Treatment of otitis externa in children

Inflammation of the external auditory canal can be localised or diffuse, and acute or chronic. Predisposing conditions include external trauma, loss of the canal's protective coating, maceration of the skin from water or humidity, and glandular obstruction. Acute otitis externa is generally caused by Pseudomonas aeruginosa or Staphylococcus aureus. Management of patients with otitis externa includes debridement, topical therapy with acidifying and antimicrobial agents, and systemic antimicrobial therapy when indicated. The management of patients with chronic otitis externa includes cleansing and debridement accompanied by topical acidifying and drying agents. This is followed by topical antibiotics and corticosteroid preparations. Surgery is mainly used to allow cleansing and aeration and/or removal of the scarred tissue. Patients with acute localised otitis externa (furunculosis) are treated with local heat and systemic antibiotics in the inflammatory stage, and drainage in the abscess state. Mycotic external otitis is managed with topical acidifying and antifungal agents, while viral (herpes) infection is treated with topical and systemic aciclovir (acyclovir). Patients with necrotising (malignant) external otitis, which is mainly caused by P. aeruginosa and S. aureus, are treated with systemic antibiotics and, rarely, by surgical debridement. Therapy for eczematous otitis externa is first directed at the secondary infection, and thereafter at the primary dermatological condition. Prevention of recurrent external otitis is aimed at minimising ear canal trauma and the avoidance of exposure to water. Preventative use of topical acidifying agents or 70% alcohol is also advocated.

Prevalence of Malassezia spp. in the ears of asymptomatic cattle and cattle with otitis in Brazil

Yeasts of the genus Malassezia are lipophilic microorganisms that are saprophytes that can act as opportunistic pathogens in animals. Malassezia pachydermatis is commonly isolated from the ear canal and skin of healthy dogs, or in association with seborrheic dermatitis and otitis externa conditions. The objective of the present study was to determine the occurrence of Malassezia spp. in the ears of healthy bovines and bovines with otitis. Specimens (secretion or cerumen) were collected with sterile swabs, inoculated onto Mycosel medium, supplemented with olive oil, and incubated at 35 degrees C for 1 week. Yeasts were identified according to morphological characteristics, growth in Dixon medium at 32 degrees C and Sabouraud glucose medium modified by the addition of Tween 20, 40 or 80. The results showed that 54.7% of the cultures were positive in bovines with otitis (75) and 34.6% were positive in healthy bovines (378). Analysis of the positive cultures (41) from animals with otitis allowed presumptive identification of 24 strains corresponding to M. globosa (12), M. slooffiae (5), M. furfur (5) and M. sympodialis (2). Further studies on a larger number of animals may confirm the trend verified thus far, i.e. a higher frequency of isolation of Malassezia spp. from animals with otitis than from healthy animals (P<0.01) and a predominance of the species M. globosa.

Wound contamination and antimicrobial susceptibility of bacteria cultured during total ear canal ablation and lateral bulla osteotomy in dogs

OBJECTIVE

To detect contamination of wound sites from surgical handling of excised tissues during total ear canal ablation and lateral bulla osteotomy in dogs, and to compare susceptibility of bacterial isolates to cefazolin with susceptibility to other antimicrobial agents.

DESIGN

Prospective clinical study.

ANIMALS

13 dogs.

PROCEDURE

Dogs were treated surgically for otitis externa and media via total ear canal ablation and lateral bulla osteotomy. Specimens for aerobic bacterial culture were obtained from SC tissue immediately following skin incision, tissues excised from the osseous bulla (after transection of the horizontal ear canal and lateral bulla osteotomy), and from SC tissue prior to skin closure. Antimicrobial susceptibility of bacterial isolates to various antibiotics was determined by use of a broth dilution assay.

RESULTS

There was a significant association between isolation of Streptococcus canis and Escherichia coli from specimens from the osseous bulla and specimens from the SC tissues prior to skin closure, indicating contamination of the SC tissues during surgery. Seventy percent of bacterial isolates were susceptible to cefazolin.

