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Otorrhea is an ambiguous symptom that underlies diverse clinical pictures. Fundamentally, the treatment of uncomplicated acute otitis externa and media can be carried out by the family physician. An ENT specialist should be definitely consulted in cases of complications or development of a chronic condition.
Eight strains of Pseudomonas putrefaciens have been received from among 466 strains of Pseudomonas submitted to the Computer Trials Laboratory for identification over the last eight years. Two of the strains of P. putrefaciens from patients with otitis media and otitis externa respectively appear to have played a pathogenic role. The biochemical characteristics of these eight strains were compared with those of seven culture collection strains.
Foreign bodies that result from traumatic injury may be the cause of many clinical symptoms. Chronic otitis externa is one of the many clinical symptoms following a traumatic perforation of a foreign body from the oral cavity penetrating the deep tissue of the neck and ultimately lodging in the external ear canal. We discuss two such uncommon cases.
Malassezia species have been recognized as members of the microbiological flora of human and animal skin; they are also considered to play an important role in the pathogenesis of folliculitis, atopic dermatitis and otitis externa. Therefore, the molecular characteristics were investigated to clarify the epidemiology and the pathogenesis of diseases associated with Malassezia species in human and animals. Molecular investigation was made of 105 clinical isolates of M. pachydermatis from dogs and cats by random amplification of polymorphic DNA (RAPD) and chitin synthase 2 (CHS2) gene sequence analyses. The RAPD analysis and CHS2 gene analysis indicated that clinical isolates of M. pachydermatis were divided into four distinct genetic types (A, B, C and D). Type A was isolated from lesions of atopic dermatitis, flea allergic dermatitis, otitis externa, pyoderma and seborrheic (dermatitidis) in dogs and cats, and might be predominant on this. The phylogenetic analysis of the nucleotide sequences of CHS2 gene fragments of standard strains of 11 Malassezia species showed 11 distinct clusters of this species.
Temporal bone cancer, a relatively rare disease, often presents in a subtle manner, which may delay diagnosis. It should be suspected in any case of persistent otitis media or otitis externa that fails to improve with adequate treatment. This article discusses physical and diagnostic imaging indications and epidemiology and histologic distribution of these tumors. Staging systems, patient selection criteria are presented as well as operative techniques and follow-up treatment. Despite advances in operative technique and postoperative care, long-term survival remains poor.
The purpose of this study was to compare computed tomography (CT) and radiography for diagnosing the presence and severity of middle ear disease in dogs with a history of chronic otitis externa. Thirty-one dogs undergoing a total ear canal ablation and bulla osteotomy were studied. Three normal dogs served as controls. All dogs were examined using radiography and CT. Three radiologists independently evaluated imaging studies in random order. A visual analog scale method was used for scoring certainty and severity of middle ear disease. Surgical findings were recorded intra-operatively. Bulla lining samples were submitted for histopathologic evaluation and scored by a single pathologist who also used a visual analog scale system. Findings from both imaging modalities agreed more closely with surgical findings than with histopathologic findings. With either surgical or histopathologic findings as the gold standard, CT was more sensitive than and as specific as radiographs for predicting presence and severity of middle ear disease. Observer performance with CT was more consistent than the performance with radiographs in the detection of changes that occur with middle ear disease. Both radiography and CT were more accurate for predicting the severity of the disease than its presence. Findings indicate that CT is more accurate and reliable than radiography in diagnosing middle ear disease for dogs having concurrent otitis externa, but only when severity of disease is moderate or high. With low severity of disease, diagnostic certainty for both modalities becomes more variable.
OBJECTIVES: To report a case of bilateral squamous cell carcinoma of the external auditory canals and to present a management algorithm for this difficult clinical scenario. STUDY DESIGN: Case report and literature review. METHODS: The study comprises a case report of a 69-year-old man who initially presented with complaints of bilateral otorrhea, left-sided otalgia, and a left-sided hearing loss. Following attempted treatment of a presumed case of otitis externa, biopsy of both external auditory canals revealed squamous cell carcinoma. A computed tomography scan demonstrated marked abnormal soft tissue in the left external auditory canal with no bony erosion and thickening of the soft tissue in the right external auditory canal. RESULTS: The left-sided lesion required a lateral temporal bone resection, a partial superficial and deep-lobe parotidectomy, and postoperative irradiation. The right-sided lesion was more limited and was managed with a lateral temporal bone resection and tympanoplasty for hearing preservation. CONCLUSIONS: Bilateral squamous cell carcinoma of the external auditory canals is an extremely uncommon but aggressive malignancy that may present with symptoms similar to a case of otitis externa, and this can result in delays in proper diagnosis. Early recognition is essential because management and prognosis are determined by the extent of the lesion.
