Otitis externa in UK general practice: a survey using the UK General Practice Research Database

BACKGROUND

Otitis externa is a common clinical problem in general practice and yet there are remarkably few data available on the demographic characteristics of patients with this condition and the approaches used by general practitioners (GPs) in the United Kingdom (UK) to manage it.

AIM

To define the descriptive epidemiology of otitis externa in the general population, to describe the first-line drug treatment used by UK GPs, and to determine factors related to second disease episodes.

DESIGN OF STUDY

Epidemiological data survey.

SETTING

All cases of otitis externa occurring in 1997 in practices contributing data to the UK General Practice Research Database.

METHOD

Data were extracted on age, sex, date of episode of otitis externa, treatment prescribed, co-existing diagnoses of eczema and diabetes, referral to ear, nose, and throat departments and occurrence of subsequent episodes of disease. Arbitrarily a second episode of disease was defined as persistence if it occurred at 28 days or fewer after the first episode and recurrence if it occurred at more than 28 days after the first episode.

RESULTS

A diagnosis of otitis externa was common in all age groups and, except in the elderly, was more common in females than males. There was an increase in disease episodes at the end of the summer in all age groups except the 60 years and over group. In the majority of cases GPs prescribed ear drops (85%), but a significant proportion of patients were also prescribed oral antibiotics (21%). Referral to secondary care was uncommon (3%). Among patients prescribed ear-drop formulations, those containing both steroid and antibiotic or steroid alone were used most commonly and were associated with the lower rates of disease persistence but not recurrence. Among patients prescribed antibiotics, penicillins were prescribed most commonly. Disease persistence rates, and to a lesser extent disease recurrence rates, were higher in patients prescribed oral antibiotics.

CONCLUSION

Otitis externa is a common condition and GPs can expect to see an excess of cases at the end of the summer. Topical ear drops are the most common treatment used in the UK. Patients prescribed steroid or steroid/antibiotic combination ear drops have fewer subsequent consultations for otitis externa over the following 28 days.

Ceruminolytic efficacy in adults versus children

OBJECTIVES

An inexpensive, nontoxic ceruminolytic with reasonable efficacy that can be used by the patient or their caregivers at home could represent significant financial saving for patients and health care systems. The purpose of this study was to compare two simple ceruminolytics for in vitro efficacy.

STUDY DESIGN

Randomized controlled trial.

METHODS

Thirty-six children and 33 adults presenting to a community family practice clinic who had cerumen occluding at least one external auditory canal were randomly assigned to compare use of 10% aqueous sodium bicarbonate and 2.5% aqueous acetic acid as ceruminolytics in occlusive cerumen.

RESULTS

We were unable to demonstrate a difference between in vivo efficacy of these two ceruminolytic solutions, but both solutions were significantly more efficacious in children than adults.

CONCLUSIONS

There is a role for these ceruminolytics in children with occlusive cerumen, but adults would be better treated in another way.

Chronic external otitis

Chronic external otitis is probably a disease of mixed etiology; infection and hypersensitivity both play an important role. As such, these two components must be recognized and respected. Steroids are the mainstay of medical management. Antibiotics should be used cautiously and probably on an intermittent basis. The disease appears to be exacerbated by any manipulation of the canal, including aggressive cleansing. Medical therapy will slow the development of fibrosis in some cases, but it does not always prevent it. Once stenosis has progressed to the point that conductive hearing loss develops, surgery will restore hearing and prevent restenosis in at least 80% of cases.

A case of feline otitis externa due to Microsporum canis

We describe a case of a 3-month-old Persian male cat with a persistent waxy, ceruminous, otic discharge in both external auditory canals. After microbiological culture, only Microsporum canis was isolated with no concurrent fungal or bacterial flora. Fungal otitis due to dermatophytes was diagnosed and specific treatment with griseofulvin was administered. After 4 weeks of treatment, no M. canis colonies were isolated and clinical recovery had occurred. In view of this case, dermatophytosis should be included in the differential diagnosis of feline otic conditions, particularly when otitis becomes chronic or is refractory to treatment.