CLINICAL IMPLICATIONS

Measures to limit bacterial contamination resulting from tissue handling during total ear canal ablation and lateral bulla osteotomy are necessary. Bacteriologic culture of tissue of the osseous bulla and determination of antimicrobial susceptibility are recommended. Administration of cefazolin alone may not be efficacious for antimicrobial prophylaxis.

Treatment patterns for otitis externa

BACKGROUND

Although otitis externa is a common and painful infection of the outer ear canal, there is little specific information available regarding current treatment patterns in the United States. We wanted to examine treatment patterns for otitis externa.

METHODS

Data were analyzed from the 1993 National Ambulatory Medical Care Survey (NAMCS) and the 1993 National Hospital Ambulatory Medical Care Survey (NHAMCS) for adults and children treated for otitis externa. Data analyses included the reasons for physician visits, concomitant diagnoses, types of physicians seen, sources of payment, medical procedures administered, drugs prescribed, and patient disposition following a physician visit.

RESULTS

Study results suggested that treatment patterns differ substantially for adults and children, as well as by physician specialty. Although otitis externa is frequently painful, few cases are classified as severe, and the data indicated that less than 20 percent of patients have concomitant diagnoses treatable by medication. Nevertheless, 40 percent of patients received both topical and systemic medication, and many of the oral antibiotics prescribed are not active against Staphylococcus aureus or Pseudomonas aeruginosa, the most common bacterial pathogens in otitis externa.

CONCLUSIONS

Appropriate treatment of localized otitis externa with topical antibiotics should eliminate the need for systemic medications. Addition of systemic medications can unnecessarily increase treatment costs and the likelihood of side effects, and could reduce the likelihood of patient compliance.

Susceptibility of bacterial isolates from chronic canine otitis externa to twenty antibiotics

In this paper we present the results of studies on the susceptibility to antibiotics of bacteria isolated from chronic canine otitis externa. We tested 46 bacterial strains (S. aureus, coagulase-negative staphylococci, Corynebacterium spp., and gram-negative bacilli) with 20 different antibiotics. We observed increased resistance to antibiotics of bacteria isolated from canine otitis externa as compared to the resistance reported earlier. This may be due to the indiscriminate use of some antibiotics in the last years and indicates the importance of sensitivity testing for the effective treatment of chronic otitis externa, especially that caused by gram-negative bacilli. The clinician may initiate empiric treatment with antibiotics before obtaining the sensitivity test results; the best results may be expected from a topical application of Bacitracin or Chloramphenicol, and from a systemic therapy with Cephalosporines. Therapeutical scheme for treating various bacterial groups are presented in the paper.

[Antimicrobial activity of ofloxacin against recent clinical isolates from otitis media and otitis externa]

In order to evaluate the annual changes of susceptibility, minimum inhibitory concentrations (MICs) of ofloxacin (OFLX) and 4 control drugs were determined against clinical isolates that were obtained from patients with otitis media and otitis externa during the periods between January and December 1993, and the periods between October 1996 and March 1997. The results are summarized as follows: 1. No annual changes were seen for MIC50 of OFLX, but MIC80 and MIC90 of that rose against methicillin-resistant Staphylococcus aureus (MRSA), coagulase-negative staphylococci (CNS) and Pseudomonas aeruginosa from 1993 to 1996. It appears that resistance to OFLX is increasing among these bacteria. Detection frequency of highly resistant strains to OFLX (MIC > 100 micrograms/ml) was lower than to other control drugs. 2. No annual changes were seen of MIC50, MIC80 and MIC90 of OFLX against methicillin-susceptible S. aureus (MSSA), Streptococcus spp., Proteus spp. and Haemophilus influenzae. OFLX showed strong antimicrobial activities against these bacteria. 3. Since there was no large annual changes in the antimicrobial activity of OFLX against clinical isolates that were obtained from patients with otitis media and otitis externa, OFLX otic solution was considered as one of the clinically useful drugs even now.

