High Yield Topics

Otitis Media/Externa

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Ovid: 5-Minute Sports Medicine Consult, The


Otitis Media/Externa
Darin Rutherford
Craig C. Young
Basics
Description
  • Acute otitis media (AOM): Rapid onset of signs and symptoms in the presence of a middle-ear effusion and with the signs and symptoms of middle-ear inflammation
    • Synonym(s): Suppurative otitis media
  • Recurrent otitis media: ≥3 episodes of acute otitis media in 6 mos
  • Otitis externa: Acute or chronic (>6 mos) infection or inflammation of the external auditory canal
    • Synonym(s): Swimmer's ear
  • Secretory otitis media
  • Catarrh of the middle ear, catarrhal otitis media, tubal catarrh, hydrops ex vacuo
Epidemiology
  • AOM:
    • Almost all (93%) children experience ≥1 episode of otitis media by age 6 yrs.
    • Most frequent primary diagnosis at U.S. office visits in children <15 yrs
    • Most common infection for which antibacterial agents are prescribed for children in the U.S.
    • Direct and indirect cost ∼$3 billion in 1995
    • Peak incidence in children age 6–18 mos
  • Otitis externa:
    • Acute (bacterial): 4 in 1,000 persons U.S. 90% unilateral
    • Chronic (fungal or allergic): 3–5% of population
Risk Factors
  • AOM:
    • Recent upper respiratory infection (URI) with eustachian tube dysfunction
    • Bottle feeding
    • Pacifier use after 6 mos of age
    • Passive smoking
    • Group child-care facility attendance
    • Previous episodes of acute otitis media, especially if first when <1 yr old
    • Sibling history of recent infection
    • Nonmodifiable risk factors: Genetic predisposition, male gender, premature birth, Native American or Inuit ethnicity, family history of recurrent otitis media, presence of siblings in the household
  • Otitis externa:
    • Aquatic athletes
    • High humidity, warm temperature
    • Local trauma (cotton swab use or hearing aids)
    • Eczema, allergic rhinitis, asthma, diabetes
General Prevention
  • Otitis externa:
    • Measures that are related to ear hygiene:
      • Avoid using cotton swabs or inserting objects into the external canal, including earplugs.
      • Avoid frequent washing of the ears with soap (leaves an alkali residue that neutralizes the acidic pH of the ear canal).
      • Avoid swimming in polluted waters.
      • Empty water from the ear canals after swimming or bathing.
  • Prophylactic eardrops with a 2:1 ratio of 70% isopropyl alcohol and acetic acid assist in drying and acidifying the ear canal after swimming.
Etiology
  • Usually eustachian tube dysfunction after viral URI, which results in fluid in the middle ear that acts a culture medium for bacterial superinfection:
    • Most common bacterial causes (account for 95% of bacterial AOM):
      • Streptococcus pneumoniae (increased incidence of drug resistance 30–60% in some communities)
      • Haemophilus influenzae
      • Moraxella catarrhalis
    • Less common bacterial causes:
      • Streptococcus pyogenes
      • Mycoplasma pneumoniae
  • Otitis externa:
    • Bacterial (91%): Pseudomonas aeruginosa (50%), Staphylococcus aureus (23%), anaerobes and gram-negative organisms (12.5%)
    • Fungal: Aspergillus (90%) and Candida
Diagnosis
  • AOM:
    • Abrupt, rapid onset of signs and symptoms
    • Presence of middle ear effusion indicated by any of the following:
      • Bulging tympanic membrane (TM)
      • Limited/absent TM mobility
      • Air fluid level behind TM
      • Otorrhea: more specific to AOM
    • Signs or symptoms of middle ear inflammation indicated by:
      • Distinct erythema of TM, OR
      • Otalgia that interferes with normal activity or sleep, OR
      • Otalgia, irritability in an infant or toddler, fever, and URI symptoms (cough, nasal discharge, or stuffiness) are nonspecific and occur in 90% with AOM and 72% without AOM
  • Otitis media with effusion:
    • Absence of signs and symptoms of acute infection
    • Reduced hearing may be present
    • TM neutral or retracted in appearance; fluid in middle-ear space
  • Otitis externa:
    • Otalgia and discharge from external canal
History
  • AOM:
    • Patient with or without recent URI symptoms complains of otorrhea, otalgia, fever, decreased hearing, or occasional vertigo
    • Other complaints: Anorexia, irritability, vomiting, diarrhea
    • May have history of otitis media
    • TM may spontaneously rupture, leading to resolution of pain.
    • Clinical history alone is poorly predictive of AOM, especially in younger children.
  • Otitis externa:
    • Otalgia
    • Aural fullness
    • Itching
    • Discharge: Initially clear and odorless, but then becomes purulent and foul-smelling
    • Tinnitus
Physical Exam
  • AOM:
    • TM bulging, full, red, and immobile; may be cloudy
    • TM rupture may lead to signs of otorrhea on examination.
    • May have tenderness in mastoid area
  • Otitis media with effusion:
    • TM neutral or retracted
    • Fluid behind TM may be present.
    • May need tympanometry or acoustic reflectometry to confirm diagnosis
  • Otitis externa:
    • Tragal tenderness with manipulation
    • Erythematous and edematous external auditory canal
    • Purulent discharge
    • Eczema of auricle
    • Periauricular and cervical adenopathy

