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Outer Ear Infections-Otitis externa
Middle Ear Problems- Otitis media (middle ear fluid or infection)
(also called an outer ear canal infection or "swimmer's ear")
Symptoms:
Physical findings:
Otitis externa is most commonly caused by a bacterium called pseudomonas. Pseudomonas is often found in fresh water including lakes, swimming pools, and occasionally, in bath water. This is why otitis externa is often referred to as "swimmer's ear."
Specific causes:
Diagnosis and Treatment
A visit to your physician is often necessary to make the diagnosis and start the appropriate medicines. Otitis externa is usually cured within several days after starting the use of antibiotic or anti-fungal ear drops, cleaning the ear canal thoroughly, and keeping water out of the ear canal at least for 7-10 days. Steroids in the drops can reduce itching and swelling of the ear canal. Sometimes other remedies such as acetic acid (vinegar) drops may be used. If the ear canal is very swollen, a wick may be placed in the ear to allow the drops to travel to the end of the canal. The wick will usually fall out after several days, as the ear canal swelling resolves, or is removed usually after 5-7 days. Acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) may help relieve pain. Re-useable ear plugs are not recommended as bacteria or fungal debris may be on the plug after the initial use and subsequent use may continue to re-infect the ear canal. Cotton coated with vaseline is recommended to keep water out of the ear canal with bathing.
Is otitis externa serious?
Acute and chronic swimmer's ear responds well to treatment, but complications may occur if it is not treated. Some individuals with underlying medical problems, such as diabetes, may be more likely to get complications such as malignant otitis externa.
Malignant otitis externa
Malignant external otitis (otitis externa) is a complication of acute otitis externa. The disease starts as a local infection of the external auditory canal and spreads through the cartilage of ear canal (in fissures of Santorini) towards the parotid gland and mastoid. This can lead to facial nerve paralysis . As the disease progresses, there is spreading along the skull base to the jugular foramen (causing involvement of cranial nerves IX, X, and XI), and finally to the hypoglossal canal (involving cranial nerve XII). Involvement of these nerves can lead to problems with the tongue, back of the throat, soft palate, voice box and muscles of the neck.
Symptoms are similar to acute otitis externa; however, the main difference is that the disease is not responsive to several weeks of conventional local therapy. On physical exam, there may be granulation tissue present in the ear canal, cranial nerve dysfunction, or a palpable bony defect in the wall of the ear canal. Risk factors include diabetes, elderly, and an immunocompromised status.
Determining the cause of the otitis externa is very important. The pathogen in malignant external otitis is nearly always Pseudomonas (99.2%). However, other relevant laboratory studies include an erythrocyte sedimentation rate (ESR) and a fasting glucose level. A bone scan is important to demonstrate bone infection (osteomyelitis). It will remain positive for years after a full recovery, so it is not useful in following response to therapy. A gallium scan will demonstrate active inflammation in either soft tissue or bone, and it will return to normal if the disease is effectively treated. A CT scan is useful to determine bony erosion and soft tissue involvement, however its sensitivity for detecting osteomyelitis is low (30%).
Therapy for malignant external otitis includes meticulous control of blood glucose, local debridement of granulation tissue, and possibly hyperbaric oxygen. Traditional antibiotic therapy is 6-8 weeks of IV drugs (usually an anti-pseudomonal penicillin or cephalosporin, and an aminoglycoside). Recent studies have demonstrated that oral ciprofloxacin has been successful in treating mild to moderate malignant external otitis. In severe disease, IV therapy is recommended initially, and then a long course of oral ciprofloxacin is needed. Therapy is continued until the gallium scan is clear.
Prevention of otitis externa
Do not scratch the ears or use cotton swabs or other objects in the ears.
The middle ear is normally an air-filled cavity. As a result of poor Eustachian tube function, negative pressure occurs in the middle ear. This negative pressure, acts as a suction causing serum to first develop in the middle ear (called serous otitis media). The serum (clear or amber colored fluid) can function as a feeding ground (culture media) for pathologic bacteria. When the fluid persists, it then can get infected resulting in a cloudy or purulent middle ear infection (called suppurative otitis media). All of the pathology is the result of poor functioning Eustachian tubes.
Facts about middle ear infections
In infants and toddlers, look for:
In older children, adolescents and adults, look for:
What causes otitis media?
Middle ear infections usually occur as a complication of a cold, allergies, nose and throat infections. Both bacteria and viruses can cause the infection. Otitis media can occur in one or both ears. Otitis media is the most frequent diagnosis recorded for children who visit physicians due to illness. It is also the most common cause of a conductive hearing loss in children. Typically after treatment, the hearing loss is resolved and hearing returns to pre-infection levels. Although otitis media is most common in young children, it also affects adults. It occurs most commonly in the winter and early spring months. Second hand smoke has shown to cause an increase in ear infections in infants and children. The Archives of Pediatrics & Adolescent Medicine reported that children living with two or more smokers have an 85% higher risk of persistent or recurrent middle ear infections.