Prevalence of otomycosis in malnourished children in Edo State, Nigeria

Out of the total number at 200 suspected cases of otomycoses consisting of 40 malnourished and 160 apparently healthy children examined in this study between the months of July and August in Edo State, 64 Cases (32%) were identified to be of fungal aetiology on the basis of positive culture and careful microscopic examination. The state at protein energy malnourishment was deterwined using physicians' comments in their case files. The fungal agents isolated were Aspergillus niger 28 (43.8%); A. fumigatus 4 (25%); Fusarium solari 4 (6.3%); Candida albicans 8 (12.5%); and Hendersonula teruloidea types torn B 5 (6.3%). Of these isolates, A. niger having an solation rate of (43.8%) was found to be the most predominant fungal species associated with otomycosis.

Identification of infectious Pseudomonas aeruginosa strains in an occupational saturation diving environment

OBJECTIVES

Occupational saturation divers have various skin disorders, of which skin infections are the most serious and frequent. Pseudomonas aeruginosa is the microbe most often isolated from skin infections in divers. The purpose of the present work was (a) to report the occurrence of P aeruginosa in skin infections in operational saturation diving in the North Sea from 1987 to 1995; (b) to report the environmental occurrence of P aeruginosa in saturation diving systems, and finally (c) to identify possible relations between infection related to strains of P aeruginosa and environmental isolates of the microbe.

RESULTS

During the period 1987-95, P aeruginosa was isolated from 257 skin infections in operational saturation divers. Most of the isolates related to infection by P aeruginosa show a unique growth inhibition pattern towards the normal skin flora, and the serotype pattern of P aeruginosa from skin infections is limited compared with similar infections in non-divers. In a mini-epidemiological study on board one diving vessel during one operational diving period, five significantly different DNA fragment profiles were found among the 12 isolates related to infection by P aeruginosa obtained from the saturation system. In two cases the infectious genotypes were detected in the fresh water for the saturation chambers weeks before the arrival of the infected diver.

CONCLUSIONS

The most commonly used epidemiological marker for P aeruginosa world wide, also used in earlier studies, is serotyping, but with pulsed field gel electrophoresis (PFGE) miniepidemiology it was shown to be insufficient for epidemiological purposes in saturation environments. PFGE analyses were shown to be superior both to antibacterial factor and to serotyping in epidemiological analyses of P aeruginosa infections in saturation diving.

Otitis externa malignant. A case report and review of literature

Otitis externa malignant (OEM) is a virulent infection if it is not diagnosed and treated promptly. Its mortality rate was reported to be 53% when there is associated facial nerve paralysis. It usually affects elderly diabetic patients, who present with deep-seated pain and other features of non-resolving otitis externa. It is mostly caused by Pseudomonas (P) aeruginosa and the treatment of choice is anti-Pseudomonas antibiotic. A 64-year-old diabetic male patient is described who presented with left ear pain and discharge for two months and did not respond to ordinary treatment. The patient also noticed a progressive facial weakness on the same side. The clinical presentation, investigations, treatment and follow-up of the OEM are discussed on the basis of our case and the review of the literature. The diagnosis of OEM is based on high index of suspicion and confirmed by histopathologic changes and radionuclide studies. Gallium 67 citrate scan is a sensitive way to diagnose and follow up the regression of the disease in response to the medical treatment. Ciprofloxacin is the treatment of choice; however, it has to be in accordance to culture and sensitivity results.

Yolk sac tumor of the ear in a child

OBJECTIVE

This study aimed to describe the clinical, histopathologic, and immunohistochemical findings of the second case of an endodermal sinus tumor of the ear.

STUDY DESIGN

This clinical study is a retrospective case report combined with a literature review.

SETTING

The patient was treated at the University Erasmus Hospital.

INTERVENTION

Diagnosis was confirmed by computed tomographic scan and histologic analysis. The treatment was surgical.

RESULTS

The patient underwent surgical treatment, and a locoregional relapse developed. The clinical evolution was in accordance with previous reports of extragonadal endodermal sinus tumor sites. The family refused chemotherapy, and the patient died 3 months after admission.