Fifty-seven strains of acinetobacter-like organisms were isolated over a period of 26 months from the ears of 55 patients with acute or chronic otitis media, or otitis externa, and one strain was isolated in a survey of 50 normal ears. After comparison with eight reference strains, 32 of the isolates were identified as Acinetobacter anitratus, 22 as Acinetobacter Iwoffii, three as Moraxella spp. and one as Achromobacter sp. Analysis of the clinical findings suggests that although most of these organisms played little part in the disease process, a few strains were probably pathogenic in this situation.
Treating a child with a draining ear is a common occurrence in the pediatric primary office. The symptoms of otorrhea are broad, and a multitude of factors must be considered in arriving at a diagnosis. The assessment begins with a thorough history of the frequency, duration, and characteristics of the drainage. Physical examination of the affected ear requires cleansing of the external auditory canal before the tympanic membrane can be accurately assessed. The ear must be adequately visualized for accurate diagnosis and treatment. Differential diagnoses include acute suppurative otitis media, otitis externa, granuloma, and bullous myringitis. The acutely draining ear is frequently an uncomplicated suppurative event that will respond well to a regimen of aural hygiene and topical therapy. Patients with a chronically draining ear should be referred to an otolaryngologist for further diagnostics and aggressive therapy. Children with tympanostomy tubes are especially at high risk for suppurative complications. Avoiding the introduction of water into the ear, protecting the ear from water, and prophylactic topical treatment are options that have been suggested for prevention of otorrhea.
OBJECTIVE: To find the relative humidity of the normal external ear canal and to demonstrate that the relative humidity of the external auditory canal was higher in abnormal ears, i.e. ears commonly associated with chronic discharge. SETTING: Secondary health care within the ENT departments of Addenbrooke's and Hinchingbrooke hospitals. DESIGN: A clinical observational study. PARTICIPANTS: Volunteers seen in ENT outpatients. Inclusion criteria for the normal ear group, was a normal ear with no history of infection or previous ear disease. Inclusion criteria for abnormal ear group commonly associated with chronic discharge. Exclusion criteria were the presence of pus or infection within the ear canal. METHOD: The relative humidity of the external ear canal was measured in normal and abnormal ears. Abnormal ears were grouped as those commonly associated with chronic discharge, mastoid cavities, tympanic perforations, recurrent otitis externa and hearing-aided ears. RESULTS: The range of relative humidity of normal ears is 40-70%. The humidity in abnormal ears was found to be significantly higher than the humidity in normal ears (P < 0.0001). CONCLUSION: The raised relative humidity in the external canal may explain the predisposition of certain abnormal ears to chronic discharge and infection. If the humidity of the canal could be brought down to a normal level, this could offer a new therapeutic treatment.
OBJECTIVE: Relapsing polychondritis (RP) is an episodic disease most likely of autoimmune etiology, characterized by recurrent inflammation of cartilaginous structures. METHODS: Retrospective case study at two tertiary referral centers with presentation of nine patients with otologic involvement of RP, review of the spectrum of otologic disorders seen, and treatment. RESULTS: The clinical course of otologic manifestations of RP was highly variable and ranged from mild to moderate. In 6/9 patients there was an association with other autoimmune disorders. In addition to recurrent auricular chondritis, which was present in 8/9 patients, our patients had otitis externa, chronic myringitis, Eustachian tube dysfunction, conductive hearing loss, sensorineural hearing loss, and tinnitus. All patients had their diagnosis of RP made on the basis of their otologic involvement and the response to systemic corticosteroids. CONCLUSION: The diagnosis of RP is primarily clinical, but laboratory studies and biopsy may contribute as well. Once the diagnosis is suspected, the otolaryngologist should consider consultation with a rheumatologist to assist in the management of additional systemic manifestations.
