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  • 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.

  • Consider sinusitis in patients with severe rhinitis and in patients with persistent or worsening upper respiratory infection (URI) symptoms after 10 days.

  • Hospitalize patients with sinusitis with orbital or intracranial extension for intravenous antibiotics, sinus imaging, and subspecialty consultation.



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 and tragus appears normal, but with manipulation elicits severe pain (a hallmark of this condition). The patient may not be able to lie down on that side or complains of even light wind eliciting pain. The ear canal itself is red and edematous with an exudate (Fig. 96-1); the tympanic membrane (TM) may be difficult to visualize. 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.

FIGURE 96-1.

Photograph showing otitis externa.

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. Hospitalize these patients for IV antipseudomonal antibiotics and otolaryngology consultation. 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


A furuncle (abscess) may develop at a hair follicle in the lateral canal. Depending on the degree of fluctuance, treat with a combination of antistaphylococcal topical or oral antibiotics and incision and drainage. 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. Prolonged retained otic foreign bodies may create pain, edema, and debris in the external auditory canal mimicking AOE. Acute otitis media (AOM) with perforation and resultant debris and exudates may be mistaken for an external ear infection. The history (upper respiratory symptoms with fever versus swimming) as well as the time of year (winter ...

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