CONCLUSIONS

An endodermal sinus tumor is a malignant germ cell tumor that usually involves the gonadal tissue. Extragonadal sites are rare, and different hypotheses have been evoked to explain these locations. Treatment options include surgical removal and chemotherapy. This is the second case of an endodermal sinus tumor of the ear.

ENT manifestations of Pseudomonas aeruginosa infection in HIV and AIDS

In acquired immunodeficiency syndrome (AIDS), opportunistic infections occur which are usually related to defects in cell-mediated immunity. However, there has also been an increase in the incidence of bacterial infections in this population, including infections caused by Pseudomonas species. This study reveals the wide range of ear, nose and throat manifestations which can be caused by Pseudomonas aeruginosa in patients with HIV and AIDS and illustrates the need for a high index of clinical suspicion combined with accurate microbiological data for treating these potentially life-threatening infections. In addition, treatment using combination chemotherapy, such as ciprofloxacin and ceftazidime, is advised, as it has been shown that dual therapy results in a significantly lower mortality.

Otitis externa--the clinical pattern in a tertiary institution in Singapore

Otitis externa is a common condition in the tropics. Most of the data related to the condition have arisen from Western sources. Locally, the aetiology and the pathogens identified have not been systematically studied. A prospective study involving 107 patients was conducted. Otomycosis was frequently encountered. Coagulase negative Staphylococcus and Aspergillus niger were the most common bacteria and fungus cultured respectively. Gentamicin and polymyxin B were the most effective topical agents against Pseudomonas aeruginosa. Self-cleaning of the ears was the most common predisposing factor.

Malignant otitis externa with optic neuritis

Malignant otitis externa is a serious condition that presents difficulties in treatment, and also in monitoring its progress. A case of malignant otitis externa with optic neuritis is presented that remained refractory to standard treatment but was cured by adjuvant hyperbaric oxygen therapy. This is the only reported case that has survived this disease with optic neuritis. The usefulness of imaging techniques in this condition is discussed, as well as the ESR, in evaluating the effectiveness of treatment.

Necrotizing external otitis caused by Aspergillus fumigatus: computed tomography and high resolution magnetic resonance imaging in an AIDS patient

Most necrotizing (malignant) external otitis (NEO) occurs in diabetic patients and is commonly caused by Pseudomonas aeruginosa. We report an acquired immunodeficiency syndrome (AIDS) patient with NEO caused by Aspergillus fumigatus in which computed tomography (CT) showed destructive petrous bone involvement and magnetic resonance imaging (MRI) of the ear discovered extensive soft tissue and facial nerve involvement. Dedicated MRI studies of the ear in this type of pathology provide new insights relating to nerve dysfunction, that cannot be obtained with CT.

Ofloxacin otic solution for treatment of otitis externa in children and adults

OBJECTIVE

To compare the safety and efficacy of ofloxacin otic solution with those of Cortisporin otic solutions (neomycin sulfate, polymyxin B sulfate, and hydrocortisone) in otitis externa in adults and children.

DESIGN

Two randomized, evaluator-blind, multicenter trials, 1 each in children and adults.

SETTING

Twenty-three primary care and referral ambulatory care sites per trial.

PATIENTS

A total of 314 adults (12 years and older) and 287 children (younger than 12 years). Of the total, data for 247 adults and 227 children were considered clinically evaluable (CE), and those for 98 children and 98 adults were microbiologically evaluable (ME).

INTERVENTIONS

Ofloxacin (adults, 0.5 mL; children, 0.25 mL) twice daily or Cortisporin (adults, 0.2 mL; children, 0.15 mL) 4 times daily for 10 days.

MAIN OUTCOME MEASURES

The CE subjects were cured if all signs and symptoms resolved at posttherapy (days 11-13) and test-of-cure (days 17-20) visits. The ME subjects had microbiological and clinical successes if they were cured and had microbiological eradication or presumed eradication.

RESULTS

Cure was observed in 82% and 97% of CE adults and children treated with ofloxacin and 84% and 95% of CE adults and children treated with Cortisporin, respectively. The most common pathogens at the pretherapy visit were Pseudomonas aeruginosa, Staphylococcus aureus, and enteric bacilli. There were no statistically significant differences in clinical or microbiological and clinical cure or in the rates of adverse events between treatment groups.