Otitis externa: a practical guide to treatment and prevention

Otitis externa is most commonly caused by infection (usually bacterial, although occasionally fungal), but it may also be associated with a variety of noninfectious systemic or local dermatologic processes. The most characteristic symptom is discomfort that is limited to the external auditory canal, while the most characteristic signs are erythema and swelling of the canal with variable discharge. Excessive moisture and trauma, both of which impair the canal's natural defenses, are the two most common precipitants of otitis externa, and avoidance of these precipitants is the cornerstone of prevention. Thorough cleansing of the canal is essential for diagnosis and treatment, but flushing should be avoided. Acidification with a topical solution of 2 percent acetic acid combined with hydrocortisone for inflammation is effective treatment in most cases and, when used after exposure to moisture, is an excellent prophylactic. Other prophylactic measures such as drying the ears with a hair dryer and avoiding manipulation of the external auditory canal may help prevent recurrence.

Comparative analysis between Pseudomonas aeruginosa genotypes and severity of symptoms in patients with unilateral or bilateral otitis externa

Random amplified polymorphic DNA (RAPD) analysis was done on 32 isolates of Pseudomonas aeruginosa. These isolates were obtained from 22 patients who presented to the emergency room in a major medical center in Beirut, Lebanon, during a 5-month period with the diagnosis of either unilateral or bilateral otitis externa. Patients had yellowish to greenish discharge, moderate to severe external auditory canal swelling, moderate to severe pain, and periauricular cellulitis. None of these patients had intrinsic predisposing factors. An ear swab was obtained from both ears of patients, cultured on trypticase soy agar. P. aeruginosa was identified on the basis of pyocyanine production and API identification kits. RAPD analysis was done by using two primers (10 mer and 21 mer primers) and appropriate PCR conditions on extracted DNA. Our data have shown 23 RAPD patterns (A-W) distributed among the 32 P. aeruginosa isolates. RAPD patterns were reproducible. Twenty of 32 isolates were recovered from 10 patients with bilateral otitis externa. The remaining 12 of 32 isolates were recovered from 12 different patients with unilateral otitis externa. Eleven RAPD patterns (A,B,C,D,E,F,H,I,R,U,V) were associated with severe clinical symptoms, including severe pain, severe external auditory canal swelling, periauricular cellulitis, and a yellowish discharge. The remaining RAPD patterns were not associated with severe infections. This denotes a possible association between certain genotypes and severity of symptoms.

[Treatment of therapy refractory chronic otitis externa by local injection of triamcinolone acetate crystalline suspension. Initial experiences]

BACKGROUND AND OBJECTIVE

External otitis is characterized by otalgia, otorrhea, itching, and hearing loss. Treatment usually consists of local application of corticosteroids and antibiotics. Chronic external otitis is accompanied by thickening of the skin in the external auditory channel. This reduces the effect of the applied substances. Local injection of suitable drugs may support the conservative treatment. The aim of the study was to evaluate the efficacy of local injection of triamcinolone acetonide in the external auditory channel.

PATIENTS/METHODS

Thirteen patients with external otitis resistant to conservative treatment received an injection of triamcinolone acetonide in the external auditory channel. The improvement achieved was assessed by clinical examination and questionnaires.

RESULTS

The symptoms improved substantially in all patients; most of the patients were cured completely.

CONCLUSIONS

Our results demonstrate that local injection of triamcinolone acetonide is effective in the management of chronic external otitis.

Otitis externa sicca/fibrotising external otitis (FEO) as a complication of Sjögren's syndrome

Sjögren's syndrome (SS) is a condition characterized by sicca symptoms and by autoimmune features. We describe two SS patients with otitis externa fibroticans/sicca. One of these 2 patients developed a lesion of the tympanic membrane making it necessary to perform a tympantomy and meatoplasty. Our findings suggest firstly that the epithelial cell-mediated secretion of lamellar bodies and the production of the permeability barrier are defective in SS. Secondly, local moisturing and/or topical corticosteroid treatment in SS patients with sicca symptoms in the auditory canal could help to avoid reconstructive surgical treatment.

[Malignant or necrotizing otitis externa: experience in 22 cases]

Malignant or progressive necrotizing otitis extrema is an uncommon but severe infectious condition of the external auditory canal. Over a period of four years, we treated 22 patients: 60% had diabetes (1/4 insulin dependent) and 13% were immunodepressed. The causal germ was Pseudomonas aeruginosa in 87% of cases. The pretherapeutic work-up included a computed tomography scan and a technetium scintigraphy to confirm diagnosis and assess extension. Repeated scintigraphies with gallium were used to follow the course under treatment. Medical treatment was used in most cases (16/22) with parenteral antibiotic therapy using a third-generation cephalosporin (ceftazidime or ceftriaxone) and a fluoroquinolone (ciprofloxacin or ofloxacin) and, if there was no contraindication, hyperbaric oxygen. Surgery is not indicated in malignant otitis externa. We had a 95% cure rate with only 10% recurrence. We reviewed the data in the literature on malignant otitis externa and present the important diagnostic, imaging and therapeutic aspects.