An ear exam is required, to evaluate the outer and middle ear status. Middle ear effusions (i.e. fluid) will result in a fullness sensation and hearing loss, and therefore most adults or older children usually can tell when the middle ear is involved. The patient may have severe pain if the middle ear effusion is infected, the eardrum is bulging due to the pressure in the middle ear, or there are blisters on the surface of the eardrum (called Bullous Myringitis). The physician is looking at the condition of the ear canal, the appearance of the eardrum, and most importantly the status of the middle ear. It is important, for example, to know if the fluid in the middle is clear or cloudy. With the gentle use of air pressure, the physician can also see if the eardrum moves. When middle ear effusions are present, there is poor eardrum mobility and a conductive hearing loss. It is important to know the degree of hearing loss temporarily caused by the fluid in the middle ear. Therefore, a hearing test may be recommended.
One or more medications are often prescribed. It is important that all the medication(s) be taken as directed and that any follow-up visits be kept. Often, antibiotics to fight the infection will make the earache go away rapidly, but the infection may need more time to clear up. Thus, be sure that the medication is taken for the full time your doctor has indicated. Medications also usually include an antihistamine (for allergies), a decongestant (especially with a cold), and/or nasal steroid sprays (to decrease inflammation).
Often medications to reduce fever and/or pain are prescribed. If allergies have been associated with chronic ear infections, testing for specific allergies and treating them are also advised.
Auto-inflation techniques are particularly helpful to get air into the middle ear. The cause of the middle ear fluid is usually the result of having little air in the middle ear. So it is advised to make every effort to re-establish the middle ear with air. The technique of auto-inflation is:
The technique is usually quite sufficient at getting air into the middle ear. Young children can use the Otovent device (this utilizes a device which the child holds over the nose and attempts to blow up a balloon). Simple balloon blowing is often helpful in older children with supervision.
Surgical treatmentsIf medication fails to clear the ear infection, further treatment may be recommended. An operation, called a myringotomy may be recommended. This involves a small surgical incision (opening) into the eardrum to promote drainage of fluid and to relieve pain. The incision heals within a few days with virtually no scarring or injury to the eardrum. In fact, the surgical opening can heal so fast that it often closes before the infection and the fluid are gone. A ventilation tube is usually placed in the incision, preventing closure of the incision. The purpose of a ventilation tube is not to drain the ear. The middle ear fluid is aspirated or drained at the time of the surgery. The purpose of the tube is to provide air to the middle ear, until the Eustachian tube functions more normally, thus preventing the build up of negative pressure and accumulation of fluid in the middle ear.
The middle ear ventilation tube (called P.E. tubes or pressure equalizing tubes) for your child will remain in place long enough for the middle ear infection to improve. Most P.E. tubes stay in place for 9-12 months. There are some smaller tubes, usually placed in adults, which are designed to fall out in about 2 months. Also there are long-term tubes, which can stay in place for 2 or more years. These are usually place in young children with palate defects or adults with chronic middle ear effusions. Long-term P.E. tubes have a higher risk of an eardrum perforation when they fall out or are removed. Generally, it is preferred to leave a tube in no longer than 2 years, because of this risk. During this time, water MUST remain out of the ears, because it could start an infection. If water gets into the ear canal when a P.E. tube is present, the ear will drain and this discharge usually has to be aspirated in the office, and ears drops will be required for at least for 7-10 days. The tubes most often completely eliminate the middle ear infections, cause very few problems when the ears are kept dry, and improve hearing. For adults, this operation can be performed in the office setting. Children require a general anesthesia, usually in an outpatient facility.
Is it serious?
Otitis Media is generally not serious if it is promptly and properly treated. However, it can be serious because of the nearby structures and hearing loss. Hearing loss, especially in children, may impair learning capacity and even delay speech development. However, if it is treated promptly and effectively, hearing can almost always be restored to normal.
Without proper treatment, a severe ear infection can cause chronic or permanent hearing loss, injury to the bones in the middle ear, facial paralysis, infections of the mastoid bone, blockage of the veins draining the brain, meningitis, or a brain abscess. Complications of otitis media can result in the need to have intravenous antibiotic therapy, having ventilation tube placement, mastoid surgery, or a neurosurgical drainage procedure, depending on the complication. Thus, it is very important to recognize the symptoms of Otitis Media and to get immediate attention from your doctor.