Management of Acute Otitis Externa in Elderly Family Medicine
Dtsch Arztebl Int. 2019 Mar; 116(13): 224–234.
Continuing Medical Teaching
Otitis Externa
Investigation and Prove-Based Handling
Susanne Wiegand
1Section of Otorhinolaryngology, Caput and Neck Surgery, University Infirmary Leipzig
Reinhard Berner
twoDepartment of Pediatrics, University Hospital Carl Gustav Carus Dresden, TU Dresden
Antonius Schneider
3Institute of General Practice, Technical Academy of Munich
Ellen Lundershausen
4HNO-Praxis Lundershausen, Erfurt
Andreas Dietz
1Department of Otorhinolaryngology, Head and Cervix Surgery, University Hospital Leipzig
Received 2018 Jun 1; Accepted 2019 Jan 21.
Abstract
Background
Otitis externa has a lifetime prevalence of 10% and can arise in acute, chronic, and necrotizing forms.
Methods
This review is based on publications retrieved by a selective search of the pertinent literature.
Results
The handling of astute otitis media consists of analgesia, cleansing of the external auditory canal, and the application of antiseptic and antimicrobial agents. Local antibiotic and corticosteroid preparations take been found useful, just in that location have been no large-scale randomized controlled trials of their utilize. Topical antimicrobial treatments lead to a higher cure rate than placebo, and corticosteroid preparations lessen swelling, erythema, and secretions. Oral antibiotics are indicated if the infection has spread beyond the ear culvert or in patients with poorly controlled diabetes mellitus or immunosuppression. Chronic otitis externa is often due to an underlying skin affliction. Cancerous otitis externa, a destructive infection of the external auditory canal in which there is likewise osteomyelitis of the petrous bone, arises mainly in elderly diabetic or immunosuppressed patients and can be life-threatening.
Decision
With correct cess of the dissimilar types of otitis externa, rapidly effective targeted treatment tin be initiated, and then that complications volition be avoided and fewer cases will progress to chronic affliction.
Otitis externa is one of the more than mutual diseases in otorhinolaryngological exercise and is also frequently encountered in primary and pediatric care. It ranges in severity from a mild infection of the external auditory canal to life-threatening malignant otitis externa. Its right handling requires a good agreement of the anatomy, physiology, and microbiology of the ear culvert. No German language guidelines bargain specifically with otitis externa; information technology is briefly discussed in the AWMF-S2k guidelines on ear pain of the German Higher of General Practitioners and Family Physicians (Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin, DEGAM) (1). Hither we talk over the epidemiology, etiology, and treatment of otitis externa in the calorie-free of the current scientific evidence.
Learning objectives
Readers of this article should
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gain an overview of the epidemiology, anatomical setting, and causes of otitis externa,
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sympathise the dissimilar forms of the disease, and
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go acquainted with their treatment.
Methods
Nosotros selectively searched the PubMed database for controlled trials, guidelines, and reviews that appeared up to 30 April 2018 with the fundamental words "otitis externa," "astute external otitis," "otitis externa diffusa," "otitis externa circumscripta," "chronic external otitis," "otitis externa maligna," and "otitis externa necroticans."
Otitis externa
Otitis externa is divers every bit an infection of the cutis and subcutis of the external auditory culvert, maybe involving the tympanic membrane and the pinna likewise. Its different forms include acute diffuse otitis externa, circumscribed otitis externa, chronic otitis externa, and cancerous (i.eastward., necrotizing) otitis externa. Its differential diagnoses include perichondritis, erysipelas, otomycosis, herpes zoster oticus, otitis externa bullosa sive hemorrhagica, otitis media (with perforation), and eczema, cholesteatoma, or carcinoma involving the external auditory canal (two).
