​Kembara Xtra - Medicine - Otitis Externa

​Kembara Xtra - Medicine - Otitis Externa 
An external auditory canal infection:
The most prevalent type, acute diffuse otitis externa, is an infectious condition that is typically bacterial but can occasionally (10%) be fungal. Acute confined otitis externa, also known as furuncle, is a superficial cellulitic form of otitis externa that is connected to an infection of the hair follicle.  Chronic otitis externa: identical to acute diffuse but lasting longer (>6 weeks) Atopic atopic dermatitis and other primary skin disorders may be accompanied by eczematous otitis externa. Necrotizing malignant otitis externa is an uncommon form of swimmer's ear that affects the skin and exocrine system and spreads into the deeper tissues next to the canal, including osteomyelitis and cellulitis.

Epidemiology 

Unknown incidence is higher during the summer and in hot, humid locations. All ages make up the majority.
Acute, chronic, and eczematous conditions are prevalent; necrotizing conditions are unusual.

Pathophysiology and Etiology 
Traumatized external canal due to acute diffuse otitis externa, such as from using a cotton swab.
Pseudomonas (67%), Staphylococcus, Streptococcus, and gram-negative rods make up 90% of the bacteria that are infected. - Aspergillus (90%), Candida, Phycomycetes, Rhizopus, Actinomyces, Penicillium, and fungal infection (10%) Chronic otitis externa: Pseudomonas bacterial infection
Eczematous otitis externa, which is connected to a fundamental skin condition - Psoriasis, eczema, and seborrhea
- Contact dermatitis - Neurodermatitis
- Otitis media with purpura
Necrotizing otitis externa - Sensitivity to topical treatments - Invasive bacterial infection: Pseudomonas, rising prevalence of methicillin-resistant MRSA Staphylococcus aureus is linked to immunosuppression

Acute and chronic otitis externa are risk factors. - Injury to the external canal
- Swimming - Humid, hot temperatures - Using hearing aids
 Necrotizing otitis externa in infants (rare) Eczematous: main skin problem Necrotizing otitis externa in adults - Advanced age - Diabetes mellitus (DM) - Debilitating disease - AIDS, immunosuppression Leukopenia, malnutrition, diabetes insipidus, and DM

Basic Prevention 
Use preventive antiseptics, such as acidifying solutions with 2% acetic acid [white vinegar] diluted 50/50 with water or isopropyl alcohol or 2% acetic acid with aluminum acetate [less irritating], after swimming and bathing. Avoid extended contact to moisture.
 Manage underlying skin issues.
Get rid of foreign things like cotton swabs and other self-inflicted harm to the canal.
 Address fundamental systemic issues.
 When swimming, earplugs

Diagnosis 

history of ear pain, discharge, and ear plugging that has lasted for a while

Visual Inspection 
Pain when manipulating the pinnae; purulent discharge and debris in the ear canal; a possible periauricular adenitis; and possible pinna eczema.
 Extremely unusual involvement of the cranial nerves (VII, IX through XII)

Differential diagnoses include basal cell or squamous cell cancer, necrotizing otitis externa, otitis media with perforation, and cranial nerve (VII, IX through XII) palsy.

Laboratory Results 

Gram stain and culture of canal discharge (rarely beneficial) - Pretreatment with antibiotics may impact outcomes.
 High-resolution CT scan, MRI, gallium scan, and bone scan for radiologic assessment of deep tissues in necrotizing otitis externa Interpretation of Tests
 Eczematous otitis externa: pathologic findings consistent with primary skin disorder; secondary infection occasionally Necrotizing otitis externa: vasculitis, thrombosis, and necrosis of involved tissues; osteomyelitis Acute and chronic otitis externa: desquamation of superficial epithelium of external canal with infection

Cleaning the external canal may help with management and recovery.
Analgesics as needed for discomfort, eczema-specific antihistamines and antipruritics, and an ear wick (Pope) to help antibiotic droplets penetrate nearly-occluded ear canals

