Dr.

Haider Salih Ibrahim

o Otitis Externa:
- Spectrum of inflammatory conditions and infections of the EAC.

 Infective Otitis Externa:

 Bacterial:
o Localized Otitis Externa (Fruncles).
o Diffuse Otitis Externa
o Malignant Otitis Externa
 Fungal:
o Otomycosis.
 Viral:
o Herpes Zoster Oticus.
o Otitis Externa Hemorrhagica.

 Reactive Otitis Externa:

 Eczematous Otitis Externa.
 Seborrhoeic Otitis Externa.
 Neurodermatitis.

- Localised Acute Otitis Externa (Furuncle and Carbuncle):

- Staphylococcal infection of hair follicle inside cartilaginous EAC,
most commonly at junction of concha and canal akin.
 Hair are confined only to cartilaginous part of EAC.
- Clinical picture:
 Small well-circumscribed pustule that enlarge to become
furuncle or merge with several similar lesions to form
carbuncle.
 Severe pain and tenderness out of proportion to the size
of the furuncle.
 Movements of the pinna are painful.
 Jaw movements cause pain in the ear.
- In case of recurrent furunculosis:
 Diabetes should be excluded.
- Treatment:
 In early cases (without abscess formation):
o Consists of medicated ear wick, systemic
antibiotics, analgesics and local heat.
 If abscess has formed:
o Incision and drainage should be done under LA in
addition to medicated ear wick, systemic
antibiotics, analgesics and local heat.

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Dr.Haider Salih Ibrahim

- Acute Otitis Externa (AOE):

- Diffuse bacterial infection of EAC skin caused by a break in
normal skin/cerumen protective barrier in presence of elevated
humidity and temperature (swimmer's ear).

- Pathophysiology:
 Aggressive washing of cerumen or retention of water
results in a more alkalotic EAC and decreased production
of antibacterial agents (eg, lysozyme), which are
permissive for bacterial overgrowth and penetration into
the pilosebaceous unit.
 Begins with itching which is commonly caused by
instrumenting EAC with a cotton swab or fingernail.
 Temporarily relieves itching but allows proliferation of
bacteria in locally macerated skin.
 Itch-scratch cycle.
 Pain.
 EAC Soft tissue swelling.
 Purulent discharge.
 Involvement of Auricle and periauricular soft tissues.

- History:
 Major symptoms of AOE:
o Pain
o Fullness
o Itching
o CHL
 Predisposing factors:
o Auricular instrumentation or trauma
o Swimmers.
o Immunocompromised:
o DM
o HIV
o Radiotherapy

- Physical Examination:
 Edematous, erythematous and tender EAC
 Purulent discharge.
 Tragal tenderness confirms the clinical suspicion.
 Periauricular erythema or cellulitis
 TM perforation may suggest underlying CSOM.

o Evaluate presence of signs and symptoms of Malignant Otitis

Externa:
 Cranial nerve involvement.
 EAC granulation tissue.

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Dr.Haider Salih Ibrahim

- Pathogens:
 Pseudomonas Aeruginosa
o Most common, opportunistic infection.
 Staphylococcus
 Other gram-negative bacilli

- Differential diagnosis of Otitis Externa:

 Malignant otitis externa.
 Bullous and granular external otitis
 Perichondritis, chondritis and relapsing polychondritis
 Furunculosis
 Psoriasis and seborrheic dermatitis
 Carcinoma

- Management of Otitis Externa:

1. Frequent and thorough Ear toilet:
o Most important single factor in treatment.
o All exudate and debris should be
meticulously and gently removed.
o Done by:
 Dry mopping
 Suction clearance
 Irrigation with warm, sterile normal
saline.
2. Antibiotics Drops:
o Anti-Pseudomonas ear drops for 7–10 days
3. Oral Pain Analgesia
4. Precautions:
o Avoid EAC trauma or intrumenation.
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Dr.Haider Salih Ibrahim

o Maintain dry ear precautions.

5. Oral Antibiotics:
o Used if infection extended beyond EAC.
o Cntinued for 10 to 14 days.

- Skull Base Osteomyelitis (SBO) /Necrotizing (Malignant)

Otitis Externa:
- Begins as AOE that does not resolve despite medical therapy.
- Infection extends from EAC into temporal bone, skull base and
jugular foramen resulting in severe progressive osteomyelitis
with multiple cranial nerve palsies.
 "Malignant" otitis externa is a misnomer.
- Caused mainly by Pseudomonas infection.
- Should be the main differential diagnosis of refractory Acute
Otitis Externa in high risk (immunocompromised) patients .
 Diabetics.
 Elderly.
 HIV.
 Radiation exposure.

