Fungal Infections of the External Auditory Canal and Emerging Pathogens

Fungal infections of the external auditory canal can range from common (otomycosis) to life threatening (necrotizing otitis externa). Proper identification of fungal pathogens is necessary to guide appropriate therapy, and a high index of suspicion for fungal causes of ear canal disease is critical. Fungal pathogens may be an especially important cause of ear canal disease in certain populations, including patients with diabetes, patients recently treated with antibiotics, and immunosuppressed patients. Opportunistic fungal infections of the ear canal are an emerging concern.

Short- and long-term outcomes of subtotal ear canal ablation and lateral bulla osteotomy in French bulldogs

The objective of this retrospective study was to report the overall peri-operative complications and short- to long-term outcomes of subtotal ear canal ablation and lateral bulla osteotomy in French bulldogs with otitis media. Medical records from 2018 to 2021 were reviewed for preoperative neurological signs, surgical technique, postoperative complications, and long-term outcomes. Postoperative complications, such as a head tilt, nystagmus, ataxia, facial nerve dysfunction, as well as skin or wound infection, were recorded. Eighteen client-owned dogs (20 ears) were included in the study. Postoperative complications were observed in 5/18 dogs (6/20 ears) with 2 of them being considered major complications. Referring veterinarians and owner telephone follow-up (mean: 33 mo, range: 17 to 56 mo) were obtained for all patients. Total recovery was reported in 9/18 dogs (11/20 ears) with a postoperative improvement of the vestibular signs and facial nerve paresis within 8 wk. All dogs maintained the pinnas' natural, erect morphology, and movement.

Effect of an ear cleaner instillation containing lipacids in a model of re-acidification of the external auditory canal in dogs

BACKGROUND

In humans, the acidic pH of the ear canal plays a protective role against infection and a change towards alkalinity of the external auditory canal (EAC) is a local factor in the progression of acute to chronic otitis externa (OE). The use of acidic preparations alone for treatment of OE without concurrent antibiotic use is well-documented in humans. In dogs, only one study has investigated the EAC pH in healthy dogs and in dogs with OE, and investigations to understand the role of EAC pH in the pathogenesis of canine OE are lacking.

HYPOTHESIS/OBJECTIVES

To obtain physiological EAC pH values in beagle dogs. To develop a model of re-acidification of the EAC in dogs and to investigate how an acidic solution may accelerate the return to a physiological pH.

ANIMALS

Ten healthy beagle dogs in a laboratory setting.

MATERIALS AND METHODS

A model of re-acidification of the EAC was developed by instillation of a pH 10.1 phosphate-buffered saline (PBS) solution and the subsequent acidic effect of an ear cleaner containing lipacids was evaluated in this model.

RESULTS

Mean physiological EAC pH was 6.12 (± 0.36). EAC re-acidification took up to 9 h in this model. Mean pH values dropped immediately to 6.38 (± 0.27) on ears treated with an acidic ear cleaner. No abrupt drop was observed of the mean pH values for the control ears.

CONCLUSION AND CLINICAL IMPORTANCE

This study confirms that physiological EAC pH in dogs is acidic. This model of re-acidification of the EAC pH allows investigations on acidic properties of topical ear products in healthy ears.

A Lateral Neck Myeloid Sarcoma Presenting as Acute Otitis Externa

Myeloid sarcoma (MS) is a solid extra-medullary tumor of immature myeloid cells which could occur before, during or after remission of acute leukemia at any site on the body. Owing to variation in differential diagnosis, pathologic evaluation and immunohistochemical staining are essential for definitive diagnosis. Rarely, MS has been shown as an isolated extramedullary relapse (iEMR) after allogeneic stem cell transplantation (allo-SCT), which often does not necessarily result in bone marrow involvement. It seems that despite chemotherapy and graft-versus-leukemia (GVL) effects on bone marrow, leukemic cells could remain alive in the extra-medullary region. However, in order to achieve longer survival, timely diagnosis as well as combined systemic, local, and cellular therapeutic modalities should be considered in any patient with iEMR after allo-SCT. We report a left lateral neck isolated MS presented as acute otitis externa in a patient with prior allo-SCT due to acute myeloid leukemia (AML). Therefore, MS should be considered in patients with any history of acute leukemia even if the patient presents with signs and symptoms of an infectious disease.

Malignant Otitis Externa Outcomes: A Study of the University HealthSystem Consortium Database

OBJECTIVE

To characterize factors that affect outcomes for patients with malignant otitis externa (MOE).

