ACUTE DIFFUSE OTITIS EXTERNA

By

Elena Mahotsaha V M.Izza naufal F

Sri Murti Sari Ningsih Ilham Isnin Dolyanov

ANATOMY

PHYSIOLOGY
Glandular

secretions combine with sloughed squamous epithelium to form an acidic coat of cerumen, one of the primary barriers to infection of the canal. short, straight excretory ducts, which drain into follicular canals. Obstruction of any part of the ductal system predisposes to infection.

The alveoli of the sebaceous and apocrine glands empty into

PHYSIOLOGY
The canal is normally a self-protecting and self-cleansing structure. The

cerumen coat gradually works its way past the isthmus to the lateral part of the canal and sloughs externally.
Instrumentation and excessive cleansing of the canal disturb this primary

protective barrier and may lead to infection.

Individual variations in the anatomy of the canal or the consistency of the

cerumen produced may predispose some people to wax accumulation.

DEFINITION
Diffuse inflammation of the external ear canal, which may

also involve the pinna or tymphanic membrane.

Rapid onset, within 48 hours in the past 3 weeks..

Hallmark sign of diffuse AOE is tenderness of the tragus,

pinna or both, that is often intense and disproportionate to what might be expected based on visual inspection (Bailey, 4th ed)

RISK FACTOR
Previous history of external ear infecton.
Swimming, diving, water activities. Warm and humid weather.

Use of hearing aid.

DM, AIDS, malnutrition. instrumenting the canal with a cotton swab or fingernail .

CAUSATIVE AGENTS
Pseudomonas aeroginosa (50%).
Proteus mirabilis. Staphylococcus aureus (23%). Anaerobic and gram negative organisms (12,5%). Fungal (12,5%).

PATHOGENESIS
If moisture is trapped in the EAC, it may cause maceration of the skin and

provide a good breeding ground for bacteria.

It may occur after swim or take a bath, or in hot humid weather. Obstruction of the EAC by excessive cerumen, debris, surfers exostosis, or a narrow and tortuous canal may also lead to infection by means of moisture retention.
Trauma to the EAC allows invasion of bacteria into the damaged skin.

This often occurs after attempts at cleaning the ear with a cotton swab, paper clip, or any other utensil that can fit into the ear.
Once infection is established, an inflammatory response occurs with skin

edema. Exudate and pus often appear in the EAC as well. If severe, the infection may spread and cause a cellulitis of the face or neck.

DIAGNOSIS

STAGES OF EXTERNAL OTITIS

Senturia et al. divided the clinical course of external otitis into the following

stages:
1. Pre inflammatory stage

2. Inflammatory stage

-Mild acute inflammatory stage -Moderate acute inflammatory stage

-Severe acute inflammatory stage

3. Chronic stage

IDENTITY
Name
Age Gender

: Mr. S
: 22 y.o. : Male

Occupation
Address Date

: Student
: Klaten : 22 Oct 2013

ANAMNESIS
Main complaint : pain in the right ear
History of present illness :

Patient presents with right ear pain for the past two days with a decrease in hearing, also a fullness sensation. No itching nor discharge was complained. Patient often uses the cotton bud to clean his ears. Patient admits the history of swimming three days ago. No history of trauma. The patient has no complaint of the left ear.

Complaints like fever, cough, and common cold were denied. He does not have any complaints regarding nose or throat.

ANAMNESIS
History of past illness
Same symptoms before (-) History of foreign body insertion (-) History of allergy (-) History of trauma (-) History of DM (-)

History of illness in the family members :

History of similar complaints (-) History of allergy (-)

ANAMNESIS RESUME
Pain in the right ear for the past two days
Decrease in hearing Fullness sensation

History of swimming three days ago and the usage of cotton bud

PHYSICAL EXAMINATION
General status
Vital signs :
Blood pressure : 120/80 mmHg

: compos mentis, well nourished

Pulse
Respiration Temperature

: 82x/min
: 18x/menit : 36,3 C

ENT EXAMINATION

EAR EXAMINATION

Tragus pain (+), auricular movement tenderness (+), swelling and redness of CAE. Intact tymphanic membrane, cone of light visible

