CASE REPORT

Acute Diffuse Otitis Externa

Presented by : dr. Angga Kusuma

Moderator : dr. Dyah Ayu Kartika Dewanti, M.Sc., Sp.T.H.T.K.L

Departement of Otorhinolaryngology Head and Neck Surgery

Faculty of Medicine University of Gadjah Mada - dr. Sardjito General Hospital

2017
INTRODUCTION with the traction on the pinna or palpation

on the tragus is the hallmark of acute otitis

Otitis externa is an inflammatory
externa. In the initial stages, patient may
process of the external ear canal. Otitis
experience mild discomfort and ear
externa can take acute or a chronic form,
pruritus. On examination, the ear canal may
with the acute form affecting four in 1000
be erythematous and slightly edematous,
person annually and the chronic form
with minimal discharge. Often the severity
affecting 3 to 5% of the population in
of pain experienced by the patient is
United States. Acute infectious disease
disproportioned to physical examination
commonly resuts from bacterial (90% of
findings. As the condition progresses, the
cases) or fungal (10% of cases) overgrowth
canal may became extremely edematous
in ear canal subjected to excess moistures
and nearly obstructed from additional
or to local trauma. Chronic disease often is
otorrhea and debris. Inflammation may
part of a more generalized dermatology or
spread to the tympanic membrane, causing
allergic problem.1
myringitis. A sensation of fullness may
Acute otitis externa is unilateral in 90%
occur, as well as hearing loss if the
of patients; it peaks in person 7 to 12 year
obstruction is severe. Regional
of age, decline after 50 year of age, and
lymphadenitis and surrounding cellulitis of
often is associated with high humidity,
the pinna may be present.3
warmer temperature, swimming, local
The unique structures of auditory canal
trauma, hearing aid or hearing protector
contribute to the development of otitis
2
use.
externa. It is the only skin line cul de sac in
Patients with Acute Otitie Externa
the human body. The external auditory
present with the rapid onset of ear pain,
canal is warm, dark and prone to become
fullness and otorrhea. Pain that is worse
moist, making it an excellent environment
for bacterial and fungal growth. The skin is canal is damaged, otitis externa results.

very thin and the lateral third overlies There are many precipitants of this

cartilage, and the rest has a base of bone. infection but the most common is excessive

The canal is easily traumatized. The exit of moistures that elevates the pH and removes

debris, secretions, and foreign bodies is the cerumen. Once the protective cerumen

impelled by a curve at the junction of the is removed, keratin debris absorbs the

cartilage and bone. The presence of hair, water, which creates a nourishing medium

especially the thicker hair common in older for bacterial growth.4

men, can be a further impediment. The

The most common microbial flora of
external auditory has some special
normal external auditory canal which is live
defenses. Cerumen creates and acidic coat
as commensal is gram positive bacteria.
containing lysozymes and other substances
The normal flora may turn pathogenic when
that probably inhibits bacterial and fungal
the protective barriers like cerumen, canal
growth. The lipid rich cerumen is
pH, diabetes and other immune
hydrophobic and prevent water to
compromised states fail to protect the ear
penetrating the skin to cause maceration.
canal.5 Goguen LA et al in their study have
Too little cerumen can predispose the ear to
noted that Staphiloccocus aureus were the
infection, but cerumen that is excessive or
most common bacteria in normal ear, while
too viscous can lead to obstruction,
Pseudomonas aeruginosa was the most
retention of debris and infection.
common cause of acute otitis externa. In
Additionally the canal is defended by
another study gram- negative organisms
unique epithelial migration that occurs from
were more frequently isolated than gram-
the tympanic membrane outward carrying
positive organisms from the subject.6
debris. When these defenses fail, or when
The clinical course of external otitis may
the epithelium of the external auditory
be divided into the following stages:
preinflammatory, acute inflammatory inflammation in the absence of treatment,

(which can be mild moderate or severe) and produce the severe inflammatory stage

chronic inflammatory. Typically, characterized by increased pain and

preinflammatory begins when stratum obliteration of lumen of the canal.

corneum becomes edematous due to the

In the chronic inflammatory stage the
removal of protective lipid layer and acid
patient experience less pain but more
mantle from the canal resulting in plugging
profound itching. The skin of the external
of the apopilosebaceus unit. As obstruction
canal is thickened and superficial flaking
continuous, a sense of fullness and itching
may be seen. The auricle and concha often
begins. The disruption of the epithelial
show secondary changes such as
layer allows invasion of bacteria that either
eczematization, lichenifikation and
reside in the canal or are introduced on
superficial ulceration. This condition is
foreign objects inserted into the canal, such
likened to eczema by chronically infected
as a cotton swab or a dirty fingernail. This
hypertrophic skin.7
produce acute inflammatory stage, which is
Management of otitis externa focuses on
accompanied by pain and tenderness of the
control of pain, eradication of infection and
auricle. In the earliest stage, the skin of
prevention of reoccurrence. Pain can be
external auditory canal shows mild
severe, and oral medication such as
erythema and minimal edema. A small
acetaminophen, ibuprofen and other
amount of clear or slightly cloudy secretion
NSAIDs may be necessary for adequate
may be seen in the canal. As pain and
analgesia. Topical anesthetics such as
itching increase the patient progresses to
antipyrine/benzocaine may provide
the moderate stage, in which the canal
temporary relief but are contraindicated in
shows more edema an a thicker more
tympanic membrane perforation due to
profuse exudate. Further progression of the
their ototoxicity.8
 A variety of preparation have been used been used, with clinical and microbiologic

for treatment, ranging from topical acidic cure rates ranging from 84% to 93%.