- Diagnosis Criteria of SBO:

 History:
1. Persistent deep-seated severe otalgia > 1 month.
2. Persistent purulent otorrhea with granulation tissue
for several weeks
3. Immunocompromised state.
4. Cranial nerve involvement
o CN-VII > CN-X > CN-XI.
 Physical Exam:
1. Granulation tissue in inferior aspect of EAC at the
bony-cartilaginous junction.
2. Purulent discharge.
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Dr.Haider Salih Ibrahim

3. Cranial nerve involvement

o CN-VII > CN-X > CN-XI.
 Culture and Biopsy:
1. Almost always P. Aeruginosa.
2. Granulations should be biopsied to rule out
carcinoma or another pathologic entity.

 Imaging:
1. CT scan temporal bone with contrast.
2. MRI with temporal bone with contrast.
3. Bone scans:
o Technetium: used for diagnosis.
o Gallium: used for follow up.

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Differential diagnosis of SBO:

 Severe AOE
 Squamous cell carcinoma
 Cholesteatoma
 Nasopharyngeal carcinoma

- Complication of SBO:
 Cranial neuropathy
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Dr.Haider Salih Ibrahim

 Sinus thrombosis
 Sepsis
 Meningitis
 Intracranial infections
 High mortality (particularly in immunocompromised).

- Management of SBO:
 Medical Management (Mainstay Therapy):
1. Aggressive diabetic control.
2. Local Ear Care:
o Frequent and thorough Ear toilet.
o Medicated Ear wick with Anti-Pseudomonas
Antibiotics drops.
o Water precatuions.
3. Prolonged IV Anti-Pseudomonas Antibiotics:
o IV Ciprofloxacin.
o Used for extended period (6 weeks).
4. Hyperbaric Oxygen

 Surgical Management:
o Surgical debridement of devitalized tissue and bone
should be done judiciously.

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Dr.Haider Salih Ibrahim

- Otomycosis:
- Fungal infection of EAC skin.
- Primary fungal infection occurs mainly in immunocompromised
patients including diabetics.
- Secondary otomycosis occurs in patients with chronic bacterial
infection in which prolonged antibiotic drops suppress EAC
normal flora and lead to a fungal super-infection.
- Basic growth requirements for fungal infections:
1. Moisture
2. Warmth
3. Darkness
- Most common fungal pathogens:
 Aspergillus:
o Most common pathogens.
 Candida Albicans:
o 10% of otitis externa.
- Clinical picture:
 Pruritus:
o Intense itching is the primary clinical complaint.
 Otalgia.
 Otorrhea.
- Diagnosis:
 Examination under microscope:
o Dotted white, black, or gray
membrane over EAC.
 Culture and sensitivity.
- Treatment:
 Thorough ear toilet:
o First and absolutely most important step.
o Removal of all discharge and epithelial debris.
 Precautions:
o Avoid EAC trauma or intrumenation.
o Maintain dry ear precautions.
 Antifungal topical drops (Canesten/Clotrimazole):
o Most effective and widely used topical azole.
 Medicated Ear wick:
o In severe cases.

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Dr.Haider Salih Ibrahim

- Herpes Zoster Oticus:

- Occurs as primary infection or reactivation of latent varicella-
zoster virus (VZV) that has remained dormant within sensory
ganglia (commonly the geniculate ganglion)
of the facial nerve.

- Risk factors for the reactivation:

 Decrease immunity.
 Physical and emotional stress.

- Clinical picture:
 Burning pain
 Localized headache
 Coetaneous vesicular eruption of EAC and pinna.
o Appear unilaterally in a dermatomic distribution.
 Involvement of CN-VII may produce paresis or paralysis
(Ramsay Hunt syndrome):
o Accounts for 10% of all facial paralyses.
o More severe paralysis and worse prognosis than
Bell palsy.
 Involvement of CN-VIII may produce SNHL and vertigo.

- Complications of HZ oticus:
 Post-herpetic neuralgia
 Residual paralysis
 Herpes zoster encephalitis

- Treatment of HZ oticus:
 Supportive Measures.
o Warm compresses
o Good analgesics
 Anti-viral:
o Acyclovir,
 Corticosteroids:
o Used to relieve acute pain, decrease vertigo, and
limit the occurrence of postherpetic neuralgia.

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Dr.Haider Salih Ibrahim

- Bullous Otitis Externa:

- Characterized by formation of
serous/hemorrhagic bullae on epithelial surface
of tympanic membrane and deep meatus.
- If it involves the tympanic membrane only, it is
called Bullous Myringitis.
- Etiology:
 Probably viral in origin.
- Clinical picture:
 Sudden severe pain in the ear.
 Blood-stained discharge when the bullae rupture.
 Hearing loss.
- Treatment:
 Analgesics is directed to give relief from pain.
 Antibiotics are given for secondary infection of the ear
canal if the bulla has ruptured.
 Severity of pain may warrant decompression of tense
bullae with a sterile straight needle