Beefcake and physiology
The external auditory canal (ear canal) has lateral cartilaginous and medial bony portions, with an overall length of 2–3.5 cm and a bore of 5–nine mm (Figure 1a). The skin of the bony ear canal is firmly bound to the periosteum, while the skin of the cartilaginous ear canal lies on a layer of connective tissue and contains hair follicles, sebaceous glands, and apocrine ceruminous glands, whose exudates, combined with desquamated epithelial cells, form cerumen. The cartilaginous ear canal has a roof of connective tissue; its floor contains the connective-tissue clefts of Santorini, along which infections can spread to the parotid gland, infratemporal fossa, and skull base. The sensory innervation of the ear canal is from the auriculotemporal nerve, the auricular branch of the vagus nerve, the greater auricular nerve, and the posterior auricular nerve. The ear canal is ordinarily colonized by bacteria, above all Staphylococcus and Corynebacterium species and streptococci (iii). Its pH is commonly in the range of 5–5.seven; the acrid environment and the hydrophobic properties of the cerumen inhibit bacterial growth (2).
a) Normal right external auditory culvert, with view of the eardrum.
b) Swollen introitus of the correct external auditory culvert in a patient with acute otitis externa.
c) An external auditory canal afflicted by bacterial otitis externa.
d) Otomycosis
Etiology and epidemiology
Otitis externa is common all over the world, with a college incidence in tropical than in temperate zones because of the higher temperature and humidity. Its lifetime prevalence is estimated at 10% (iv). It affects adults virtually commonly, and children only rarely (generally aged seven to 12) (e1). Studies from holland and the U.k. have shown an annual incidence of circa i% (5, e2). The incidence is increased fivefold in swimmers (6); thus, the status is also called "swimmer's ear." The pathogenesis of otitis externa is multifactorial; a list of predisposing factors is shown in Table 1.
Table 1
Predisposing factors for otitis externa (modified from Schäfer et al. [7])
| Anatomical factors | Pare diseases | Ecology factors | Trauma | Systemic diseases | Endogenous factors | Other factors |
| Stenosis of the external auditory canal Exostoses of the external auditory culvert Heavy coverage of the external auditory canal with hair | Eczema Psoriasis Seborrhea Neurodermatitis Other inflammatory diseases of the peel | Loftier humidity of the ambient air High ambient temperature | Manipulation/ excoriation Cerumen removal Hearing aids Earplugs Foreign bodies | Metabolic diseases Diabetes mellitus Immunosuppression | Lack or overproduction of cerumen Sweating | Water in the ear canal/ pond Irritants (soap, shampoo, etc.) Radiation Chemotherapy Purulent otitis media Prior surgery of the external ear canal Stress |
More than 90% of cases of otitis externa are due to bacteria (6), most normally Pseudomonas aeruginosa (22–62%) and Staphylococcus aureus (11–34%). Polymicrobial infection is mutual (8, e3– e5). Fungi are a rare cause of acute otitis externa (x%) (e6) and a more common cause of chronic otitis externa; typical pathogens are Aspergillus (60–90%) (9) and Candida species (10–40%) (e7). Predisposing factors for fungal otitis externa include long-term antibiotic apply, immunosuppression, and diabetes mellitus.
The changes in the ear canal that are seen in otitis externa (due east.g., hyperkeratosis of the epidermis, chronic granulation tissue, edema, or fibrosis of the dermis) tend to narrow the culvert. Epithelial cell migration commonly rids the ear canal of cerumen, cellular detritus, and microorganisms. Interference with this process by inflammation or stenosis predisposes to the evolution and maintenance of otitis externa.
Symptoms
The characteristic symptom of acute otitis externa is severe pain in the ear (otalgia) due to irritation of the periosteum just under the thin dermis of the bony ear canal, which has no subcutis. The pain is typically worsened by pressure on the tragus or tension on the pinna. Further symptoms are otorrhea, itch, erythema, and swelling of the ear culvert, potentially leading to conductive hearing loss.