solutions to antibiotics. Acetic acid and However, recent studies have shown

boric acid decreased the pH on the external increasing bacterial resistance in addition to

canal where applied, resisting bacterial and adverse effect, including pain during

fungal growth. Potential problem with this administration, the potential for ototoxicity

treatment include the need of multiple and a high rate of hypersensitivity to

application per day, pain with application in neomycin.9

the external canal is inflamed, and potential

Topical fluoroquinolone such as
ototoxicity when the tympanic membrane is
ciprofloxacin and ofloxacin have similar
perforated. Topical antibiotics are the
efficacy rates and have become the
medication used most commonly and are
antibiotics of choice. Their neutral pH
preferred to systemic antibiotics because of
causes less pain during administration, and
the high concentration of antibiotics
dosage is only twice daily with rare report
achievable by direct installation into the ear
of hypersensitivity. Because ciprofloxacin
and minimal systemic absorption, leading
or hydrocortisone otic preparation is not
to fewer systemic adverse effect and less
approved for use when the tympanic
bacterial resistance. Obtaining a culture is
membrane is perforated due to the risk of
not necessary before initiating treatment.
ototoxicity, ofloxacin is a better choice if
Antibiotic choice should be directed toward
membrane patency is a concern.8
Pseudomonas aeruginosa, Staphylococcus
Most acute otitis externa can adequatey
aureus, including methicillin resistant
be treated with debridement and otic
Staphylococcus aureus. Historically
antibiotic preparations. In some situations,
polymyxin B/neomycin/hydrocortisone
systemic antibiotic should be added. If the
preparations given four times daily had
patient is diabetic or otherwise
immunosuppressed, systemic treatment CASE REPORT

will be another barrier to deeper and more

A 20 years old girl presented to ENT
life-threatening spread of the infection. In a
clinic with pain in the left ear. She
patient in whom the swelling of the canal
complained that her ear was in severe pain
has become so profound that a wicks has
every time she ate something. The pain
had to be placed, systemic antibiotics will
started four days prior to presentation and
ensure adequate penetration of coverage.10
gradually increasing followed by a sense of

The complication of acute otitis externa fullness and itch in the left ear due to the

occurs when the infectious agent penetrates watery ear discharge. She denied about

to deeper tissue to involve bone and deeper deafness, tinnitus, dizziness, sore throat,

fascial planes. Although it is usually common cold, sneeze as well as any

initially limited to the temporal bone and its complaint in the right ear. She also denied

adjacent structures, it can spread medially any foreign body insertion and trauma to

to become a full-fledge osteomyelitis of the the left ear, but she admitted that she had

base of the skull. As it advances, it will frequent use of cotton bud to clean her ears

cause dysfunction of the cranial nerves as every time she finished her shower.

their foramina are involved. Infection can

On examination, the patient generally in
also spread to the subarachnoid space
good condition, afebrile and normal vital
resulting in meningitis. These condition is
signs. Pinna were morphologically normal
called necrotizing otitis externa which are
and there was no deformity. There is
typically older and diabetic. They may also
tenderness that occurs with traction of the
otherwise immune-suppressed.10
left ear and increasing pain when pressure

on the tragus being applied. On otoscopy

the left ear canal was edematous and

erythematous. A thin yellowish discharge

was detected at the auditory meatus. Since unit being obstructed. The disruption of the

the tympanic membrane was not clearly epithelial layer allows invasion of bacteria

visible, the serous secretion and debris were that either reside in the canal or are

removed under direct observation. the introduced on foreign objects inserted into

tympanic membrane was translucent, the canal, such as a cotton swab or a dirty

pearly gray color and the light reflex was fingernail. The most common bacteria

present. No foreign body was detected. causing acute otitis externa is Pseudomonas

Examination of the nose, mouth and throat aeruginosa and Staphylococcus aureus.

within normal limit.

Prevention of recurrence of otitis externa

The patient is diagnosed with acute primarily consist of avoiding the many

diffuse otitis externa based on rapid onset precipitants and dermatologic disorders.

of symptoms and signs of external canal This particularly important for patient with

inflammation. The patient given four drops unusually viscous cerumen, a narrowed

of otopain ear drop four times daily and 50 external auditory canal, or systemic

mg potassium diclofenac twice a day. The allergies. After bathing or swimming, the

medication was given for five days. external auditory canal should not be dried

using cotton bud swab, if needed it could be

Problem to discuss from this case is
dried using hair dryer with the lowest heat
prevention of recurrence.
setting. Manipulation of the skin of external
DISCUSSION
auditory canal such as scratching or

Otitis externa is an inflammatory overzealous cleaning should be avoided.

process of the external ear canal. the Any time the external auditory canal is

inflammation begins when the protective cleaned and the cerumen is removed, the

lipid layer and acid mantle of external canal canal becomes more vulnerable to

being removed and the apopilosebaceus infection. Too little cerumen can predispose
the ear to infection, but cerumen that is
excessive or too viscous can lead to
obstruction, retention of debris
infection. If cerumen is excessive and
difficult to remove a cerumenolytic agent
such as carboglyserin should be used to
soften the cerumen first to
traumatizing the canal. person who swim
frequently should use a barrier to protect
their ears from water. However,
impermeable earplug act as a local irritant
to predispose the ear canal to otitis externa.
A tight-fitting cap offers a better protection.
CONCLUSION
We have reported a 20 year old female
with acute diffuse otitis externa. She has
been treated with otopain eardrop and oral
potassium diclofenac and she has showed
an improvement with no ear discharge and
no pain in five days of treatment.
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