METHODS

Retrospective review of inpatients with MOE was performed. Patient demographics, comorbid conditions, complications, procedures, and mortalities were analyzed.

RESULTS

A total of 786 patients with MOE were identified. The mean hospitalization length of stay (LOS) was 18.6 days (SD = 19.7). The overall mortality rate was 2.5% (n = 20), and complication rate was 4.3% (n = 34). Increasing age significantly and positively correlated with the incidence of MOE (r = 0.979, P < .0001). Factors that were associated with an increased rate of mortality were sepsis (odds ratio [OR] = 18.5; ES = 0.94; 95% CI, 0.47-1.42), congestive heart failure (OR = 3.1; ES = 0.42; 95% CI, 0.02-0.82), weight loss (OR = 10.2; ES = 1.23; 95% CI, 0.61-1.85), and coagulopathy (OR = 8.8; ES = 1.84; 95% CI, 0.91-2.77). Surgical intervention was performed in 19.2% (n = 151) of patients. Facial nerve involvement was present in 15.5% (n = 122) of patients and was associated with a significantly longer LOS of 12.9 days (SD = 19.6; ES = 0.21; 95% CI, 0.03-0.41).

CONCLUSIONS

This large multi-institutional database study of MOE demonstrates that several patient factors impact the LOS and mortality. Patients at risk for unfavorable outcomes include the elderly, male gender, comorbidities, or cranial nerve involvement.

Aviation Fuel Exposure Resulting in Otitis Externa with Vertigo

BACKGROUND

Otitis externa secondary to irritant or chemical exposure is well documented; however, specifically secondary to jet fuel exposure and its associated toxicology is not. Over 2 million military and civilian personnel per year are occupationally exposed to aviation fuels.

CASE REPORT

An aircraft maintainer presented with noninfectious acute otitis externa secondary to external ear canal exposure to JP-5 jet fuel. Proper exposure guidelines were followed, but it was not realized that the external ear canal was involved. The first symptoms to emerge were vertigo, dizziness, and disequilibrium; however, on physical exam it appeared that there was no middle ear involvement.

DISCUSSION

Otitis externa normally does not present with vestibular symptoms as the pathology affects the external ear canal dermal tissue. Upon review of JP-5's toxicology profile, dermal absorption is a route of entry and can cause general neurological symptoms, including loss of coordination. This case highlights potential deficiencies in the standardized safety data sheets that are used after exposure. Without mention of possible auricular exposure one may focus on the logical protection of the eyes, mouth, and visible skin. This is concerning due to potential delayed exposure symptoms, dermal absorption, high level of dermal destruction, and the close proximity to the sensory system. The goal of this case report is to improve the knowledge of providers caring for personnel who may be exposed and to suggest possible revisions to the Safety Data Sheets for jet fuel.Long RJ, Charles RA. Aviation fuel exposure resulting in otitis externa with vertigo. Aerosp Med Hum Perform. 2018; 89(7):661-663.

Otitis externa in military divers: more frequent and less harmful than reported

INTRODUCTION

Although otitis externa (OE) is a common disease, data related to (military) divers are limited. This study aimed to determine the incidence of OE in military divers during their initial training. We also wished to consider seasonal influences on incidence and whether early detection increases completion of the diving course.

METHODS

From January 2011 to October 2016 the Royal Netherlands Navy Diving School trained 189 divers. Up to December 2015 we used the training records for the analyses. From January 2016 onward all divers were prospectively screened. Pearson's chi-squared 2 and Fisher's exact tests were used to analyse the data.

RESULTS

In the 162 included divers, 30 cases of OE were identified. The incidence in 2016 was significantly higher than in 2011-2015 (17/35 (49%) versus 13/127 (10%), P < 0.001). Almost all cases developed after three weeks of diving. No influence of season was found (P = 0.354). Early diagnosis and treatment of OE does not seem to affect completion of diving courses (P = 0.28). Only in three cases did a diver have to discontinue the course due to OE.

DISCUSSION

This study suggests that OE is more frequent among military divers than earlier reported, most likely caused by prolonged water exposure. Diving activities can often be continued with standard topical treatment.