In the article that follows, Carroll and Reimer address a number of issues related to the clinical and laboratory diagnosis of upper respiratory tract infections. These syndromes occur with great frequency in both adults and children and have tremendous economic impact, related not only to lost productivity in the workplace but also to the frequent prescription by physicians of antibiotics, even when the etiologic agents of infection almost certainly are not bacteria. Most of these infections are diagnosed clinically, and specimens for microbiological identification are not obtained. Indeed, the difficulty in obtaining microbiological specimens that are not contaminated by resident colonizing flora often results in laboratory culture reports of dubious clinical value. As the authors note, the most standardized procedures are for the diagnosis of pharyngitis due to Streptococcus pyogenes. The preferred culture methods are reviewed as are the sensitivities, specificities, and limitations of rapid direct tests for group A streptococcal antigens. Currently, as the authors emphasize, a negative direct test mandates a conventional culture for S. pyogenes. More problematic are requests for isolation of other streptococci, Haemophilus species, corynebacteria, and gram-negative bacteria. Given limited resources, cost-containment imperatives, and the absence of clear evidence that these organisms are pharyngeal pathogens associated with important sequelae, my laboratory does not attempt to isolate these bacteria unless the ordering physician has directly consulted with me (the laboratory director). Carroll and Reimer emphasize that nasopharyngeal cultures have no place in the microbiological diagnosis of otitis media and that diagnostic tympanocentesis is the only procedure for obtaining specimens that yield reliable microbiological findings. They also point out the futility of using swabs to obtain material for the diagnosis of otitis externa, since the external auditory canal cannot be decontaminated sufficiently to obtain a meaningful culture result. Finally, the authors address the available methods for obtaining specimens to establish the etiology of sinusitis. For microbiological diagnosis, direct antral puncture has been the method of choice for many years. However, otorhinolaryngologists now obtain many specimens endoscopically. It probably is not possible to obtain specimens by this method without contamination by normal upper respiratory flora. Thus, results of cultures of endoscopic specimens are more difficult to interpret. For patients with complicated illnesses, use of the diagnostic "gold standard" of antral puncture, as well as biopsy with histopathologic correlation, should be encouraged.
Three techniques for the assessment of the integrity of the canine tympanic membrane were evaluated experimentally. Tympanometry, an objective technique, was shown to be very accurate for the evaluation of the integrity of the ear drum. Otoscopic examination by experienced personnel was shown to be moderately accurate under controlled conditions when the external ear canal was not inflammed. However, under field conditions when otitis externa was present, visual inspection of the tympanic membrane was seldom possible even after lavage of the ear. Palpation of the tympanic membrane with a blunt probe was shown to be very inaccurate and led to rupture of the tympanic membrane in a high proportion of cases. These results imply that two widely used techniques for the examination of the canine tympanic membrane are unsatisfactory. Furthermore, they suggest that previous reports of the prevalence of ear drum perforations in dogs may need reappraisal. Tympanometry is a non-invasive, objective and practical technique for the assessment of ear drum integrity which is worthy of further evaluation.
OBJECTIVE: To evaluate the safety and efficacy of the OtoClear Safe Irrigation System for removing cerumen from the external auditory canal in children. METHODS: Eligible subjects were 6 months-17 years of age with cerumen obstructing > or = 50% of the tympanic membrane (TM) from view (by otoscopy). Pneumatic otoscopy, tympanometry, and audiometry were performed followed by cleansing of the affected ear canal(s) with the OtoClear Safe Irrigation System and warm tap water. Otoscopy was performed after each wash of the canal. A curette or small alligator forceps was used to remove remaining cerumen if necessary. Tympanometry and audiometry were repeated after all procedures were completed. Telephone contact was made 1 week later regarding symptoms of acute otitis externa or any other problems. RESULTS: Eighteen children (28 ears) ages 1-10/12 to 11-2/12 years were entered. Four had previously had tympanostomy tubes. At entry, there was no visible TM in 19 ears, 5-10% visible TM in 5 ears, 20% in 1 ear, and 30-40% of the TM in 3 ears. The number of washes needed per ear was: 1 wash--16 ears, 2 washes--8 ears, 3 washes--1 ear, 4 washes--2 ears; washing was stopped in 1 ear because of pain. After irrigation, a curette or forceps was used in 6 ears. Following the procedures, > or = 95% of the TM was visible in 24 ears, and > or = 80% was visible in all ears. Six ears (4 children) with flat tympanograms at entry became normal after irrigation. On audiometry, a conductive loss in 2 ears at entry resolved after irrigation. The mean change in pure tone average (PTA) was -2.9 dB. Three subjects were noted to have hearing losses >5 dB at some frequencies which on review by audiologists were deemed non-significant. No perforations of the TM occurred. There were no reports of otitis externa or any other adverse events occurring after leaving the clinic. CONCLUSION: We found the OtoClear Safe Irrigation System to be safe and effective in our small sample of children. It was well tolerated in most and provided a non-traumatic method for the removal of obstructing cerumen.
Patients receiving Gentisone HC, Sofradex and Otomize for chronic suppurative otitis media and otitis externa were investigated for compliance of medication. Drops were accurately weighed before and after use so that both the amount used and the expected amount patients should have used could be calculated. The amount used differed statistically from the amount expected for Sofradex (P = 0.0008) but not for Gentisone HC (P = 0.1049) or Otomize (P = 0.7553) when analysed by a Mann-Whitney U-test. There was a trend to overdose with both Sofradex & Gentisone HC. The reason for the differences, we believe, is due to a combination of both differing delivery systems and drop viscosities. Manufacturers need to improve delivery systems so that patients can deliver a reproducible volume of medication each time with ease.
