Umanand Prasad School of Medicine 2018 Microbiology Seminar Report Student Name Synthia Smriti Achari Student ID 20170175 Lecturer Dr

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Umanand Prasad School of Medicine 2018 Microbiology Seminar Report Student Name Synthia Smriti Achari Student ID 20170175 Lecturer Dr. Diva Singh Otitis Externa Aim The aim of this presentation is to discuss about Otitis Externa, discuss its classifications, explain its pathophysiology and its clinical manifestations and to outline its diagnostic and treatment options available. Table of Contents Page No.1.0 Introduction12.0 Anatomy of the External Ear Canal23.0 Classification 3.1 Acute diffuse otitis externa 3.2 Acute localized otitis externa 3.3 Chronic otitis externa 3.4 Eczematous (eczematoid) otitis externa 3.5 Necrotizing (malignant) otitis externa 3.6 Otomycosis 2 2 3 3 3 3 34.0 Etiology 4.1 Bacteria 4.2 Fungi (rare) 4.3 Others 3 4 4 45.0 Pathophysiology46.0 Clinical Manifestations 47.0 Differential Diagnosis58.0 Diagnosis 8.1 Laboratory testing 8.2 Imaging studies6 6 69.0 Brighton Grading Scheme610.0 Treatment 10.1 Drug Therapy 10.2 Non-Drug Therapy7 7 711.0 Complications812.0 Prevention813.0 Conclusion9Bibliography10 1.0 Introduction Otitis Externa is a condition in which there is inflammation of the external ear canal. It is also called swimmers ear because repeated exposure to water can make the ear more prone to infection. (, 2018). It is a common infection which can be occur in people of all age groups. Otitis externa mostly occurs due to bacterial infection of the skin of the ear canal, but is can also be occur due to a fungal infection. There are several factors that can generally lead to an infection of the ear canal, leading to the development of otitis externa Absence of cerumen High humidity Retained water in ear canal Increased temperature Local trauma (e.g. use of cotton buds or earphones) (, 2018) Source (, 2018) Figure 1.1 Site of infection Swimmers are more vulnerable to having otitis externa due to continuous exposure to water. This is because continuous exposure to water causes removal of cerumen thus causing drying of the ear canal. Water retention in the ear canal can cause softening of the skin thus leading to increased chances of bacterial or fungal infection. (, 2018) 2.0 Anatomy of the External Ear Canal – Source (Health Jade, 2018) Figure 1.2 Anatomy of the external ear canal The auricle is made out of elastic cartilage with the overlying skin attached directly to the perichondrium. The perichondrium is the connective tissue that envelopes cartilage when it is not at a joint. The external (outer) ear canal is approximately 2.5cm in length and 0.7 cm in diameter and is lined with squamous epithelium. The function of the external ear canal is to transfer sound to the middle ear and to protect the internal structures from foreign bodies and changes in environmental conditions. The outer one thirds of the canal is mainly cartilaginous with thicker skin whereas the inner two thirds is osseous and covered with thinner skin. The inner portion of the canal does not contain and hair follicles or apocrine glands. There are apopilosebaceous units in the external ear canal which comprises of the apocrine and eccrine glands. These glands secrete their products around the base of the hair follicles which then combine with sloughed squamous epithelium (cerumen), this coats the canal and helps maintain an acidic pH of around 4-5. The waxy nature of the cerumen helps prevent the softening and breakdown of skin while its acidity helps to prevent bacterial or fungal growth. (, 2018). 3.0 Classification Otitis externa may be classified as follows 3.1 Acute diffuse otitis externa This form of otitis externa is most common and is usually seen in swimmers. It is characterized by rapid onset. Often presents with ear pain, discharge hearing loss and lymphadenopathy. It has a short duration, usually less than 6 weeks. (Simon, Dorp and Everitt, 2015) 3.2 Acute localized otitis externa This condition is associated with an infection of a hair follicle. It is also known as furunculosis. (, 2018) 3.3 Chronic otitis externa It is the same as acute diffuse otitis externa, however the duration is longer ( 3months). There is ongoing discharge and also hearing loss. Chronic otitis externa causes canal stenosis and can also lead to permanent hearing loss. (Simon, Dorp and Everitt, 2015) 3.4 Eczematous (eczematoid) otitis externa This form of otitis externa involves various dermatologic conditions (e.g. atopic dermatitis, psoriasis, systemic lupus erythematosus) that may infect the ear canal and cause otitis externa. (, 2018) 3.5 Necrotizing (malignant) otitis externa Necrotizing (malignant) otitis externa occurs when the infection spreads deeper into the tissues next to (adjacent) the ear canal. This usually occurs in adult patients who are immunocompromised (e.g. due to diabetes mellitus or AIDS) and can cause cellulitis and osteomyelitis. (, 2018) 3.6 Otomycosis Otomycosis is the infection of the ear canal be fungal species. Examples of such species are Candida and Aspergillus. 