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Diagnostic Tests & Interpretation
Tympanocentesis may be helpful in selected refractory or recurrent cases to make microbiologic diagnosis.
Differential Diagnosis
  • AOM:
    • Redness: Crying, fever, cerumen removal with irritation of external canal
    • Earache: Referred pain from throat, jaw, teeth, other nearby structures
    • Tympanosclerosis
  • Mastoiditis:
    • Tenderness in mastoid area may be due to otitis media.
  • Otitis externa:
    • Foreign body
    • Mastoiditis
    • Herpes zoster
Treatment
  • AOM:
    • Usually treated empirically with antibiotics (see “Etiology”)
    • First line: Amoxicillin: 500 mg t.i.d. Peds: 80–90 mg/kg/day (American Academy of Pediatrics/American Academy of Family Physicians 2004 treatment guidelines). Not effective against H. influenzae or M. catarrhalis (B-lactamase producers).
    • Penicillin allergy: Erythromycin or trimethoprim-sulfamethoxazole. Cefdinir, cefpodoxime, or cefuroxime if no type I hypersensitivity reaction.
    • Acetaminophen or ibuprofen for mild pain, and narcotic analgesics for moderate-to-severe pain.
    • Tympanostomy
    • AOM with tympanic membrane rupture:
      • Oral antibiotics (amoxicillin or amoxicillin-clavulanate)
    • AOM treatment failures:
      • Switch in empiric therapy recommended after 48–72 hr if not responding
      • Drugs of choice: Amoxicillin-clavulanate (Augmentin), cefuroxime axetil (Ceftin), and IM ceftriaxone (Rocephin)
  • Otitis media with effusion:
    • Initial diagnosis may be confirmed with tympanometry; usually observe or treat with oral antibiotic.
    • Decongestants, antihistamines, and oral steroids not indicated
    • May need tympanostomy tube following complete ear, nose, and throat (ENT) evaluation
  • Otitis media and tympanostomy tubes:
    • Ciprofloxacin 0.3%/dexamethasone 0.1% 4 drops b.i.d. × 7 days
  • Otitis externa:
    • Bacterial: Gentamicin/betamethasone otic drop 2–3 drops q.i.d. × 7–10 days or ciprofloxacin 0.3%/dexamethasone 0.1% 4 drops b.i.d. × 7 days
    • Fungal: Clotrimazole 1% otic sol 4 drops q.i.d. × 7–10 days
Additional Treatment
General Measures
  • Outpatient management except in cases requiring surgical intervention.
  • Modification of environmental risk factors (see “Risk Factors”)
Surgery/Other Procedures
Consider tympanocentesis for treatment failures, especially if several recent courses of antibiotics; allows for pathogen-directed treatment.
Ongoing Care
  • Age 1–3 yrs:
    • If effusion present for >6 wks, consider hearing evaluation
    • If effusion present for >3 mos, need hearing evaluation and possible ENT referral for tympanostomy tube (grommet) placement
  • Older individuals:
    • May need grommet placement after 3 mos following complete ENT evaluation to exclude other causes of effusion
Complications
Otitis externa: Local purulent extension of disease, such as the following:
  • Necrotizing otitis externa
  • Mastoiditis
  • Chondritis of the auricle
  • Bony erosion of the base of the skull
  • CNS infection
Additional Reading
Gary JP. Otitis Externa. eMedicine. Updated Nov 30 2007.
Neff MJ, AAP, AAFP et al. AAP, AAFP, AAO-HNS release guideline on diagnosis and management of otitis media with effusion. Am Fam Physician. 2004;69:2929–2931.
Neff MJ, American Academy of Pediatrics, American Academy of Family Physicians. AAP, AAFP release guideline on diagnosis and management of acute otitis media. Am Fam Physician. 2004;69:2713–2715.
Osguthorpe JD, Nielsen DR. Otitis externa: Review and clinical update. Am Fam Physician. 2006;74:1510–1516.
Ramakrishnan K, Sparks RA, Berryhill WE. Diagnosis and treatment of otitis media. Am Fam Physician. 2007;76:1650–1658.
Wright D, Safranek S. Treatment of otitis media with perforated tympanic membrane. Am Fam Physician. 2009;79:650, 654
Sexton S, Natale R. Risks and benefits of pacifiers. Am Fam Physician. 2009;79:681–685.
Codes
ICD9
  • 380.10 Infective otitis externa, unspecified
  • 380.11 Acute infection of pinna
  • 380.12 Acute swimmers' ear
Clinical Pearls
  • Diving should be avoided until normal TM mobility because of increased risk of rupture at depths >4.3 ft.
  • Be careful with over-the-counter decongestants. Drugs containing ephedrine or pseudoephedrine are banned by the International Olympic Committee. Sedating antihistamines are banned by the IOC for shooting sports. If in doubt, call the United States Anti-Doping Agency Drug Reference Line at 1–800–233–0393.
  • There is no evidence that athletes with grommets are at greater risk of developing otorrhea; possible decreased incidence in swimmers vs nonswimmers. Decreased incidence of infection with use of polymyxin B-Neosporin-hydrocortisone (2 drops at night after swimming).
  • There is no evidence of decreased infection rate with earplug use. Surface swimming only; increased pressure in diving may increase infection rate.


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