Professional Documents
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Case Report:
Otitis
Externa
Clinical Rotation
Department of Otorhinolaryngology-Head and Neck Surgery
Faculty of Medicine, Universitas Gadjah Mada
Group 17205
P A G E 2
ACKNOWLEDGEMENT
Residence in Department of Head, Nose, Throat, and Surgery on Head and Neck
Presenting Team:
Agustian Winarno P 16/411540/KU/19775
Amima Meiza Azzyati 16/411516/KU/19780
Dicky Yulianda 16/411540/KU/19804
Erinda Maharani Rambu 16/411548/KU/19812
Karina Umma 16/411574/KU/19838
Naufal 16/411598/KU/19862
P A G E 3
Introduction
• Otitis externa is inflammation of the external ear canal (EAC)
that can be acute or chronic caused by bacterial, viral and
fungal infection (Rosenfeld et. al., 2014).
• Acute diffuse otitis externa is the most common form of OE,
usually involves 2/3 inner part of EAC, with edema and
hyperemic EAC (Rosenfeld et. al., 2014).
• The annual incidence of AOE is between 1:100 and 1:250 of the
general population (Wipperman, 2014)
P A G E 4
Introduction
• Nearly all (98%) AOE in North America is bacterial. The most common
pathogens are Pseudomonas aeruginosa and Staphylococcus aureus often
occurring as a polymicrobial infection (Rosenfeld et. al., 2014)
• The risk factor of OED is living in warmer, humid climates and swimming,
increased moisture in the ear canal, loss of protective cerumen, and trauma
to the ear canal (Schaeffer and Baugh, 2012)
• The mainstays of treatment for AOE include pain control, treatment of
infection, and avoiding precipitating factors (Wipperman, 2014)
P A G E 5
Otitis Externa
(Swimmer’s Ear)
P A G E 11
Definition (Schaeffer and Baugh, 2012)
Etiology
(Schaeffer and Baugh, 2012)
Epithelial Cerumen
migration
Symptom
• Ear pain s
• Itching
• Fullness with
or without
hearing loss
or jaw pain
Symptoms and Sign (Schaefer and Baugh, 2012)
• Inspection:
Sig Ear canal
edema/erythema with
n or without otorrhea
• Palpation:
tenderness of
tragus/pinna, local
lymphadenitis
• Otoscopy:
Canal Edema
Tympanic membrane
erythema
P A G E 19
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
(Wippermen, 2014)
P A G E 21
Supporting Examination
mostly redundant, except for patient with immunocompromised
immune system/complication (Schaefer and Baugh, 2012)
Externa
P A G E 22
Treatment
1. Preinflammatory
Prevention
Removing cerumen
The use of acidifying ear drops shortly
before swimming, after swimming, at
bedtime, or all 3 times
The use of earplugs while swimming
The avoidance of trauma to the external
auditory canal helps to prevent otitis
externa diffuse.
(Johnson and Rosen, 2014; Rosenfeld et al.,
2014)
P A G E 24
2. Acute inflammatory
Aural toilet :
1. Hydrogen peroxide
2. Saline solution
3. Body-temperature
water
Antibiotic topical
Analgesic
(Rosenfeld et. al., 2014)
P A G E 25
3. Chronic Inflammatory
Systemic antibiotics –
Ciprofloxacin
Aural toilet :
1. Hydrogen peroxide
2. Saline solution
3. Body-temperature water
Antibiotic topical
Analgesic
(Rosenfeld et al., 2014)
Aural Toilet & Cerumen Excavation P A G E 26
• Main treatment:
Topical Antimicrobials w/ or w/o topical corticosteroids
e.g. Aminoglycosides, Polymyxin B, quinolones, acetic
acid
• Topical Corticosteroids
More rapid improvement in symptoms such as pain,
canal edema and erythema
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P A G E 28
Oral Antibiotics
(Schaefer and Baugh, 2012)
• Cellulitis
Cellulitis is a deep-layer bacterial skin infection that can occur as a result of otitis
externa
Case Report
P A G E 33
Patient Identity
• Name : Ms. DA
• Gender : Female
• Age : 21 y.o.
• Address: Pakisrejo
• Religion: Islam
P A G E 34
Anamnesis
Chief Complaint
> Pain in the right ear since 1 week
ago
P A G E 35
Anamnesis (2)
• Vital Sign
• Blood Pressure: 112/76
• HR : 90 x/min
• RR : 24 x/min
• Temperature : 37.2 oC
P A G E 38
Physical Examination (2)
• Ear
• Dextra
Cerumen (+)
Intact Tympanic Membrane
Edema and redness of Canalis
Auricula Externa
Thick Yellowish discharge
• Sinistra
Normal
• Nose and Throat
Normal
P A G E 39
DIAGNOSIS
Pharmacological
Topical Antibiotics with Corticosteroids:
Otopain (Per 5 mL Polymyxin B sulfate 50,000 IU, neomycin sulfate 25 mg,
fludrocortisone acetate 5 mg, lidocaine HCl 200 mg)
Non-Pharmacological
Cerumen Excavation
Education
Prognosis
• Bonam
P A G E 42
Discussion
P A G E 43
Diagnosis
This patient is given otopain. Traditionally neomycin has been use with
polymixin B for their activities against S. aureus and Pseudomonas
aeruginosa for topical treatment.
We’ve done an aural tiolet to this patient to remove cerumen and discharge from her right ear that
can disturb the effectivity of topical treatment
• For topical antibiotics to be effective, they must contact the epithelial lining. Therefore, in patients
with a significant amount of debris or otorrhea, aural toilet may be necessary (Wipperman, 2014)
• Aural toilet may be done with a gentle lavage using body-temperature water, saline solution, or
hydrogen peroxide. Alternative methods of aural toilet include physically removing the obstructing
debris with suction or dry mop (blotting with cotton). Adequate visualization for suctioning may be
facilitated by using an otoscope with an open head or a binocular otologic microscope (Rosenfeld,
2014)
P A G E 47
2. Topical Antibiotic
This patient is given otopain for a week and education how to applied it
• Topical antimicrobials are beneficial for AOE, but oral antibiotics have limited utility (Rosenfeld et
al., 2006).
• The oral antibiotics selected are usually inactive against P aeruginosa and S aureus may have
undesirable side effects, and, because they are widely distributed, serve to select out resistant
organisms throughout the body (Kaushik et al., 2010; Manolidis et al., 2004).
P A G E 48
• Traditionally neomycin has been use with polymixin B for their activities
against S. aureus and Pseudomonas aeruginosa for topical treatment
(Rosenfeld, 2006)
• If the tymphanic membrane intact, and there is no concern in
hypersensitivity to aminoglycoside, a neomycin/polymixin B/ hydrocortisone
otic preparation would be the first line therapy because it’s effectiveness and
low cost(Rosenfeld, 2006).
• The addition of a topical steroid to topical antimicrobial drops has been
shown to has ten pain relief in some randomized trials (Manolidis et. al.,
2004)
• A 2010 Cochrane review found no difference in efficacy between classes of
eardrop antibiotics for acute otitis externa (Kaushik, 2010)
P A G E 49