4.0 Etiology 4.1 Bacteria Pseudomonas aeruginosa Gram negative Rod shaped Aerobic nonfermenting Actively motile Staphylococcus aureus Gram positive Grape-like structure(cocci) Proteus vulgaris Gram negative Rod-shaped Escherichia coli Gram negative Facultative aerobes Rod-shaped 4.2 Fungi (rare) Aspergillus niger Candida albicans 4.3 Others Trauma (from scratching, cotton buds, ear plugs) Dermatologic conditions (e.g. allergic dermatitis, atopic dermatitis, psoriasis) Swimming 5.0 Pathophysiology The progression of otitis externa can be divided into the following four categories Obstruction of the ear canal resulting in water retention Absence of cerumen, which may occur due to recurrent water exposure or over cleaning Trauma Alteration of the pH of the ear canal The trapping of moisture in the ear canal leads to the softening and breakdown of skin, this provides a good breeding ground for bacteria. Obstruction of the external ear canal, which can occur due to excessive cerumen/ debris/ surfers exostosis/narrow or tortuous canal, also leads to moisture retention thus causing infection. Trauma to the canal allows bacteria to invade into the damaged skin. Trauma usually occurs as due to attempts of cleaning the ear with a cotton swab, paper clip, and any other material that fits into the ear. (, 2018) Once there is infection it is followed by inflammation. The skin ends up erythematous, swollen, delicate/tender, and warm, prompting debris and discharge. The combination of debris accumulation and narrowing of the canal leads to further trapping of pathogens and spreading of the infective process. (TeachMeSurgery, 2018) 6.0 Clinical Manifestations The most common clinical presentation of otitis externa is progressive ear pain with a purulent discharge, the patient might also complain of itchiness or ear fullness. Other symptoms include Hearing loss Tinnitus Swollen and erythematous external ear canal Tragus may be tender on palpitation The color of the discharge indicates the underlying cause White yellow- bacterial infection Thick white grey with visible hyphae or spores- fungal infection Clear grey- otitis media Source (, 2018) Figure 1.2 Discharge due to otitis externa 7.0 Differential Diagnosis The most common differentials to consider for any patient presenting with ear discharge include Otitis media with perforation- patient usually presents with clear/bloody discharge followed by relief of pain and will also have an inflamed tympanic membrane with perforation. Ramsay Hunt syndrome- patient may present with symptoms of otitis externa but will also show signs of vesicular eruptions within 2 days of first onset of pain. Furuncle- patient will present with a painful ear canal due to abscess formation due to the infection pf the hair follicle. Upon examination with an otoscope a bulge will be visible. The less common conditions that could be considered as differentials are Ear canal malignancy Branchial cyst Atopic dermatitis Exostosis 8.0 Diagnosis Diagnosis can usually be done based on the patients history and physical examination (including otoscopy) as it provides adequate information for the clinician to make the diagnosis of otitis externa. However, if the infection is not resolving with antibiotics or if there are indications of fungal diseases upon otoscopy then further investigations may be done. 8.1 Laboratory testing Swabs of the discharge are taken and sent to the lab for the following test Gram staining and culture For patients who are immunocompromised, blood glucose level and urine dipstick tests are useful. 8.2 Imaging Studies Imaging studies are not required for most instances of otitis externa. However, radiologic examination might be useful if an invasive infection, for example, necrotizing (malignant) otitis externa is suspected or if a diagnosis of mastoiditis is being considered. (, 2018) The following imaging studies are used High-resolution computed tomography (HRCT) scan- is the most preferred method of imaging depicts bony erosion better Radionuclide bone scanning Gallium Scanning Magnetic resonance imaging (MRI) 9.0 Brighton Grading Scheme The Brighton Grading System can be used to degree the severity of otitis externa. Brighton GradeDescriptionGrade ILocalized canal inflammation with mild pain, no hearing loss and tympanic membrane visibleGrade IIDebris in ear canal (not completely occluded) and erythematous ear canal, tympanic membrane may be partially obscured. Grade IIIThe ear canal is edematous, erythematous and occluded (often completely closed) and the tympanic membrane cannot be seen.Grade IVThe tympanic membrane is obscured, perichondritis and pinna cellulitis, and signs of systemic involvement. (TeachMeSurgery, 2018) 10.0 Treatment Most patients presenting with otitis externa receive empirical treatment. Primary treatment includes the following Pain management Removal of debris from the external ear canal Administration of topical medications to control edema and infection Avoidance of contributing factors 10.1 Non-Drug Therapy Carefully and gently remove debris or exudate, cleansing the ear canal and drying with tissue spears (rolled tissue paper). Repeat ear toilet at least daily for severe infections. A topical corticosteroid with antibacterial combination can be used in addition to ear toilet. If there is no improvement in 48 hours (or if there is a fungal infection) use topical