OTITIS MEDIA AND OTITIS EXTERNA IN ADULTS
Jeff Stein, M.D.
WEEK 11: 03/14 – 03/18/05
Learning Objectives:
1. Describe diagnostic features, and a short differential diagnosis of, otitis
media and otitis externa in adults
2. Prescribe appropriate therapy for uncomplicated cases of otitis media or
externa
3. Recognize more serious variants or complications of these conditions
Author’s Note:
Acute otitis media (AOM), the most common type of “ear infection” in children, is
much less frequent in adults for a variety of reasons including evolution of
eustachian tube anatomy, decreased frequency of viral URI’s, etc. There is
correspondingly much less literature on this problem in adults; the clinical
approaches described in most references are often extrapolated from those in
children. Nonetheless, you are likely to encounter both otitis media and otitis
externa in adult patients.
CASE ONE:
A 25-year-old woman presents with unilateral ear pain of several hours duration.
The pain has now developed after several days of a viral URI, characterized by
nasal congestion and mild cough. It’s worse with swallowing. The patient has no
associated dizziness or fever, but the ear “feels like it’s blocked.” PMHx reveals no
major medical problems. There is no history of recent ear trauma or infections,
though she had many of the latter as a child.
Questions:
1. Assuming the remainder of the exam is normal in each case, describe your
clinical impression and management plan if the ear exam shows:
a. An intact, patent ear canal and the tympanic membrane have a dull
appearance, with clear fluid and a couple of small bubbles visible
through the TM in the middle ear.
This patient has a middle ear effusion; the effusion and associated
symptoms may be the result of virus-associated eustachian tube
inflammation and dysfunction +/- a viral infection of the middle ear. Early
bacterial otitis media is a possibility, but a trial of an analgesic alone
(such as an NSAID) would be reasonable, with re-evaluation as needed if
symptoms persist.
b. An intact, patent ear canal with a red, bulging tympanic membrane
and opaque fluid behind it
This is a classic constellation of findings for acute suppurative otitis
media caused by bacterial superinfection of a stagnant middle ear effusion
(see above).
The usual therapeutic approach involves prescription of oral antibiotics.
Theoretically, these would be chosen to cover the most likely pathogens.
[Ask what these are] Answer= Strep. pneumoniae, non-typable
Hemophilus influenzae, moraxhella catarrhalis, and less often, Strep.
pyogenes or Staph. aureus]. In practice, amoxicillin is often used initially,
even though some H. influenza and most Moraxella catarrhalis are betalactamase positive and resistant in-vitro. This approach often works
anyway due to the high spontaneous cure rate, even without treatment.
[Refer housestaff to the Cochrane Database of Systematic Reviews- those
on otitis media therapy fail to describe much benefit, although most of the
data is from children.] First-line alternatives would also include
TMP/SMX, second-generation cephalosporins, later-generation
macrolides, and amoxicillin/clavulanic acid.
Non-antibiotic therapies such as decongestants, directed at the eustachian
tube dysfunction, have also been tried, but have not been shown to be
effective in treating the infection itself.
c. Tympanic membrane as in (b) and the ear canal have some mild
swelling and erythema along the posterior wall. There is also some
mild postauricular erythema, swelling, and tenderness, and
questionable slight protrusion of the pinna compared with the
contralateral ear.
The external and periauricular features here, including displacement of
the auricle, indicate acute infectious mastoiditis complicating the picture
of acute otitis media. The prominent tympanic membrane and
auricular/periauricular findings relative to the limited canal involvement
also serve to distinguish this from otitis externa. While the mastoid air
cells, contiguous with the middle ear, often develop subclinical
inflammation/infection in AOM, clinically evident mastoiditis, as in this
case, is a serious problem that may require hospitalization, parenteral
antibiotics, and otolaryngology should be consulted promptly.
d. An intact, patent ear canal with dull tympanic membrane (TM)
containing patches/plaques of embedded white material
The white material is a “red herring” (no pun intended!)- it represents
tympanosclerosis, a common scar-like sequella of recurrent otitis media. It
would not be expected to cause her symptoms. This patient may have
eustachian tube dysfunction as in part (a).