Diagnosis
Otitis externa is diagnosed from the history and physical examination, including, as a minimum, otosopic or otomicroscopic examination of the ear culvert and tympanic membrane (if visible), every bit well as examination of the pinna, the surrounding lymph nodes, and the peel. Peculiarly if the tympanic membrane cannot exist seen, screening tests of hearing or an audiological examination should be performed to rule out inner ear involvement. When the ear canal is swollen, the tuning-fork examination and the tone threshold audiogram typically reveal conductive hearing loss. The characteristic findings in acute otitis externa are pain induced by pressure on the tragus and tension on the pinna, forth with swelling of the ear canal, perhaps to the betoken of total obstacle; the skin of the ear canal can exist either erythematous or pale considering of edema (Figures 1b, c). Secretion is common and tin can be swabbed for culture and pathogen resistance testing. Rarely, swelling makes the pinna protrude (pseudomastoiditis). Balmy fever (up to 39°C) may exist nowadays; markedly higher temperatures suggest spread of the infection across the ear canal.
Treatment
The handling of uncomplicated acute otitis externa consists of cleansing the ear canal, topical antiseptic and antimicrobial treatment, and adequate analgesia. Master oral antibiotic treatment should exist given simply if the infection has spread beyond the ear canal, in the setting of poorly controlled diabetes mellitus or immunosuppression, or if topical treatment is not possible (ten) (effigy 2). The DEGAM, in its guideline on ear pain, accordingly recommends cleansing the ear canal and using local antibiotics and/or corticosteroids equally indicated, in consideration of their availability, costs, and risks. Systemic antibiotic treatment should be considered in individual cases if there are systemic manifestations, or whenever problematic organisms are found (1).
Treatment algorithm for acute otitis externa (modified from Rosenfeld et al. [viii])
Cleansing the ear canal
Atraumatic cleansing of the ear canal consists of the removal of cerumen and exudate; the exudate may incorporate toxins (east.g., Pseudomonas exotoxin A [e8]) that sustain the inflammatory procedure and limit or forestall the efficacy of topical drugs. Cleansing should be performed by an experienced otorhinolaryngologist under microscopic vision with suction or an audible claw; injury to the ear canal must be avoided. Once a defect of the tympanic membrane has been ruled out, the ear canal can alternatively be cautiously rinsed with distilled water or normal saline. In rural areas without otolaryngology coverage, this can also be done by a general practitioner or pediatrician. Patients should not clean their own ears with cotton fiber swabs, considering microtrauma encourages bacterial invasion.
Topical treatment
Topical treatment with antiseptic agents, antibiotics, corticosteroids, and combinations of these is recommended for the handling of uncomplicated astute otitis externa because of its condom, efficacy compared to placebo, and excellent results in randomized trials and meta-analyses (10– 12, e9– e11). Whichever topical agent is used, 65–90% of patients ameliorate clinically in 7–10 days (8). In a Cochrane meta-assay of randomized controlled trials, antiseptic agents and antibiotics yielded equally good clinical results; no divergence was constitute between unmarried agents and combinations of agents, with or without boosted corticosteroids (10). Nonetheless, the additional assistants of topical steroids tin can lessen erythema and secretions. A few trials have shown unlike results from monotherapy as opposed to combination therapy, but the heterogeneity of the substances used makes it hard to draw whatever general conclusions (x). In a systematic review, topical antimicrobial drugs were constitute to increment the clinical cure rate by 46% and the bacteriological cure rate by 61% compared to placebo (xi). Ototoxic substances must exist avoided if the eardrum is perforated. No randomized trials have been performed on the insertion of a drug-soaked gauze strip into the ear canal every bit the sole treatment, but this method does seem to improve the local efficacy of topical handling and to lessen inflammatory edema (x). The decisive factor for optimal topical handling is patient instruction in how to apply the eardrops. The patient should lie on his or her side with the affected ear upward, apply the drops in the ear canal, and keep lying on 1 side for 3–5 minutes thereafter. Gently moving the ear back and along helps convey the drops to their site of action (8). The drops should be applied two to five times daily, depending on the preparation (table 2). Topical treatment leads to a cure of astute otitis externa in 65–xc% of patients in vii–x days, whatever agent is called (8). In the past, dyes such as gentian violet and acid bright dark-green were commonly used for the local antiseptic and desiccating therapy of various ear diseases, simply these are toxic and no longer approved for audible employ.