[Malignant external otitis: a rare complication after autologous bone marrow transplantation]

We present a case of 39 year old woman who developed malignant external otitis (m.e.o.) of Pseudomonas aeruginosa aetiology during pancytopenia after autologous bone marrow transplantation (ABMT). The infection was probably of endogenous origin. 7 days before ABMT otolarygological examination including otoscopy and external ear lavage was performed. Slight inflammatory reaction of external ear was accompanied by the massive involvement of middle ear followed by infiltration of petrous pyramid and mastoid process and finally facial and vestibulocochlear nerve paralysis. Initially the symptoms indicated subarachnoid haemorrhage. Mononuclear cells detected in cerebrospinal fluid as well as CT scan were suggestive of leukaemic infiltration. The latter was negated by immunophenotyping of cerebrospinal fluid cells and MR imaging. Antibiotic therapy resulted in clinical improvement. Life-threatening complications are not frequent after ABMT (transplant related mortality--14/310 (4.5%) in our center). We have met m.e.o. for the first time. At present--13 months after ABMT the patient shows slight symptoms of nerve VII and VIII paresis and remains in complete remission of acute leukaemia. We emphasize the importance of proper preparation of patients for high dose chemotherapy followed by bone marrow transplantation as well as diagnostic difficulties related to pancytopenia.

Granular myringitis: is it a surgical problem?

OBJECTIVE

An attempt to settle the controversies associated with granular myringitis (GM) including incidence, etiology, pathology, presentation, relation to chronic otitis media, and treatment.

STUDY DESIGN

Retrospective.

SETTING

Tertiary referral center and private otology practice.

PATIENTS

94 patients presenting with GM over 28 years.

INTERVENTION

Diagnosis by otoscopy, audiometry, radiology, and bacteriology; long-term follow-up (6 months to 12 years); assessment of treatment results.

MAIN OUTCOME MEASURES

The pathologic states of the affected tympanic membranes were studied in both active and quiescent stages. The results of conservative versus surgical management were evaluated.

RESULTS

The disease presents with chronic painless otorrhea, normal hearing and mastoid pneumatization, and granular areas, which may be patchy, diffuse, or segmental. The latter is the most frequent and is most commonly posterosuperior. The infecting organism is Pseudomonas aeruginosa. The pathologic process affects all drum layers and can cause a perforation. The most important predisposing factor is disturbed epithelial migration, which may be exaggerated by eustachian tube dysfunction. Of 26 cases treated conservatively, none healed without recurrence. Of 48 cases treated surgically, there were 2 recurrences.

CONCLUSIONS

Pathologically, the disease affects all drum layers. It presents with an active stage, which may be misdiagnosed as chronic otitis media or cholesteatoma, and a quiescent stage when it may be overlooked. Although distinct from chronic otitis media, it can cause a perforation. The disease responds readily to medical treatment, but recurrence is common. Radical surgery offers a curative measure in refractory cases.

[Malignant otitis externa and diabetes: report of 4 cases]

Malignant otitis externa (MOE) is an uncommon infective but potentially fatal entity caused by Pseudomonas aeruginosa. It involves almost exclusively advanced aged diabetic patients. We report here four cases diagnosed at our hospital during the last 7 years. Clinical manifestations included otalgia, purulent otorrhoea, involvement of different cranial nerves and bony destruction; one patient died because of bronchoaspiration and two are alive but with sequelae. MOE should be suspected in every diabetic patient with otitis which goes unresolved with the usual antibiotic therapy. On the other hand, facial palsy should not always be attributed to a diabetic mononeuropathy and the presence of MOE should be ruled out when otitis coexists or precedes it.

A case of malignant otitis externa following mastoidectomy

We present a case of a 63-year-old diabetic male who developed malignant otitis externa following mastoidectomy. Extensive skull base osteomyelitis caused thrombosis of the jugular bulb and subsequent paralysis of cranial nerves VII, IX, X and XII. He was treated aggressively with intravenous antibiotics and debridement of granulation tissue in the mastoid bowl with full recovery of the cranial nerve palsies associated with recanalization of the jugular bulb. We believe this is the first reported case of malignant otitis externa to occur following mastoidectomy with complete recovery of the cranial nerve paresis.