Within normal limit

Intact tymphanic membrane, cone of light visible

NOSE EXAMINATION
Inspection Deformity (-) Nasal septum deviation (-) Concha inferior D/S within normal limit Discharge D/S (-)

Palpation
Tenderness (-) Crepitation (-)

THROAT EXAMINATION
Inspection Cavum oris within normal limit Uvula in the middle, edema (-) Arcus pharynx simetris Tonsils hypertrophy (-) Pharyngeal wall hyperemic (-), granulation (-) Palpation Lymph node enlargement (-)

TUNING FORK EXAMINATION Right Ear Rinne Weber Swabach AC < BC Left Ear AC > BC

Lateralization to the RIGHT Increase Same with examiner

Conclusion

Conductive hearing loss of right ear

DIAGNOSIS
ACUTE DIFFUSE OTITIS EXTERNA AURIS DEXTRA

TREATMENT
Medication :
Otopain ear drop 3 x 4 gtt AD (Polymyxin B sulfate + Neomycin sulfate

Fludrocortisone acetate + lidoqain Hcl)

Na diclofenac tablet 2 x 50 mg

Education :
Keep the ear in dry condition.
Dont use cotton bud to clean the ears. Follow up in three days.

PROBLEM
Therapy

DISCUSSION
Treatment and Management
Primary treatment of diffuse otitis externa :
1. Removal of debris from EAC

2. Administration medication to control edema and infection

3. Avoidance of contributing factors 4. Management of pain

REMOVAL OF DEBRIS FROM EAC

Removal of debris from the ear canal improves the effectiveness of the topical

medication.
Gentle cleaning with soft plastic curette or a small suction tip under direct

vision is appropriate
Irrigation with a mix of peroxide and warm water may be useful for removing

debris from the canal, but only if the tympanic membrane is intact

ADMINISTRATION MEDICATION TO CONTROL EDEMA

AND INFECTION
Antibiotic
Aminoglycoside and quinolone

Topical

Treatment of Diffuse Otitis Externa

Ear pad

Quinolone

Oral Medications
Ciprofloxacin

CONT..
An aminoglycoside combined with a second antibiotic and a topical steroid

(eg, neomycin-polymyxin B-Hydrocortisone) used to be the most commonly prescribed topical preparation.
Otic antibiotic and steroid combinations have shown to be hughly successful

in treatment, with cure rates of 87-97 %.

Use of aminoglycoside antibiotic eardrops in the presence of a perforation or

ventilation tube may cause problems. Amonoglycoside eardrops may be ototoxic if they enter the middle ear
Floroquinolones are not associated with autotoxicity and ofloxacin is safe in

cases of perforated tympanic membrane.

CONT..
Most persons with OE do not require oral medications. Oral antibiotics are

generally reserved for patients with fever, immunosuppression, diabetes, adenopathy, or an infection extending outside the ear canal. We can use broad-spectrum antibiotics (cephalosporins first gen or fluoroquinolones).

AVOIDANCE OF CONTRIBUTING FACTORS

Elliminate any self-inflicted trauma to ear canal.
Avoid frequent washing of the ears with soap. Avoid swimming in polluted waters.

Ensure that ear canals are emptied of water after swimming or bathing

MANAGEMENT OF PAIN
Simple nonsteroid anti-inflammatory drugs (NSAIDs) reduce inflammation and

irritation.
Acetaminophen is appropriate for most patient

SUMMARY
Have been reported, patient, male, 22 years old, based on history taking and physical examination diagnosed with otitis externa diffusa auricular dextra. The patient treated by Otopain (Polymyxin B sulfate + Neomycin sulfat Fludrocortisone acetate + lidoqain Hcl ) and Na-diclofenac and educated to prevent reccurent infections.
Otopain eardrop was given to the patient because the membrane tymphany was intact and the edema was not blocking the ear canal.

TERIMA KASIH
By

Elena Mahotsaha V M.Izza naufal F

Sri Murti Sari Ningsih Ilham Isnin Dolyanov