Table 2
Eardrops that are canonical in Germany for the topical treatment of otitis externa
| Substance class | Active agent or combination of active agents | Approval | Dosage | Use in patients with eardrum perforation (according to manufacturer'southward information*1) | Requires prescription? |
| Antibiotic eardrops | Ciprofloxacin 2 mg/mL | Depending on preparation, from age 1 year or 2 years | Depending on preparation, 0.25 mL bid for vii days or 0.v mL bid for 7 days | Depending on preparation*2 no (restricted awarding) or yes | Yes |
| Ciprofloxacin three mg/mL | From historic period 1 yr | 3 drops bid (children) iv drops bid (adults) | Yep | Yes | |
| 7500 IU polymyxin B sulfate/mL 3500 IU neomycin sulfate/mL 0.02 mg gramicidin/mL | No data | 2–3 drops 3–5×/d for 5–7 days | No | Aye | |
| Antibiotic and steroid eardrops | 3 mg ciprofloxacin/mL 1 mg dexamethasone/mL | From historic period ane yr | 4 drops bid for 7 days | Yes | Yeah |
| 3 mg ciprofloxacin/mL 0.25 mg fluocinolone acetonide/mL | From age half dozen months | vi–8 drops bid for 7 days | Aye | Yes | |
| Steroid eardrops | Fluocinolone acetonide 0.25 mg/mL | From age 18 years | 0.4 mL bid for seven days | No | Yep |
| Steroid andanalgesic eardrops | Dexamethasone 0.224 mg/mL Cinchocaine 5.08 mg/mL Butane-ane,3-diol 539.728 mg/mL | No information | 2–4 drops tid-qid for a maximum of 10 days | In case of perforated eardrum, treatment for a short time under an otologist'southward supervision | Aye |
| Analgesic eardrops | Phenazone 50 mg Procaine HCl 10 mg | From historic period 3 years; in younger children but under a physician's supervision | Age 0–2 years: but under a medico's supervision Age three–14 years: 2–3 drops tid-qid from age xv years: 5 drops tid-qid | No | No |
Topical antiseptic agents
The treatment of acute otitis externa with various topical antiseptic agents has been described, including acerb acid, chlorhexidine, aluminum acetate, silver nitrate, N-chlorotaurine, fuchsin, and eosin (5, xiii, 14, e12– e14). The advantage of topical clarified agents is their broad-spectrum efficacy. Many preparations contain alcohol, which is an constructive disinfectant and, in high concentration, removes water from tissue and thus lessens edema. pH reduction by acid preparations (eastward.g., 2% acetic acrid) inhibits bacterial growth (three, xiv), as about leaner prefer a pH-neutral environment. Thus, otitis heals more speedily if treated in this way rather than with placebo. Acetic acid is comparably constructive to antibody or corticosteroid drops afterwards 7 days of handling, but significantly less constructive if treatment is needed for 2–iii weeks (x).