CASE TWO:
A 55-year-old man presents with unilateral waxing/waning ear pain for the past
week. He had a URI a few weeks ago, but most of his symptoms resolved except for
some frontotemporal headaches. When seen by you three months ago for a routine
physical exam, he had an asymptomatic middle ear effusion on that same side.
2. Describe your clinical impression and plan if ear exam today showed:
a. Normal landmarks and anatomy
The absence of middle ear findings should raise index of suspicion for
referred pain from other head/neck problems (e.g. TMJ dysfunction,
sinusitis, dental problems), and further evaluation focused on these
possibilities.
b. Findings similar to Case 1(a)
A persistent middle ear effusion, while possibly residual from a recent
URI, should raise the possibility of other causes. Most concerning, though
not common, is the possibility of an occult head/neck tumor in an adult. If
unrelenting, ENT consultation would be advisable.
CASE THREE:
A 78-year-old woman presents with a several-day history of progressively worsening
unilateral ear discomfort. She wears a hearing aid on that side. She has no history of
ear trauma or infection; in fact, she prides herself on the clean state of her ears,
maintained through regular swabbing with Q-tips.
3. Describe your clinical impression and therapeutic approach to a patient like
this in each of the following scenarios:
a. There are no other symptoms, and no other medical problems. There
is no discomfort on retraction of the pinna. The ear canal is partially
covered by some yellowish material with black dots. The tympanic
membrane is dull, but otherwise unremarkable. The periauricular
exam is normal.
This patient has a mild otitis externa likely due to superficial fungal
infection. Gentle removal of visible fluid/debris (accomplished in the
generalist’s office with cotton swabs and/or irrigation) is recommended
routinely in cases of otitis externa. In addition, topical application of
acetic acid (e.g. VoSol), boric acid drops, Burow’s solution (aluminum
acetate in water, an astringent) and alcohol rinses; and perhaps topical
anti-fungal drops would be helpful here.
b. There are no other symptoms, and no other medical problems. There
is minimal discomfort on retraction of the pinna. The ear canal is
erythematous along part of its circumference, with some flaky yellowgreen material along the inferior aspect, but a clear view of the
tympanic membrane (dull but otherwise unremarkable). The
periauricular exam is normal.
This is a case of localized acute otitis externa, likely caused by bacterial
superinfection. [Ask which pathogens are usually involved:
answer=pseudomonas aeruginosa or staph aureus]. In addition to gentle
removal of debris, mild cases like this may resolve with topical
antibiotic/anti-inflammatory drops (e.g. Cortisporin, or Cipro-HC) alone.
c. She has nasal congestion and a cough, but is otherwise healthy. There
is minimal discomfort on retraction of the pinna. The ear is draining
yellowish fluid that precludes adequate examination of the canal or
tympanic membrane. The periauricular exam is normal.
In the absence of visible canal inflammatory changes or significant pain
on pinna retraction, a canal filled with purulent fluid may present
confusion between otitis externa, and otitis media with tympanic
membrane perforation. In the acute setting, the latter is sometimes
associated with RELIEF of pain. But where differentiation is difficult, you
may need to treat empirically for both. Historically, this was often done
using a broad-spectrum oral antibiotic, e.g. amoxicillin-clavulanic acid or
perhaps a respiratory-pathogen-effective quinolone. In recent years, it has
become apparent that many topical (otic drops) antibiotics can be used
safely (particularly the quinolones) even in the presence of a TM
perforation (where the drops would wash into the middle ear
compartment).
d. As in (c), except that there is moderate pain on retraction of the pinna,
which is not protruding at rest. The ear canal is swollen and
erythematous for the short distance that is visualizable before the
lumen is blocked by wet yellowish curdlike material in the lumen.