[The current views of the treatment of diffuse external otitis]

The objective of the present study was to evaluate the clinical effectiveness and safety of the local application of triderm for the treatment of diffuse external otitis. The study included 68 patients presenting with bacterial and fungal diffuse external otitis. The treatment in the form of local empiric therapy was continued till the results of microbiological treatment became apparent. The beneficial outcome achieved in 91.2% of the patients was clinically manifest as the regression of the inflammatory process in the external auditory meatus. No complications, such as ototoxic events, either local or systemic allergic reactions, were documented. The authors substantiate the possibility of the application of the medication under consideration for the treatment of diffuse external otitis based on the knowledge of the mechanism of the actin of its constituent components, viz. betamethasone, dipropionate, gentamicin sulfate, and clotrimazole, taking into account the occurrence of the most common causative agents of diffuse external otitis. It is concluded that triderm is a safe medication for the local application and, probably, for the initial empiric therapy of diffuse external otitis to be continued till the results of the microbiological treatment become apparent.

Ear Mite Removal in the Santa Catalina Island Fox (Urocyon littoralis catalinae): Controlling Risk Factors for Cancer Development

Ear mites (Otodectes cynotis) and ear canal tumors are highly prevalent among federally endangered Island foxes (Urocyon littoralis catalinae) living on Santa Catalina Island off the coast of Southern California. Since studies began in the 1990s, nearly all foxes examined were found to be infected with ear mites, and ceruminous gland tumors (carcinomas and adenomas) were detected in approximately half of all foxes ≥ 4 years of age. We hypothesized that reduction of ear mite infection would reduce otitis externa and ceruminous gland hyperplasia, a risk factor for tumor development. In this study, we conducted a randomized field trial to assess the impact of acaricide treatment on ear mite prevalence and intensity of infection, otitis externa, ceruminous gland hyperplasia, and mite-specific IgG and IgE antibody levels. Treatment was highly effective at eliminating mites and reducing otitis externa and ceruminous gland hyperplasia, and mite-specific IgG antibody levels were significantly lower among uninfected foxes. Ceruminous gland hyperplasia increased in the chronically infected, untreated foxes during the six month study. Our results provide compelling evidence that acaricide treatment is an effective means of reducing ear mites, and that mite removal in turn reduces ear lesions and mite-specific IgG antibody levels in Santa Catalina Island foxes. This study has advanced our understanding of the underlying pathogenesis which results in ceruminous gland tumors, and has helped inform management decisions that impact species conservation.

[Common infections of the ear, nose, and throat]

Infectious diseases of the ear, nose and throat are common reasons why patients visit their family physician. Therefore, the aim of this mini-review is to give an overview of the most important and frequent infectious diseases of the ear, nose and throat, the appropriate diagnostic measurements and therapy with relevance for the family physician. Most of these infectious diseases can be treated by the family physician and do not necessarily need to be seen by an ENT-specialist.

Otitis externa following aural irrigation linked to instruments contaminated with Pseudomonas aeruginosa

BACKGROUND

The incidence of acute otitis externa, an infection of the external auditory canal, in general practitioners' (GP) practices in The Netherlands is about 14 per 1000 patients per year. In early 2010, one of the authors noted that some of the otitis externa patients in his GP practice had undergone cerumen removal by ear syringing a few weeks earlier. Bacterial cultures of samples taken from the instruments used showed contamination of an ear syringe by Pseudomonas aeruginosa. From then on, P. aeruginosa isolates from patients' ears were stored in the laboratory.

AIM

It was assessed whether cross-contamination with P. aeruginosa between patients in the same GP practice could occur through the use of contaminated ear lavage instruments.

METHODS

From 17 GP practices, the otolaryngology Outpatient Department and the Out-of-Hours GP Service, instruments used for examining and cleaning the outer ear were swabbed. Strains of P. aeruginosa cultured from the instruments were genotyped together with isolates of patients registered in the same practice.

FINDINGS

In four practices where contaminated instruments were found, genotyping showed similarity between P. aeruginosa strains isolated from a patient and the ear syringe, and/or between strains of different patients in the same practice.

CONCLUSIONS

Transmission of P. aeruginosa from ear lavage instruments to patients appears to occur with otitis externa as a result. Together with the Infection Control Unit of our hospital we have formulated recommendations for the appropriate cleaning, disinfection and storage of re-usable ear lavage instruments for the GP practices to implement.

[When external otitis does not heal]

An illness initially started as external otitis in a healthy and physically fit middle-aged person turned out to be a difficult-to-manage Langerhans cell histiocytosis. The disease occurs mostly in children, and international clinical guidelines have accordingly been devised mainly for juvenile patients. Treatment of adult patients is thus essentially empirical. The disease may affect several organs, as in our case report, in which the disease after progression to a multisystemic disease led to secondary leukemia and death of the patient.