Topical antibiotics
Topical antibiotics should cover the most mutual pathogens, i.e., Pseudomonas aeruginosa and Staphylococcus aureus, and should exist tailored to the drug resistance and sensitivity patterns of the cultured pathogen, if possible. The approved types of antibiotic eardrops in Germany contain quinolones (ciprofloxacin), aminoglycosides (neomycin), or polymyxins (polymyxin B) (tabular array 2). Compared to placebo, these lead to more rapid symptomatic relief and cure, and to lower recurrence rates (eleven). Quinolones are highly effective and cause no local irritation, only prolonged exposure to them tin lead to resistance against this of import class of antibiotics. Neomycin is effective but ototoxic and should be given only if the eardrum is intact. It also causes contact dermatitis in xv–thirty% of patients (nine, 15– 17, e15). Polymyxin monotherapy is not effective confronting? staphylococci and other Gram-positive microorganisms (9). A Cochrane analysis showed no departure in the clinical efficacy of quinolone versus not-quinolone preparations (10). In clinical practice, just every bit in clinical trials, ophthalmological antibiotic preparations are sometimes used off characterization to care for otitis externa; the nigh common active substance is ofloxacin (10, xi). Topical administration results in a high local concentration of drug without the side effects of systemic treatment. Nonetheless, for the reasons only explained, topical antibiotics such as ciprofloxacin or ofloxacin should non be given any longer than necessary. Ototoxic substances must not be used if the eardrum is perforated.
Topical corticosteroids
Topical corticosteroids are used mainly considering they lessen edema; antibacterial and antifungal effects have too been described (three). Only private case reports on topical corticosteroid monotherapy are available (18, 19), so the evidence for this practice is still weak (10). In a few randomized controlled trials, treatment with topical combinations of antibiotics and corticosteroids lessened swelling, erythema, and secretions more effectively than antibiotics alone. The greatest deviation was seen during the outset few days of treatment (20, 21). High-potency corticosteroids are probably more than constructive than low-authority corticosteroids confronting hurting, inflammation, and swelling (22) (tabular array 2).
Antifungal treatment
In case of fungal infection (Figure 1d), strips soaked in a solution of antifungal drug (ciclopirox, nystatin, clotrimazole, or miconazole) should be laid in the ear canal. Dye solutions are no longer recommended because of their potential toxicity to the inner ear and their low efficacy (23). If the eardrum is perforated, systemic antifungal treatment should be given according to the resistance and sensitivity pattern (due east.m., fluconazole or itraconazole) (23).
Analgesia
Pain relief is an essential office of the treatment of acute otitis externa. Severe ear hurting arises because the highly sensitive periosteum of the bony ear canal is unremarkably involved in the inflammatory process. Suitable analgesia should, therefore, be provided, e.g., with ibuprofen or acetaminophen. Topical local anesthetics can be used every bit well (table 2), unless the eardrum is perforated or a myringostomy tube is in identify. Local anesthetics, all the same, tin as well mask progressive affliction; if they are used, the patient should be followed upward clinically in 48 hours so that the issue of treatment can be judged (8).
Oral antibody treatment
Despite the well-documented prophylactic and efficacy of topical preparations, 20–twoscore% of patients treated for acute otitis externa receive systemic antibiotics as their primary treatment (24, 25). This should be avoided in elementary astute otitis externa because of the side furnishings and the risk of inducing drug resistance. On the other hand, oral antibiotics are indicated to care for acute otitis externa if the patient suffers from poorly controlled diabetes mellitus or immunosuppression, or if the infection extends across the ear canal. Antibiotics should exist given that are effective against both Pseudomonas aeruginosa and Staphylococcus aureus (e.g., quinolones). Optimally, antibiotics should be tailored to the findings of bacterial culture and sensitivity testing.
Follow-upward and secondary prevention
The response to handling should be checked in 48–72 hours. If there is no response, the correctness of the diagnosis and the adequacy of treatment should be critically reconsidered, and the causative pathogen should exist identified if possible. Known take chances factors should exist avoided to prevent further episodes of infection. In particular, the ear canal should be kept dry out and should be dried with a hair dryer if water enters it (x). If the self-cleansing mechanism of the ear canal is dysfunctional, then the ear canal should be cleansed past a physician whenever the patient intends to spend a considerable amount of time pond (due east.g., a beach holiday).
Circumscribed otitis externa
Confining otitis externa is an abscess-forming infection of a hair follicle (i.due east., a furuncle) in the cartilaginous office of the external auditory canal, mostly due to Staphylococcus aureus. If balmy, it is treated with topical antibiotic eardrops, salves, or salve strips, along with analgesics. If more severe, it is additionally treated with oral antibiotics and lancing of the furuncle, as needed.