A case of diffuse acute otitis externa. In addition to superficial
aspiration/swabbing to remove visible purulent material, instillation of
topical antibiotic/anti-inflammatory drops using indwelling cotton wicks
may be necessary to penetrate the medial aspect of the canal. Oral
antibiotics effective against the likely pathogens [again, (staph aureus and
pseudomonas most frequently) may be needed, such as quinolones. Close
follow-up, within 1-2 days initially, would be important to ensure
response/resolution.
e. As in (d), but the patient has severe pain and a fever, and has
underlying diabetes mellitus.
No discussion of adult infectious ear problems would be complete without
mention of necrotizing (“malignant”) otitis externa, an uncommon but
very serious infectious (not neoplastic!) complication to which patients
with diabetes or other immunosuppressive conditions are more
susceptible. Other worrisome features might include red granulation
tissue visible in the canal, extension of cellulitis onto the auricle, and/or
an ipsilateral facial nerve palsy. A more aggressive approach is required
for necrotizing OE- the patient should be hospitalized, parenteral
antibiotics initiated [same pathogens as in diffuse OE]; and
otolaryngology consulted emergently.
4. What advice would you give to a patient to prevent otitis externa?
Practices or activities in adults that predispose to otitis externa include:
a. Foreign-body insertion, esp. cotton-tipped swabs for cleaning the ear
(disrupts the ear’s usual self-cleansing mechanisms, pushes debris deeper,
and can abrade the delicate skin lining the canal). This practice should be
discouraged in everyone!
b. Frequent swimming (hence the common lay term “swimmer’s ear”).
Swimmers should ensure adequate drying of the ear canal afterwards.
This may be accomplished with alcohol drops. Some have also used hair
blow dryers.
c. Usage of a hearing aid. These may need to be removed when not in use.
CASE FOUR:
A 49-year-old woman presents with several weeks of malodorous, unilateral ear
drainage that has not improved despite treatment with a course of amoxicillin and a
course of cefaclor, prescribed at two different walk-in clinic visits. Ear exam is
notable for normal external structures, absence of pain on pinna retraction, but
inability to view into the canal because of purulent fluid.
5. Describe your clinical impression and plan.
This description suggests chronic suppurative otitis media. This is usually
associated with a non-healing TM perforation. In addition to involvement of a
different spectrum of bacteria (including aerobes, anaerobes, non-respiratory
gram negatives), there may be an underlying cholesteatoma (a non-malignant but
locally invasive/destructive squamous epithelial overgrowth that can cause
permanent damage/hearing loss). Topical antibiotics similar to those discussed in
Case 3c. (quinolones) could be tried. However, ENT consultation would also be
prudent.
CASE FIVE – EXTRA CREDIT:
A previously healthy 65-year-old man presents with lancinating right ear pain for
the past two days. He feels like his speech is slightly slurred, his tongue and
ipsilateral eye feel “funny.” He has a mild right facial droop, and vesicles in the
right ear canal, which is otherwise unremarkable.
6. What does this patient have?
A case of Ramsay-Hunt syndrome, i.e. herpes zoster oticus, from “shingles” in the
distribution of cranial nerve VII, giving rise to a peripheral facial nerve palsy.
Specifics of treatment (e.g. acyclovir +/or steroids +/or surgical decompression)
have been controversial. However, in view of the substantial rate of permanent
deficit, it may be prudent to consult otolaryngology.
References:
rd
1. Otologic Infections.Textbook of Primary Care Medicine, 3 edition. John Noble
MD (Editor-in-chief). Mosby, 2001:1731- 1736.
2. Glasziou, PP. Del Mar, CB. Sanders, SL. Hayem, M. Antibiotics for acute otitis
media in children. Cochrane Database of Systematic Reviews 2004;3.
Additional References:
1. Otitis Externa. Up-To-Date. Dec.3, 2004.
2. Also worth consulting “on the fly” in clinic are the chapters in Barker’s Principles
of Ambulatory Medicine, 6th edition, and Goroll’s Primary Care Medicine
textbook.