[Local antibacterial therapy for the inflammatory diseases of the external and middle ear]

The objective of the present study was to estimate the efficacy and safety of candibioic designed for the treatment of the patients presenting with diffuse otitis externa and chronic otitis media. The open randomized trial included 40 patients with diffuse otitis externa and 40 ones with chronic otitis media who had undergone a surgical sanitation procedure. Their standard clinical and otorhinolaryngological examination was supplemented by the characteristic of clinical symptoms and personal complaints using the 10-score scale. The composite preparation candibiotic was found to be equally effective for the treatment of both diffuse otitis externa and chronic otitis media. The results of the study give reason to recommend the use of candibiotic as an efficacious and safe drug for the treatment of these conditions.

Acute bacterial otitis externa: efficacy and safety of topical treatment with an antibiotic ear drop formulation in comparison to glycerol treatment

OBJECTIVES

To demonstrate the efficacy and safety of an antibiotic ear drop formulation combining polymyxin B sulfate, neomycin sulfate and gramicidin (PS) in patients with acute bacterial otitis externa (AOE). The combination was compared to glycerol ear drops, a non-pharmacologic treatment of AOE.

METHODS

An active controlled, double-blind, randomized, parallel group, multicenter clinical trial study design was performed in ear, nose and throat (ENT) practices with a planned interim analysis for sample size adaptation. In total, 244 patients aged 19-84 with no previous episode of otitis externa within the last year were randomized to receive either PS or glycerol ear drops thrice daily for 10 ± 2 days.

OUTCOME MEASURES

Absolute change in the clinical symptom score (CSS) (with subscores redness, swelling, pain, and secretion) from Day 1 to 4 was measured. As second endpoints, absolute change in CSS, individual subscores, pain perception measured on a visual analog scale (VAS) and intake of paracetamol 500 mg tablets were noted. Moreover, patient's assessment of efficacy at Day 10 and the frequency and type of adverse events were noted.

RESULTS

On Day 4, the CSS showed a clear advantage for the PS group over the glycerol group, being lower by 0.6 (p < 0.03); the clinical outcome was even more pronounced after 10 days (p = 0.006). The swelling subscore showed a statistically significant difference favoring the PS treatment group in Days 1-4 (p = 0.01) and Days 1-10 (p = 0.003). More PS- than glycerol-receiving patients rated the efficacy as good (glycerol: 32%; PS: 36%) or very good (glycerol: 38%; PS: 48%). Males, patients with AOE for >2 days and those with positive microbiologic findings profited most from PS therapy.

CONCLUSION

This study proves that PS is an effective and well-tolerated drug, showing results superior to glycerol, especially in patients with a longer pre-existing condition before therapy. The absence of a group treated with another established antibiotic is a limitation of this trial.

Ear disorders in scuba divers

History of underwater diving dates back to antiquity. Breath-hold technique in diving was known to the ancient nations. However, deep diving progressed only in the early decades of the 19th century as the result of advancements in efficient underwater technologies which subsequently led to invention of sophisticated sets of scuba diving in the 20th century. Currently, diving is performed for various purposes including commercial, recreational, military, underwater construction, oil industry, underwater archeology and scientific assessment of marine life. By increasing popularity of underwater diving, dive-related medical conditions gradually became more evident and created a new challenge for the health care professionals, so that eventually, a specialty the so-called "diving medicine" was established. Most of the diving-associated disorders appear in the head and neck. The most common of all occupational disorders associated with diving are otologic diseases. External otitis has been reported as the most common otolaryngologic problem in underwater divers. Exostosis of the external ear canal may be formed in divers as the result of prolonged diving in cold waters. Other disorders of the ear and paranasal sinuses in underwater divers are caused by barometric pressure change (i.e., barotraumas), and to a lesser extent by decompression sickness. Barotrauma of the middle ear is the most prevalent barotrauma in divers. The inner ear barotraumas, though important, is less common. The present paper is a brief overview of diving-related ear disorders particularly in scuba divers.

[External otitis in children: etiology and principles of therapy]

External otitis accounts for 21 to 25% of all inflammatory ear diseases. This paper presents the original data providing a deeper insight into etiology of this disease taking into consideration the great variety of its pathogenic agents, the possibility of development of mixed forms, and changes of whether conditions at the peak of morbidity. In addition, the results of assessment of the efficacy of Pimafucort designed for both mono- and combined therapy of the disease of interest are reported.