Chronic otitis externa
Manifestations of otitis externa lasting longer than three months, or more than 4 attacks of otitis externa per year, are designated as chronic otitis externa. This may upshot from inadequately treated astute otitis externa, although 15% of cases of acute otitis externa heal inside x days (e16), simply the cause usually lies elsewhere. Involvement of the ear canal by a skin disease such every bit atopic dermatitis or psoriasis is mutual. An alkaline pH in the ear canal due to the inflammatory procedure can likewise predispose to chronic otitis externa (e17). The chronic grade of the condition affects both ears in more than than half of patients (26). Its typical symptoms are itch and conductive hearing loss due to obstacle, while ear pain is rare. There are two main clinical presentations: the seborrheic course is characterized by a lack of cerumen and by dry, scaly, red, or shiny skin in the ear canal, the eczematous form by moist, erythematous peel (26). Itching can lead the patient to manipulate the ear canal, leading to excoriation and, in turn, to acute inflammation. Chronic inflammation causes progressive fibrosis of the ear canal.
Handling
The goals of treatment are to return the skin of the ear canal to its original, normal state and to promote the product of cerumen. All potential irritants, such equally shampoo or soap, should be kept away from the ear, and the ear canal should be kept dry. The treatment of underlying illnesses, such as skin diseases or autoimmune disorders, is the footing of therapy. Only a few randomized controlled trials on drug therapy for chronic otitis externa have been carried out, by and large on a mixture of patients with acute or chronic otitis externa, and so that no explicit recommendations tin can be derived for the treatment of chronic otitis externa as a singled-out entity (e18– e20). The goal of topical treatment is to suppress chronic inflammation. Swabbing for culture, to exclude bacterial or fungal infection as the crusade, is recommended. The application of strips soaked in alcohol or corticosteroid solution can locally lessen edema. In case of an acute exacerbation, topical antibacterial or antifungal drugs may exist needed. Chronic otitis externa often fails to respond to treatment administered for several weeks.
Oral corticosteroids can be effective in cases resistant to other forms of treatment (27). Local treatment with tacrolimus has been described as well (28). Surgical canaloplasty to widen the ear canal is only indicated if the canal is stenotic.
Malignant (necrotizing) otitis externa
Cancerous (necrotizing) otitis externa is a subversive infection of the external auditory culvert with invasive perichondritis and osteomyelitis of the lateral skull base, arising mainly in elderly men who are either diabetic or immunosuppressed (29). Its incidence is non precisely known. Rare cases have been described in severely immunocompromised children, such as children with acute leukemia or who have undergone os marrow transplantation (e21, e22). Early diagnosis is essential; intractable otitis externa should always prompt the suspicion that the patient might actually exist suffering from the malignant (necrotizing) grade of the condition.
Diagnosis and manifestations
In about 90% of cases, Pseudomonas aeruginosa tin can be isolated from the exudate in the ear canal (6, e23). Proteases released into the surrounding tissue can crusade marked tissue destruction and accompanying vasculitis (thirty). The infection tin spread along the clefts of Santorini to the parotid gland, the periauricular soft tissue, and the temporomandibular articulation. Spread of infection along the skull base can lead to inner ear damage, cranial nerve deficits, venous sinus thrombosis, meningitis, and brain abscess. Otalgia is intense, merely nonspecific (frequency, 84–100% [29]); along with conductive hearing loss and fetid otorrhea (frequency, 17.6–100% [29]), granulations or polyps are typically institute in the flooring of the ear canal (frequency, 42.one–100% [29]), sometimes with exposed os, particularly at the junction of the bony and cartilaginous portions of the canal, due to the underlying osteitis (8) (figure three). Further manifestations tin can arise that reflect further complications. Imaging studies typically reveal soft-tissue swelling in the external auditory canal. Petrous osteomyelitis is manifested past bony destruction, usually (fourscore%) spreading toward the temporomandibular joint and the clivus (31). The gold standard for the diagnostic imaging of petrous osteomyelitis is a combination of static and functional imaging (where bachelor), with fluorodeoxyglcose positron-emission tomography and magnetic resonance imaging (FDG-PET/MRI) every bit well as high-resolution computed tomography (CT). Functional imaging enables the detection of osteitis in an early stage before bone erosion can be seen on CT (31). The advantages and disadvantages of each imaging modality for the evaluation of petrous osteomyelitis are listed in Table iii. A biopsy should always exist performed to rule out a cancerous tumor or cholesteatoma of the external auditory culvert. Malignant otitis media is very rare in children; when it is suspected, MRI is the imaging written report of option.
