Chapter 95: Ear and Nose Emergencies

High-Yield Facts

• The diagnosis of otitis media is based on the rapid onset of signs and symptoms of middle ear inflammation in the presence of middle ear effusion. Pneumatic otoscopy is an essential component of the ear examination.

• Worsening otitis media, while on antibiotics, may be a sign of a suppurative complication.

• Sinusitis should be considered in patients with severe rhinitis and in patients with persistent or worsening URI symptoms after 10 days.

• Hospitalization for intravenous antibiotics, sinus imaging, and subspecialty consultation are indicated in patients with sinusitis with orbital or intracranial extension.

Acute Otitis Externa

Diagnosis

The fragile skin of the external auditory canal is easily infected when disrupted by trauma or inflammation, permitting the normal ear flora (Staphylococcus spp., Streptococcus spp., diptheroids, and Pseudomonas aeruginosa) to invade the tissue. Acute uncomplicated otitis externa is diagnosed clinically. A history of local trauma, water exposure (“swimmer's ear”), and travel to a warm humid climate may be present.^1,2 Most patients will present with localized ear pain and itching. The pinna appears normal, the ear canal red and edematous with an exudate, and manipulation of the pinna or tragus usually elicits pain (a hallmark of this condition) (Fig. 95-1). If the infection is due to a fungus (predominantly Aspergillus spp.), white or gray masses composed of hyphae may be seen in the canal. Local lymphadenopathy may be present.

Malignant or necrotizing otitis externa is most commonly caused by P. aeruginosa and is characterized by a severe cellulitis of the external canal with osteomyelitis of the underlying bone. Hospitalization for intravenous (IV) antipseudomonal antibiotics and otolaryngology consultation are indicated. Imaging with MRI or CT is often necessary to define the extent of any bony and soft-tissue involvement.³ Otomycosis and necrotizing otitis externa are predominantly seen among diabetic or immunocompromised patients.¹

Differential Diagnosis

A furuncle (abscess) may develop at a hair follicle in the lateral canal. Depending on the degree of fluctuance, a combination of antistaphylococcal topical or oral antibiotics and incision and drainage should be employed. Conditions affecting the skin of the ear, such as atopic dermatitis, seborrheic dermatitis, and contact dermatitis, may also lead to itching and inflammation of the external canal. Retained otic foreign body or an acute otitis media with perforation and resultant debris and exudates may be mistaken for an external ear infection.

Management

Treatment of uncomplicated acute otitis externa consists of a combination of topical antimicrobial preparations (targeting P. aeruginosa) and external ear cleaning.⁴ Options include acetic acid, ...