Data from drug trials are typically of poor quality and may not be entirely applicable to settings for basic care.
● The most prevalent bacterium is pseudomonas, which is more vulnerable to fluoroquinolones like ciprofloxacin or ofloxacin and has a rising resistance to aminoglycocide.
Both fluoroquinolone and polymyxin B combinations can kill Staphylococcus. Change the antibiotic class and take cultures and sensitivities into consideration if a patient has recurrent episodes or does not get well in 2 weeks.
● Although there is no proof that applying a topical antibiotic together with a corticosteroid boosts the overall cure rate, there is evidence that doing so reduces the time it takes for symptoms to go away. There isn't enough proof to show that one antibiotic regimen is unquestionably better than another.
● Only in cases with concomitant otitis media are oral antibiotics recommended. Oral antibiotics by themselves are ineffective and significantly raise the risk of developing into chronic otitis externa.
 Painkillers as required.
● Applying equal volumes of white vinegar and isopropyl alcohol (over-the-counter [OTC] rubbing alcohol) to the external auditory canals after bathing and swimming can help avoid recurrent otitis externa.
All topical quinolone antibiotics may increase the incidence of tympanic membrane perforation, according to newly available information.


Initial Line

A wick may be beneficial in severe cases of acute bacterial and chronic otitis externa by keeping the canal open and maintaining antibiotic solution in contact with infected skin.
- Ofloxacin 0.3% solution (cheap generic) or ciprofloxacin 0.3% and dexamethasone 0.1% suspension (expensive brand): 4 drops BID for 7 days. 10 drops used once day for seven days; claimed reduced ototoxicity and antibiotic resistance- 5 drops QID of neomycin/polymyxin B/hydrocortisone (generic Cortisporin). Use the suspension if the tympanic membrane is broken; otherwise, use the solution. The solution may cause ototoxicity and may cause Staphylococcus and Streptococcus sp. to acquire resistance.
- Hydrocortisone and 2% acetic acid 1%: 3 to 5 drops every 4 to 6 hours for 7 days; mild local stinging may occur. a reasonable generic. This works just as well as polymyxin B and neomycin. The symptoms may disappear after a further 2 days.
Topical treatment for fungal otitis externa, anti-yeast medication for yeast or Candida Acetic acid at 2% 3 to 4 drops QID, 1% clotrimazole solution, and oral itraconazole Amphotericin B for parenteral antifungal therapy Ramsay Hunt syndrome patients IV acyclovir
Eczematous external otitis: topical treatment Aluminum acetate (5%; Burow solution) and acetic acid, each at a concentration of 2% each
- Creams, lotions, and ointments containing steroids (such as triamcinolone 0.1% solution). - If superinfected, antibacterial
Necrotizing external otitis
- Parenteral antibiotics for pseudomonas and staphylococci - 4 to 6 weeks of treatment
- Second Line Fluoroquinolones PO for 2 to 4 weeks
Chronic and acute bacterial otitis externa
Without the risk of ototoxicity or antibiotic resistance, betamethasone 0.05% solution may be just as effective as a polymyxin B combination. However, the statistics are not very reliable, necessitating further research.
Antifungal azoles for fungal otitis externa

instances that are difficult to refer or those that require surgery

Necrotizing otitis externa or furuncle surgical procedures


Alternative Therapies 
3 drops of OTC white vinegar in the affected ear for mild cases
Tea tree oil has been used as an antiseptic in a variety of concentrations. At very high doses, ototoxicity has been shown in animal experiments.
Various amounts of grapefruit seed extract have been touted as helpful in lay literature.

Admission 

Otitis medium with necrosis that needs parenteral antipseudomonal medications

Patient Follow-Up Monitoring
Chronic otitis externa may require changes to topical medications, such as antibiotics and steroids, every two to three weeks for repeated canal cleaning. Necrotizing otitis externa: Baseline auditory and vestibular testing at the start and conclusion of treatment; daily inpatient surveillance for infection spread

Acute otitis externa prognosis: fast response to treatment and complete resolution Chronic otitis externa: The majority of patients will improve with regular cleaning and antibiotic treatment.
In some circumstances, surgical intervention is necessary for stubborn cases.
Eczematous otitis externa: Recovery will happen after the underlying skin problem is under control.
When treatment is insufficient, the recurrence rate for necrotizing otitis externa is 100%. Usually, débridement and antipseudomonal antibiotics help control this condition. In cases that are resistive or when cranial nerves are involved, surgery may be required. The high mortality rate is likely a result of the underlying illness.


Complications 
Necrotizing otitis externa has the potential to extend to nearby bone and CNS tissues.
Chondritis may result from the spread of acute otitis externa to the pinna.

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