Exposed os in the floor of the external auditory culvert in a patient with malignant otitis externa
Table iii
Relative advantages and disadvantages of various imaging modalities for the diagnosis and follow-up of skull-base osteomyelitis (in illustration to van Kroonenburgh et al. [31])
| Features | Radiological techniques | Nuclear medicine techniques | Hybrid techniques | ||
| CT | MRI | SPECT (Tc99m-MDP) | FDG-PET/CT | FDG-PET/MRI | |
| Bone erosion | ++ | − | − | + | − |
| (Os) metabolism | − | − | + | + | + |
| Soft tissue | ± | + | − | ± | + |
| Spatial resolution | + | ++ | − | ± | + |
| Radiation exposure | − | + | − | − | ± |
| Follow-up | − | − | − | ± | + |
Treatment
Loftier-grade evidence on the treatment of malignant otitis externa is lacking (29). Pathogen-specific parenteral or oral antibiotics, tailored to the findings of sensitivity and resistance testing, are recommended for at least iv–vi weeks (29, 32), as information technology takes this long for the involved bone to become revascularized (33). If the sensitivity and resistance testing is non yet definitive, empirical antibody treatment against Pseudomonas aeruginosa should be begun, depending on the severity of the status. Topical treatment with antiseptic or antimicrobial strips in the ear canal can be given in addition. If the condition takes a protracted course or fails to answer to medical treatment, necrotic tissue and bone sequestra should be surgically removed, because they impair the penetration of antibiotics and the body's own defensive substances into the involved tissue (34). Extensive resection in the region of the lateral skull base does not improve the outcome. Optimal blood sugar control is mandatory. Accompanying hyperbaric oxygen therapy may increase the cure rate, just no randomized controlled trials on this topic are available (35). Regular clinical and radiological follow-up examinations are needed to certificate the response to treatment and to observe whatever recurrence. The suggested strategies range from imaging just if new symptoms arise to intermittent imaging at 2–vi calendar week intervals until no infectious process tin can be seen any longer (36). Petrous os osteomyelitis in cancerous otitis externa is associated with a mortality of 10–21% (17, 37– 39, e24). Mortality is elevated if 2 or more than of the post-obit factors are present: historic period >lxx, diabetes mellitus, facial nervus palsy, or a positive CT (bone erosion, soft-tissue swelling) (xl).
Conclusions for routine clinical practice
Otitis externa is diagnosed from the history and physical examination. Simple acute otitis externa can exist treated to good effect with cleansing of the ear culvert, antiseptic or antibiotic eardrops with or without corticosteroids, and preventive measures. Otomycosis should be treated with antifungal agents. For patients with chronic otitis externa, irritating substances should be kept away from the ear, and potential underlying diseases should be treated. Persistent otitis externa, granulation tissue, or freely exposed bone in the external auditory canal may be a sign of cancerous (necrotizing) otitis externa. Early diagnosis and the rapid initiation of a 4- to half-dozen-week grade of antibiotics help lower the morbidity and mortality of this condition.
Acknowledgments
Translated from the original German by Ethan Taub, Thousand.D.
Footnotes
Disharmonize of involvement statement
The authors state that they accept no conflict of involvement.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522672/
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