CONCLUSIONS

Ofloxacin given twice daily is as safe and effective as Cortisporin given 4 times daily for otitis externa. The bacteriological findings and treatment responses do not differ between adults and children.

Bacterial flora of stethoscopes' earpieces and otitis externa

External otitis caused by Staphylococcus aureus was observed in a nurse after extensive use of a stethoscope. The infection recurred and a similar organism was isolated from the stethoscope's earpiece. The infection did not recur after the earpiece was cleansed after each use. In a prospective study, the bacterial flora of 35 earpieces was evaluated. Fifty-three isolates, 36 aerobic or facultative and 17 anaerobic, were recovered. The number of organisms per earpiece ranged from 14 to 204 (average 92 +/- 17). The predominant isolates were Staphylococcus epidermidis (16 isolates), Propionibacterium acnes (12), and Saureus (7). The study demonstrates the colonization of the stethoscope's earpiece with microorganisms that possess the potential for causing nosocomial infection.

Antimicrobial sensitivity in microorganisms isolated from canine otitis externa

It is important to test the antimicrobial sensitivity of the aetiological agents of otitis externa before starting treatment in order to prevent the development of antibiotic resistance in the microorganisms. In this study the sensitivity patterns in bacteria and yeasts isolated as aetiological agents from otitis externa were analysed. Antifungal and antibacterial activity tests were done using the automated system ATB Fungus and the classic diffusion test respectively. The azole compounds had the greatest antifungal properties, while beta-lactams had the strongest antibiotic activity. This study reflects the increasing importance of sensitivity tests in chronic otitis externa due to the increasing antimicrobial resistances in bacteria and yeasts. If it is necessary to initiate an empiric treatment before the results of the antimicrobial test, the application of miconazole or econazole for yeasts and oxacillin or amoxicillin-clavulanic acid against bacteria is recommended.

[Otitis externa among users of private swimming pools]

The purpose of this study was to detect risk factors for developing otitis externa (OE) with special regard to swimming in private pools in holiday houses. Data were collected in a retrospective case-control study from June to October in 1993 and over the same period in 1994. Patients who had OE diagnosed by a general practitioner were included. In 1993 controls were 134 guests from 27 holiday houses where nobody got o.e. during their stay. The number of cases was 35. In 1994 the design was changed so that controls were the 95 healthy inhabitants from the same houses as the 23 cases. The amounts of time spent in the pools and the total bacteria count in the water were significant risk factors for developing OE. Pseudomonas aeruginosa was found in 80% of the ear swabs of the casegroup. In 1993 30% and in 1994 83% of the pools fulfilled the requirements for public pools set by the Danish authorities.

[First isolation of Bilophila wadsworthia in otitis externa]

Bilophila wadsworthia is an obligately anaerobic, gram-negative rod, which was first described in 1989. The natural habitat of this species seems to be the lower intestinal tract where it was recovered from about 60% of the persons investigated. Bilophila wadsworthia is mainly associated with intra-abdominal infections, but the species was also isolated as part of aerobic-anaerobic mixed infections at various extra-abdominal sites. Otological infections due to Bilophila wadsworthia have as yet not been described. In the present paper, we report a case of a patient with postoperative otitis externa following stapedectomy, probably caused by the anaerobes Bacteroides fragilis and Bilophila wadsworthia.

Otomycosis: the detection of fungi in ears by immunofluorescence microscopy

The procedure currently used to diagnose infection in otitis externa has several limitations: it is slow to culture organisms on growth media, fungal infections are often missed, and extensive laboratory facilities and mycological expertise are required. A rapid, accurate and sensitive assay would greatly improve patient care by initiating appropriate antifungal treatment at the onset of disease. We report the development of a rapid detection assay for otomycosis using fungal-specific monoclonal antibodies to detect fungi in ear swabs by immunofluorescence microscopy. This assay could form the basis of a detection assay for fungal infections of the head and neck.