OBJECTIVE: To detect contamination of wound sites from surgical handling of excised tissues during total ear canal ablation and lateral bulla osteotomy in dogs, and to compare susceptibility of bacterial isolates to cefazolin with susceptibility to other antimicrobial agents. DESIGN: Prospective clinical study. ANIMALS: 13 dogs. PROCEDURE: Dogs were treated surgically for otitis externa and media via total ear canal ablation and lateral bulla osteotomy. Specimens for aerobic bacterial culture were obtained from SC tissue immediately following skin incision, tissues excised from the osseous bulla (after transection of the horizontal ear canal and lateral bulla osteotomy), and from SC tissue prior to skin closure. Antimicrobial susceptibility of bacterial isolates to various antibiotics was determined by use of a broth dilution assay. RESULTS: There was a significant association between isolation of Streptococcus canis and Escherichia coli from specimens from the osseous bulla and specimens from the SC tissues prior to skin closure, indicating contamination of the SC tissues during surgery. Seventy percent of bacterial isolates were susceptible to cefazolin. CLINICAL IMPLICATIONS: Measures to limit bacterial contamination resulting from tissue handling during total ear canal ablation and lateral bulla osteotomy are necessary. Bacteriologic culture of tissue of the osseous bulla and determination of antimicrobial susceptibility are recommended. Administration of cefazolin alone may not be efficacious for antimicrobial prophylaxis.
The efficacy and safety of ciprofloxacin in the treatment of Pseudomonas aeruginosa infections was evaluated in 72 patients suffering from upper urinary tract infection (19 patients), deep soft tissue infection (16), chronic osteomyelitis (12), abscess (7), chronic otitis media (6), otitis externa (3) and bronchopneumonia (9). Forty-eight patients received an oral dose of 500 mg or 750 mg b.i.d. and five patients an i.v. dose of 200 mg b.i.d., while 19 patients were given both oral and parenteral doses. The duration of therapy ranged from seven days to more than four months. The MICs of ciprofloxacin for the Pseudomonas aeruginosa strains isolated were in the range less than 0.06-2 mg/l; 36% of the strains were resistant to all other available antibiotics. At follow-up after a minimum of six months the clinical success rate was 75% and the infecting organism was permanently eradicated in 49% of the patients. In nine patients the organism developed resistance, particularly when the initial MIC was higher than 0.5 mg/l. No significant adverse reactions were observed. Ciprofloxacin is the first antipseudomonal antimicrobial agent which can be administered orally and therefore fulfills a need in chemotherapy.
OBJECTIVE: Epidermolysis Bullosa encompasses a group of inherited disorders characterized by excessive susceptibility of the skin and mucosa to separate from underlying tissues following mechanical trauma. Information in the literature and guidance on the management of Ear, Nose and Throat problems in such children is scarce. The aim of this study is to report the experience of an Ear, Nose and Throat department in a tertiary paediatric hospital linked to a national Epidermolysis Bullosa unit, describing how children have presented and the care that has been given including a theatre protocol aimed at reducing shearing forces. METHODS: Retrospective case note review of Epidermolysis Bullosa patients referred to Otolaryngology over an 8-year period. RESULTS: Reviewing notes of 307 EB patients identified 15 that had been referred to the ENT department. Four children with middle ear effusions were effectively treated by watchful waiting or grommets. Three children with otitis externa had some relief from careful microsuction but reinfection from ulcers on other parts of the children's bodies tended to occur. One child with profound sensorineural hearing loss benefited from cochlear implantation but later passed away from unrelated sepsis. One child with intrinsic rhinitis was treated with steroid and then a salt-water nasal spray. Five children had nasal crusting documented, although this was not a specific reason for referral. When severe this had been treated with topical steroids by the dermatology team. One patient with obstructive sleep aponea had tonsillectomy and examination of the post-nasal space. Of the five patients referred with glottic or supraglottic scarring, the management of four included a tracheostomy. When carried out tracheostomy sites healed well in each case. With repeated endoscopic procedures it was subsequently possible to remove the tracheostomy in the two of the children. Using a special theatre protocol no new ulcers were recorded as being precipitated by any of the procedures children underwent. CONCLUSIONS: Optimal management depends on the support of a multidisciplinary team, including otolaryngologists, pediatricians, dermatologists, anaesthetists, and specialist nurses. Adherence to a protocol for theatre management can help avoid intraoperative complications.