaneous closure of a perforation. © Bruce Black MD

Diffuse thicker myringitis coating the entire pars tensa. Removal off the collagenous drum layer by fine dissection, then using an onlay graft will usually eliminate this problem. © Bruce Black MD

Granular myringitis. Cautery with AgNO3 will shrink the granulations and antibiotic/antiseptic treatment may reduce them further, but surgery may be necessary, particularly in

the anterior angle. © Bruce Black MD

Extensive myringitis which has extended from the drum to eliminate the squamous epithelium of the deep canal. This

will deteriorate, requiring surgery (canalplasty). © Bruce Black MD

Cicatrising fibrosis, the end phase of chronic myringitis. Correctable only by EAC clearance and total split skin

grafting. © Bruce Black MD

Chronic Myringitis Management

Suction toilet Cauterise granulations Ciprofloxacin drops Excise and graft resistant cases

© Bruce Black MD

Note: Chronic myringitis is notoriously difficult to eradicate. Surgery is frequently the only effective option

Viral External Otitis Viral / Bullous myringitis

Pain and blockage Glairish / haemorrhagic blebs on drum May be confused with advanced AOM

Herpes zoster oticus (Ramsey Hunt Synd.) Lancing pain Vesicles in EAC, pinna Associated facial palsy, vertigo, SND

© Bruce Black MD

Bullous/viral myringitis, exhibiting haemorrhagic blebs totally obscuring the pars tensa.

© Bruce Black MD

Viral myringitis showing the glairish fluid-filled blistering of the drum. Can be confused with the blebs that develop as a

result of AOM. © Bruce Black MD

Herpes zoster oticus. Scattered small crusts cover the sites of recent vesicular formations on the conchal bowl. Facial palsy and severe cochleo-vestibular symptoms may be

present. © Bruce Black MD

Seborrhoeic Otitis Externa

Greasy scaling skin, also face, neck Erythema, exfoliation, inflammation,

oedema Dandruff, oily hair Cause uncertain, possibly Malassezi

furfur (yeast)

© Bruce Black MD

Seborrhoeic dermatitis showing the typical greasy scalp and dandruff.

© Bruce Black MD

Diffuse peri-otic skin with erythema, oedema and dandruff due to seborrhoea.

© Bruce Black MD

Allergic Otitis Externa

Intense pruritis Serous exudate, often profuse Periotic Inflammation, oedema History of recent topical medication

© Bruce Black MD

Erythema of the lower face and neck secondary to ciprofloxacin drops used for otitis externa.

© Bruce Black MD

Conchal bowl erythema and swelling, plus serous exudate, secondary to neomycin drop usage.

© Bruce Black MD

Gross oedema, inflammation and exudate after iodoform paste used on a mastoidectomy cavity.

© Bruce Black MD

Marked exfoliation, oedema and inflammation. Neomycin ear drops

© Bruce Black MD

ALLERGIC OTITIS EXTERNA Management

Clean thoroughly Liberal steroid ointment Avoid further causative agent

exposure

© Bruce Black MD

Neurodermatitis Lichen Simplex Chronicus,

Eczema Pruritis, discomfort Watery otorrhoea, intermittent Blockage: semiliquid powdery otorrhoea Conchal bowl erythema, oedema,

exfoliation Habitual rubbing, scratching Commonly smokers

© Bruce Black MD

Erythema and marked exfoliation of the conchal bowl and tragus. Neurodermatitis in a heavy smoker. The tobacco

tars are irritative, causing chronic pruritis. © Bruce Black MD

Advanced neurodermatitis. Chronic habitual rubbing and scratching. Cleaning and steroid ointment produced rapid

remission. © Bruce Black MD

NEURODERMATITIS Management

Clean debris Moisten well, peel away keratin Steroid and antibiotic ointment Avoid further self-trauma Wash hands after tobacco

© Bruce Black MD

OTHER EAC INFECTIONS

© Bruce Black MD

Infected sebaceous cyst. These classically occur in the floor of the entrance to the EAC. If recurrent, marsupialise.

© Bruce Black MD

Chronic debris accumulation and infection, secondary to a keratosis obturans. This will cause progressive erosion or

even extensive osteitis if not cleaned regularly. © Bruce Black MD

Osteitis in the floor of the EAC, complicating a keratosis obturans. Clean regularly, removing infected bony spicules. Advanced cases may require surgical excision and grafting. © Bruce Black MD

OTITIS EXTERNA Summary

Assess aetiology Clean thoroughly Appropriate management Persistent? Suspect fungal origin

© Bruce Black MD