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Otitis externa, or “swimmer's ear,” is characterized by pruritus, pain, and tenderness of the external ear. Erythema and edema of the external auditory canal, otorrhea, crusting, and hearing impairment may also be present. Pain is elicited with movement of the pinna or tragus. Risk factors for development of otitis externa include swimming, trauma of the external canal, and any process that elevates the pH of the canal.
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The most common organisms implicated in otitis externa are Pseudomonas aeruginosa, Enterobacteriaceae and Proteus species, and Staphylococcus aureus, with P aeruginosa being the most common organism causing malignant otitis externa. Otomycosis, or fungal otitis externa, is found in tropical climates and in the immunocompromised or subsequent to long-term antibiotic therapy. Aspergillus and Candida are the most common fungal pathogens.
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The treatment of otitis externa includes analgesics, cleaning the external auditory canal, acidifying agents, topical antimicrobials, and occasionally topical steroid preparations. Ofloxacin otic 5 drops 2 times daily, acetic acid/hydrocortisone otic 5 drops 3 times daily (do not use with perforated TM), and ciprofloxacin/hydrocortisone otic 3 drops 2 times daily are commonly used for 7 days to treat otitis externa. If significant swelling of the external canal is present, a wick or piece of gauze may be inserted into the canal to allow passage of topical medications.
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Malignant otitis externa is a potentially life-threatening infection of the external auditory canal with variable extension to the skull base. In greater than 90% of cases, it is caused by Pseudomonas aeruginosa. Elderly, diabetic, and immunocompromised patients are most commonly affected. Diagnosis of malignant otitis externa requires a high index of suspicion. Computed tomography (CT) is necessary to determine the extent and stage of the disease. Emergent otolaryngologic (ENT) consultation, tobramycin 2 milligrams/kilogram IV and piperacillin 3.375 to 4.5 grams IV, or ceftriaxone 1 gram IV, or ciprofloxacin 400 milligrams IV, and admission to the hospital are mandatory.
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The incidence and prevalence of otitis media (OM) peak in the preschool years and decline with advancing age. The most common bacterial pathogens in acute OM are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. The predominant organisms involved in chronic OM are S aureus, P aeruginosa, and anaerobic bacteria.
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Patients with OM present with otalgia, with or without fever; occasionally, hearing loss and otorrhea are present. The tympanic membrane (TM) may be retracted or bulging and will have impaired mobility on pneumatic otoscopy. The TM may appear red as a result of inflammation or may be yellow or white due to middle ear secretions.
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A 10-day course of amoxicillin 250 to 500 milligrams PO 3 times daily for 7 to 10 days is the preferred initial treatment for OM. Alternative agents include azithromycin 500 milligrams PO daily for 1 day then 250 milligrams PO daily for 4 days, or cefuroxime 500 milligrams PO 2 times daily for 10 days. Cefuroxime or amoxicillin/clavulanate may be given for OM unresponsive to first-line therapy after 72 hours. Antibiotic coverage should be extended to 3 weeks for patients with OM with effusion. Analgesics should be prescribed for patients with any degree of pain. Patients should follow-up with a primary care physician for reexamination and to assess the effectiveness of therapy.
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Complications of OM include TM perforation, conductive hearing loss, acute serous labyrinthitis, facial nerve paralysis, acute mastoiditis, lateral sinus thrombosis, cholesteatoma, and intracranial complications. TM perforation and conductive hearing loss are most often self-limiting and often require no specific intervention. Facial nerve paralysis is uncommon but requires emergent ENT consultation.
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Acute mastoiditis occurs as infection spreads from the middle ear to the mastoid air cells. Patients present with otalgia, fever, and postauricular erythema, swelling, and tenderness. Protrusion of the auricle with obliteration of the postauricular crease may be present. CT will delineate the extent of bony involvement. Emergent ENT consultation, vancomycin 1 to 2 grams IV or ceftriaxone 1 gram IV, and admission to the hospital are necessary. Surgical drainage ultimately may be required.
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Lateral Sinus Thrombosis
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This condition arises from extension of infection and inflammation into the lateral and sigmoid sinuses. Headache is common and papilledema, sixth nerve palsy, and vertigo may be present. Diagnosis may be made with CT, although magnetic resonance imaging or angiography may be necessary. Therapy consists of emergent ENT consultation, combination therapy with nafcillin 2 grams IV, ceftriaxone 1 gram IV, and metronidazole 500 milligrams IV, and hospital admission.
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Bullous myringitis is a painful condition of the ear characterized by bulla on the TM and deep EAC. Numerous pathogens have been implicated including viruses, Mycoplasma pneumoniae, and Chlamydia psittaci. The diagnosis is made by clinical examination. The treatment consists of pain control and warm compresses. Antibiotics can be given for concomitant OM.
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A hematoma can develop from any type of trauma to the ear. Improper treatment of ear hematomas can result in stimulation of the perichondrium and development of asymmetric cartilage formation. The resultant deformed auricle has been termed cauliflower ear. Immediate incision and drainage of the hematoma with a compressive dressing is necessary to prevent reaccumulation of the hematoma.
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Thermal injury to the auricle may be caused by excessive heat or cold. Superficial injury of either type is treated with cleaning, topical nonsulfa-containing antibiotic ointment, and a light dressing. Frostbite is treated with rapid rewarming by using saline soaked gauze at 38°C to 40°C. The rewarming process may be very painful and analgesics will be necessary. Any second- or third-degree burn requires immediate ENT or burn center consultation.
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Foreign Bodies in the Ear
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On examination, the foreign body is usually visualized and signs of infection or TM perforation should be sought. Live insects should be immobilized with 2% lidocaine solution distilled into the ear canal before removal. Foreign bodies may be removed with forceps and direct visualization or with the aid of a hooked probe or suction catheter. Irrigation is often useful for small objects; however, organic material may absorb water and swell. ENT consultation is required for cases of foreign body with TM perforation or if the object cannot be safely removed.
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Tympanic Membrane Perforation
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TM perforations can result from middle ear infections, barotrauma, blunt/penetrating/acoustic trauma, or (rarely) lightning strikes. Acute pain and hearing loss are usually noted, with or without bloody otorrhea. Vertigo and tinnitus, when present, are usually transient. As most TM perforations heal spontaneously, antibiotics are not necessary unless there is persistent foreign material in the canal or middle ear. Patients with perforations from isolated blunt or noise trauma can be discharged with expedited specialty referral and should be instructed not to allow water to enter the ear canal.
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Tinnitus is the perception of sound without external stimuli. It may be constant, pulsatile, high or low pitched, hissing, clicking, or ringing in nature. Objective tinnitus can be heard by the examiner, whereas the more common subjective tinnitus cannot. Causes of tinnitus include vascular, mechanical, neurologic, Ménière disease, and other causes. Common medications resulting in tinnitus include aspirin, nonsteroidal anti-inflammatory drugs, aminoglycosides, loop diuretics, and chemotherapeutics; if the patient's condition allows, potentially offending drugs should be stopped. Accurate diagnosis usually requires referral to an otolaryngologist. Pharmacologic treatment with antidepressant medications may alleviate tinnitus in which no correctable cause can be found.
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Causes of sudden hearing loss are varied and may be idiopathic (most common), infectious, vascular or hematologic, metabolic, rheumatologic, or conductive. Other causes include Ménière disease, Cogan syndrome, acoustic neuroma, cochlear rupture, and ototoxic medications. Indictors of poor prognosis include severe hearing loss on presentation and the presence of vertigo. If the cause is not readily determined by history and physical examination, otolaryngologic consultation is necessary.