Use of infrared thermography to detect inflammation caused by contaminated growth promotant ear implants in cattle

OBJECTIVE

To compare the infrared thermographic appearance of bovine ears that had received contaminated growth promotant implants with ears that had received clean implants and ears without implants.

DESIGN

Prospective study.

ANIMALS

32 yearling crossbred beef steers with a mean weight of 322 kg (708 lbs).

PROCEDURE

Contaminated (n = 16) and clean (16) implants were placed in the ears of feedlot cattle. Nonimplanted (n = 32) ears served as a within-animal control for thermographic comparisons. Images of rostral and caudal surfaces were obtained during a 21-day period, using an infrared thermal imaging radiometer. Repeated measures ANOVA was used to determine the relationship between mean temperature in a zone on the rostral surface of the ear and at 3 locations (proximal, middle, distal) on the caudal surface of the ear (response variables) with treatment (ears with contaminated implants or clean implants vs control ears with no implants), time (repeated day of measurement), and interactions among these variables.

RESULTS

Significant temperature differences existed between ears with contaminated implants and control ears. Temperatures for ears with clean implants were significantly higher than control ears on day 2. At low ambient temperatures when the ears became wet, a greater temperature contrast was detected between ears with contaminated implants and control ears.

CONCLUSIONS AND CLINICAL RELEVANCE

Thermal imaging of the ears of feedlot cattle is a noninvasive diagnostic tool that can be used to identify cattle with abscesses caused by contaminated growth-promotant implants.

Effects of ear type, sex, age, body weight, and climate on temperatures in the external acoustic meatus of dogs

OBJECTIVE

To investigate effects of ear type, sex, age, body weight, and ambient climatic conditions on external acoustic meatus (external ear canal) temperatures in dogs.

ANIMALS

650 dogs without clinical signs of ear disease.

PROCEDURE

Dogs were assigned to 5 groups on the basis of auricular conformation and amount of hair in the external ear canal and 4 groups on the basis of body weight or age. External ear canal temperatures (EECT) were measured, using an infrared thermometer. Mean EECT determined for each group were compared to evaluate effects of ear type, age, weight, and sex, and EECT measured at different ambient temperatures and humidities were compared to determine climatic effects.

RESULTS

Dogs with hirsute ear canals had significantly lower EECT than dogs with hairless ear canals, whereas significant differences were not detected between dogs with erect and pendulous auricles. Dogs < 6 years old had higher EECT than older dogs, and dogs that weighed < 6 kg had lower EECT than larger dogs. External ear canal temperatures measured when ambient temperatures were < 25 C were less than those measured at warmer temperatures. Sex and relative humidity did not affect EECT CONCLUSIONS AND CLINICAL RELEVANCE: EECT of dogs without ear disease were affected by weight and age, amount of hair in the external ear canal, and ambient temperature. However, hirsute ears had lower, not higher, EECT than hairless ears, suggesting that EECT may play less of a role in the development of otitis externa than believed.

[Malignant external otitis: 4 cases report]

OBJECTIVE

To improve the level of diagnosis and treatment of malignant external otitis (MEO).

METHOD

Four cases with MEO were reported.

RESULT

Three in four cases were followed up. One patient was cured, and the others died of intracranial infection.

CONCLUSION

Early diagnosis of MEO is very important for treatment. The patients of MEO with diabetes often died of intracranial infection.

When is a biopsy justified in a case of relapsing polychondritis?

Relapsing polychondritis (RP) is a relatively rare rheumatic condition of unknown aetiology. It is characterized by recurrent episodic inflammation of cartilaginous structures (nose, ear and trachea). The clinical diagnosis of polychondritis can frequently be made with confidence in the absence of histological confirmation. A 61-year-old diabetic man, with bilateral relapsing aural inflammation, left ear deafness with tinnitus and pain at the sternocostal junctions is reported. After clinical diagnosis of relapsing polychondritis steroid therapy was started. An ear cartilage biopsy was performed confirming the clinical diagnosis. Subsequently soft tissue infection occurred at the operation site. The abscess was drained and oral ciprofloxacin was given with complete resolution of the infection over 30 days. As the infection is the main cause of death in these patients, we analyse whether biopsy is absolutely necessary for the diagnosis of RP in some patients.

Long-term morbidity from Pope Ear Wicks

Images