Otitis externa

An overview of Fungal infections affecting the external ear

1. Otitis Externa Dr. Kripa Jacob ENT Specialist ATLAS Hospital Ruwi

2. Anatomy and Physiology Consists of the auricle and EAM Skin-lined apparatus Approximately 2.5 cm in length Ends at tympanic membrane Auricle is mostly skin-lined cartilage External auditory meatus Cartilage: ~40%, Bony: ~60% S-shaped, Narrowest portion at bony-cartilage junction

3. Anatomy and Physiology EAC is related to various contiguous structures Tympanic membrane Mastoid Glenoid fossa Cranial fossa Infra-temporal fossa

4. Anatomy and Physiology Innervation: cranial nerves V, VII, IX, X, and greater auricular nerve Arterial supply: superficial temporal, posterior and deep auricular branches Venous drainage: superficial temporal and posterior auricular veins Lymphatics

5. OTITIS EXTERNA

6. DEFINITION An acute or chronic infection of the whole or a part of the skin of the external ear canal

7. CAUSES OF OTITIS EXTERNA INFECTIVE REACTIVE Bacterial Fungal Viral Staph. arues Pseudomonos Others Aspirigillus Niger Candida Albicans Herpes zoster Others Eczematous Seborrheic

8. Speculum findings: the canal may be so swollen that a view into the ear is impossible In swimmers, divers and surfers, chronic water exposure can lead to the growth of bony swellings in the canal known as exostoses . These can interfere with the drainage of wax and predispose to infection.

9. Organisms Pseudomonas species Staphylococci Streptococci/Gram negative rods Fungi ( Aspergillus / Candida species)

10. Acute Otitis Externa (AOE) “ swimmer ’ s ear ” Pre-inflammatory stage Acute inflammatory stage Mild Moderate Severe

11. Factors contributing to AOE High humidity Water exposure Maceration of canal skin High environmental temperature Local trauma Perspiration Allergy Stress Removal of normal skin lipids Absence of cerumen Alkaline pH of canal

12. AOE: Pre-inflammatory Stage Oedema of stratum corneum and plugging of apopilosebaceous unit Symptoms: pruritus and sense of fullness Signs: mild edema Starts the itch/scratch cycle

13. AOE: Mild to Moderate Stage Progressive infection Symptoms Pain Increased pruritus Signs Erythema Increasing edema Canal debris, discharge

14. AOE: Severe Stage Severe pain, worse with ear movement Signs Lumen obliteration Purulent otorrhoea Involvement of peri -auricular soft tissue

15. AOE: Treatment Most common pathogens: P. aeruginosa and S. aureus, E.coli and proteus . Four principles Frequent canal cleaning; swab or suction With sever EO, placement of a wick made of sponge or gauze provides a pathway for drops to be delivered to the EAC wall skin for 48-72 hours! Topical antibiotics, and if severe>> Systemic or PO-ABT Pain control Instructions for prevention

16. AT A GLANCE. . . Otalgia Tenderness on palpation or manipulation ( Tragus sign ) Ear fullness Conductive hearing loss. Erythema of meatus and canal Swelling and obstruction of canal Crusting and discharge Odor!

17. Furunculosis Acute localized infection Lateral 1/3 of posterosuperior canal Obstructed apopilosebaceous unit Pathogen: S. aureus

18. Furunculosis : Symptoms Localized pain Pruritus Hearing loss (if lesion occludes canal)

19. Furunculosis : Signs Edema Erythema Tenderness Occasional fluctuance

20. Furunculosis : Treatment Local heat Analgesics Oral anti-staphylococcal antibiotics Incision and drainage reserved for localized abscess IV antibiotics for soft tissue extension

21. Erysipelas Acute superficial cellulitis Group A, beta hemolytic streptococci Skin: bright red; well-demarcated, advancing margin Rapid treatment with oral or IV antibiotics if insufficient response

22. Otomycosis Acute Fungal infection of EAC skin 10% of OE caused by fungi, not bacteria Primary or secondary Two most common pathogens 80%-90% caused by Aspergillus Candida M ostly in patients who have previously been treated with antibacterial or corticosteroid ear drops

23. OTOMYCOSIS

24. Otomycosis : Symptoms Pruritus deep within the ear Dull pain Hearing loss (obstructive) Tinnitus Symptoms are similar to bacterial otitis externa , but otomycosis is often associated with less pain and more pruritus

25. Otoscopic examination : Signs S wollen and erythematous EAC A bundant fungal debris containing filamentous elements (white, gray, yellow, or black) in cheesy material White, or black fungal debris

26. Otomycosis

27. Otomycosis : Treatment Thorough cleaning and drying of canal Topical antifungals ( clotrimazole for eg ., amphotericine B, oxytetracycline-polymyxin , and nystatin are very effective!) Acidifying of the EAC with drops like 2% acetic acid, 3% boric acid are also helpful in the t/t of fungal infections.