corticosteroid with antifungal combination. If there is narrowing of the ear canal due to swelling causing difficulty in administering ear drops then saturate a wick with drops and insert into the ear canal. (AMH Drug Choice Companion, 2008) 10.2 Drug Therapy Diffuse, inflammatory Corticosteroid with antibacterial ear drop Drug(s) dexamethasone, framycetin and gramicidin Brand Name Otodex, Sofradex Dosage 3 drops, 3-4 times daily for 7days (for adults and children) Corticosteroid with antibacterial/antifungal ear drop Drug(s) flumethasone with cliquinol Brand Name Locarcorten-Vioform Dosage 3 drops, twice daily for 3-7days (for adults and children 2years) OR Drug(s) triamcinolone, neomycin, gramicidin and nystatin Brand Name Kenacomb Otic, Otocomb Otic Dosage 3 drops, 2-3 times daily for 3-7days (for adults and children) (AMH Drug Choice Companion, 2008) Localized otitis externa (boil or episipelas) Drug(s) dicloxacillin or flucloxacillin Dosage Adults, oral 500mg 4 times daily for 5 days Child, oral 12.5-25mg/kg (maximum 500mg) 4 times daily for 5 days In penicillin allergy (not severe or immediate) Drug(s) cephalexin Dosage Adults, oral 500mg 4 times daily for 5 days Child, oral 6.25-12.5mg/kg (maximum 500mg) 4 times daily for 5 days (AMH Drug Choice Companion, 2008) 11.0 Complications Usually antibiotics otitis externa resolves with topical however in cases where there is delayed presentation or the patient is immunocompromised the infection may become severe. When this happens the patient develops complications. Probable complications of otitis externa include Malignant otitis externa- is an extension of otitis externa into the mastoid and temporal bones. Mastoiditis Osteomyelitis Intracranial spread 12.0 Prevention Avoid water accumulation and retention in the ear canal- this can be done by avoiding the factors that cause water retention, such as, blockage of external ear canal by wax or foreign body, extended use of ear plugs, and swimming. Avoid causing trauma to the external ear canal by cotton buds. Avoid the use of foreign objects in the ear. Treat any underlying skin conditions, such as, dermatitis. 13.0 Conclusion Otitis externa, also known as swimmers ear is the inflammation of the external ear canal. This is most often caused by bacteria, such as, Pseudomonas aeruginosa, Proteus vulgaris, Staphylococcus aureus, and Escherichia coli. However, in some rare cases, otitis externa can be caused by some fungal species as well. Aspergillus niger and Candida albicans are the two fungal species that can cause otitis externa. The most common presentation of otitis externa is ear pain with a purulent discharge. Diagnosis is usually based on clinical presentation however, suspicion of complicated disease may lead to lab testing and imaging studies. The management for otitis externa includes prevention, aural toileting, topical antibiotics and analgesia. Bibliography Illing, E., Zolotar, M., Ross, E., Olaleye, O. and Molony, N. (2011). Malignant otitis externa with skull base osteomyelitis.Journal of Surgical Case Reports, 2011(5), pp.6-6. Schaechter, M., Engleberg, N., DiRita, V. and Dermody, T. (2013).Schaechters mechanisms of microbial disease. 5th ed. Philadelphia, PA Wolters Kluwer Health/Lippincott Williams Wilkins, pp.223-227. Simon, C., Dorp, F. and Everitt, H. (2015).Oxford handbook of general practice. 4th ed. Oxford Oxford University Press, pp.944-945. Tortora, G., Funke, B. and Case, C. (2010).Microbiology. 10th ed. San Francisco, CA Benjamin Cummings, pp.625-626. (2018).Otitis externa – Symptoms, diagnosis and treatment BMJ Best Practice. online Available at HYPERLINK https// https// Accessed 3 Aug. 2018. (2018).Otitis externa – Symptoms, diagnosis and treatment BMJ Best Practice. online Available at HYPERLINK https// https// Accessed 3 Sep. 2018. (2018).Hygiene-related Diseases Hygiene-related Diseases Hygiene Healthy Water CDC. online Available at HYPERLINK https// https// Accessed 23 Aug. 2018. (2018).Otitis Externa Practice Essentials, Background, Anatomy. online Available at HYPERLINK https// https// Accessed 29 Aug. 2018. (2018).Otitis externa. online Available at HYPERLINK https// https// Accessed 13 Aug. 2018. (2018).Acute otitis externa. online Available at HYPERLINK https// https// Accessed 20 Aug. 2018. Health Jade. (2018).Outer Ear Anatomy – Outer Ear Infection Pain – Causes Treatment. online Available at HYPERLINK https// https// Accessed 3 Sep. 2018. Healthline. (2018).Outer Ear Infection (Swimmers Ear). online Available at HYPERLINK https// https// Accessed 15 Aug. 2018. MSD Manual Professional Edition. (2018).External Otitis (Acute) – Ear, Nose, and Throat Disorders – MSD Manual Professional Edition. online Available at HYPERLINK https//,-nose,-and-throat-disorders/external-ear-disorders/external-otitis-acute https//,-nose,-and-throat-disorders/external-ear-disorders/external-otitis-acute Accessed 3 Sep. 2018. (2018).Otitis externa symptoms and treatments. online Available at HYPERLINK https// https// Accessed 13 Aug. 2018. TeachMeSurgery. (2018).Otitis Externa – Causes – Clinical Features – Management – TeachMeSurgery. online Available at HYPERLINK http// http// Accessed 9 Aug. 2018. PAGE MERGEFORMAT 1 fd
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