28. Necrotizing (malignant) External Otitis(NEO) Potentially lethal infection of EAC and surrounding structures Pseudomonas aeruginosa is the usual culprit Risk Factors : - Diabetes Mellitus - Elderly - Immunocompromised state - Human Immunodeficiency Virus (HIV) Typically seen in diabetics and immunocompromised patients

29. NEO: Signs & Symptoms Similar to Otitis Externa except Severe, unrelenting Ear Pain and Headache Persistent discharge Does not respond to topical medications Commonly associated with Diabetes Mellitus Granulation tissue in posterior and inferior canal Pathognomonic for necrotizing otitis Occurs at bone-cartilage junction Extra-auricular findings Cervical Lymphadenopathy Trismus (TMJ involvement) Facial Nerve Palsy or paralysis (Bell's Palsy) Associated with poor prognosis

30. NEO: Diagnosis, Prevention and Treatment: Prognosis; Reportedly mortality 20-53% Diagnosis : History, Physical Examn , Labs and Imaging: Labs; FBC, Culture of discharge, ESR, Serum glucose, Serum creatinine . Radiology; CT, or MRI (ear) Prevention: Avoid use of cotton swabs in ear and other canal trauma . Use caution when irrigating ear of high risk patients . Treat eczema of ear canal and other pruritic dermatitis

31. NEO: Treatment Intravenous antibiotics for at least 4 weeks – with serial gallium scans monthly Local canal debridement until healed Pain control Use of topical agents controversial Hyperbaric oxygen experimental Surgical debridement for refractory cases

32. NEO: Mortality Death rate essentially unchanged despite newer antibiotics (37% to 23%) Higher with multiple cranial neuropathies (60%) Recurrence not uncommon (9% to 27%) May recur up to 12 months after treatment

33. Perichondritis / Chondritis Infection of perichondrium/cartilage Result of trauma to auricle May be spontaneous (overt diabetes) Usual pathogens include pseudomonas species and mixed flora

34. Perichondritis : Symptoms Pain over auricle and deep in canal fever Pruritus Perichondritis : Signs Tender auricle Induration Oedema erythaema Advanced cases Crusting & weeping Involvement of soft tissues

35. Perichondritis : Treatment Aspiration of the pus Use antibiotics of gram-negative coverage, specifically anti- pseudomonals . If frank chondritis develops, incisions should be made in the cartilage in order to provide adequate drainage. Mild: debridement, topical & oral antibiotic Advanced: hospitalization, IV antibiotics Chronic: surgical intervention with excision of necrotic tissue and skin coverage

36. Herpes Zoster Oticus (Ramsay Hunt Syndrome) J. Ramsay Hunt described in 1907 Viral infection caused by varicella zoster Infection along one or more cranial nerve dermatomes (shingles). herpes zoster of the pinna with otalgia. facial paralysis sensorineural hearing loss Bullus myringitis A vesicular eruption of the concha of the pinna and the EAC.

37. Symptoms Early: burning pain in one ear, headache, malaise and fever Late (3 to 7 days): vesicles, facial paralysis Treatment Corneal protection Oral steroid taper ( 10 to 14 days) Antivirals ( e.g . Valacyclovir ) Facial nerve decompression (controversial)!

38. Bullous Myringitis Viral infection Confined to tympanic membrane Primarily involves younger children

39. Bullous Myringitis : Symptoms Sudden onset of severe pain No fever No hearing impairment Bloody otorrhoea (significant) if rupture Bullous Myringitis : Signs Inflammation limited to TM & nearby canal Multiple reddened, inflamed blebs. Hemorrhagic vesicles

40. Bullous Myringitis : Treatment Self-limiting Analgesics Topical antibiotics to prevent secondary infection Incision of blebs is unnecessary

41. Chronic Otitis Externa Acute otitis externa occurs in 4 of every 1000 people per year Otitis externa is defined as chronic when the duration of the infection exceeds 4 weeks or when more than 4 episodes occur in 1 year Bacterial, fungal, dermatological aetiologies COE: Symptoms Unrelenting pruritus Mild discomfort Dryness, Crusting, and flaking of canal skin

42. COE: Signs Asteatosis Dry, flaky skin Hypertrophied skin Muco -purulent otorrhoea (occasional)

43. COE: Treatment Similar to that of AOE Topical antibiotics, frequent cleanings Topical Steroids Surgical intervention Failure of medical treatment Goal is to enlarge and resurface the EAC

44. Relapsing Polychondritis Uncommon progressive inflammatory disorder that may affect children, but more commonly in adults. Episodic and progressive inflammation of cartilages Autoimmune etiology? External ear, larynx, trachea, bronchi, and nose may be involved Involvement of larynx and trachea causes increasing respiratory obstruction

45. Relapsing Polychondritis Fever, pain Swelling, erythaema Arthralgia! Tenderness of the nasal septum may progress to complete destruction of the septum

46. Diagnosis and Treatment Weak + ve RF ANA + ve High ESR, Anaemia And definitive Diagnosis is made by a biopsy from the affected cartilage Systemic steroids such as prednisolone In resistant cases; dapsone , cyclophosphamide or azithioprine may be used

47. Radiation-Induced Otitis Externa OE occurring after radiotherapy Often difficult to treat Limited infection treated like COE Involvement of bone requires surgical debridement and skin coverage

48. Granular Myringitis (GM) De- epithelization of the TM Localized chronic inflammation of pars tensa with granulation tissue Sequelae of primary acute myringitis , previous OE, perforation of TM Common organisms: Pseudomonas, Proteus

49. GM: Symptoms Foul smelling discharge from one ear Often asymptomatic Slight irritation or fullness No hearing loss or significant pain GM: Signs TM obscured by pus “ peeping ” granulations No TM perforations

50. GM: Treatment Careful and frequent debridement Topical anti- pseudomonal antibiotics Occasionally combined with steroids At least 2 weeks of therapy May warrant careful destruction of granulation tissue if no response

51. Eczema External signs to OE (atopic, contact and sebrrheoic ) dermatitis Usual symptom is itching. P/E; erythaema , oedema , flaking and crusting. Treatment: Local cleansing. Usage of corticosteroid and drying agents. Metal sensitivity is the most common form of chronic dermatitis involving the ear.! Nickel is the most common offending metal. Women are affected more than men. - Ear piercing is an important cause of primary sensitization to nickel.

52. Conclusions Careful History Thorough physical exam Understanding of various disease processes common to this area Vigilant treatment and patience

53. THANKS