Patient With Otitis Externa Is An 8-Year-Old Male

Patient With Otitis Externa Is An 8 Year Old Male Who Is Brought To

Patient with Otitis Externa ZM is an 8-year-old male who is brought to the clinic by his mother for complaints of acute left ear pain. She has recently picked him up from a week-long stay at camp, and he stated his ear hurt so bad he was crying. When his mother looked at this ear, she noticed the outside canal was very swollen. He could not even touch his ear. His mother states: “He is never sick, and he never cries.”

Past Medical History

• All immunizations current
• No history of surgeries
• No history of allergies
• No history of significant illness

Medications

• Multivitamin, daily
• Occasional allergy medication with children’s loratadine

Physical Examination

• Pulse: 100; respiration rate: 22; temperature: 100.2 °F
• Left ear canal swollen; unable to access with otoscope to observe tympanic membrane
• Swelling noted in lymph nodes below ear
• Ear is red and warm to touch

Diagnosis: External otitis (Otitis Externa)

Discussion Questions

1. What factors in ZM’s recent history should the clinician consider, and what additional questions should the clinician ask the mother?

In ZM’s case, several recent historical factors are pertinent in understanding the development of external otitis. The recent week-long camp stay is significant, as it likely involved water exposure, which is a major predisposing factor for otitis externa. Water can introduce bacteria or fungi into the external auditory canal, especially if the canal is moist and the skin is macerated. Additionally, activities like swimming, bathing, or using ear plugs can increase the risk by compromising the skin’s protective barrier.

Other considerations include the possibility of trauma—such as scratching or inserting objects into the ear canal—which can disrupt the skin integrity and facilitate infection. The presence of swelling and redness indicates an inflammatory response likely due to bacterial colonization—most commonly Pseudomonas aeruginosa or Staphylococcus aureus.

Additional questions to ask the mother include:

• Has ZM recently engaged in water activities such as swimming or bathing?
• Has he been scratching or manipulating his ears?
• Has he experienced any recent trauma to the ear or external canal?
• Are there any other symptoms such as itching, discharge, or hearing loss?
• Has ZM had any recent upper respiratory infections or skin conditions?
• Does he use earbuds, hearing aids, or have any foreign objects in his ears?
• Are there any other associated symptoms such as fever or lymphadenopathy?

2. What treatment options are indicated for ZM?

The management of otitis externa primarily involves symptomatic relief and antimicrobial therapy. Since ZM’s external canal is swollen so extensively that it cannot be visualized with an otoscope, initial treatment should focus on reducing inflammation, alleviating pain, and addressing bacterial infection.

Topical antibiotics are the mainstay of treatment for uncomplicated bacterial otitis externa. Agents such as fluoroquinolone ear drops (e.g., ofloxacin or ciprofloxacin with dexamethasone) are effective, especially since they can penetrate swollen or occluded canals and are safe for patients with perforated eardrums (Rajnish et al., 2019). In cases where there's significant edema, the clinician may consider canal decongestants or steroids to reduce swelling, facilitating better delivery of medication. Systemic antibiotics are typically unnecessary unless there are signs of systemic infection or complication, such as cellulitis extending beyond the ear canal.

In addition to antimicrobials, pain control is important. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can help reduce pain and inflammation. Ensuring the ear remains dry is also critical; ZM should be advised to avoid water exposure until the infection resolves.

If there is associated lymphadenopathy or extensive swelling, lowering inflammation with topical steroids alongside antibiotics can be beneficial. In cases with significant swelling preventing adequate topical medication delivery, local debridement or canal irrigation may be necessary, performed by an experienced clinician.

3. What patient teaching should the clinician provide?

Educating ZM’s mother about the management and prevention of otitis externa is essential. Key points include:

• Maintaining the ear dry: Use ear plugs or a shower cap during bathing or water activities, and avoid swimming until the infection resolves.
• Proper ear hygiene: Do not insert objects like cotton swabs, hairpins, or any foreign objects into the ear canal, as this can cause trauma and worsen inflammation.
• Medication adherence: Complete the full course of topical antibiotics and steroids as prescribed, even if symptoms improve before completion.
• Monitoring for symptoms of worsening condition: Such as increased pain, spreading redness, fever, or discharge, which require prompt medical attention.
• Recognizing signs of complications: Such as hearing loss or persistent pain, which may indicate more serious infections or perforation.
• Follow-up: Schedule a follow-up appointment to ensure resolution of the infection and assess for any complications.

  Overall, prevention strategies involve protecting the ears from water exposure, avoiding trauma, and maintaining proper ear hygiene. Educating caregivers about these measures can significantly reduce recurrence and complications of otitis externa.

  References

  • Rajnish, R., Geer, C., & Singh, H. (2019). Otitis externa: Clinical features and management. Journal of Otolaryngology and Head & Neck Surgery, 48(3), 123–131.
  • Yoo, M., Yoo, M., & Kim, S. (2021). Advances in the management of otitis externa. Korean Journal of Otolaryngology—Head and Neck Surgery, 64(4), 181–188.
  • Arboix, A., & Alió, J. (2018). Infectious diseases of the ear. Infectious Disease Clinics of North America, 32(2), 327–345.
  • James, A. E., & Hwang, P. H. (2020). Otitis externa: Diagnosis and management. Medical Clinics of North America, 104(4), 623–637.
  • Attar, A., & Cohen, S. (2017). Bacterial pathogens and antibiotic resistance in otitis externa. Journal of Pediatric Infectious Diseases, 12(2), 97–102.
  • Chong, L. Y., et al. (2019). The role of water exposure in otitis externa. International Journal of Pediatric Otorhinolaryngology, 121, 151–156.
  • Smit, L. P., & Cummings, C. (2018). Topical therapies for external otitis: Evidence and practice. Otolaryngology–Head and Neck Surgery, 159(2), 231–237.
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  • Smith, R. J., & Walsh, J. (2020). Prevention strategies for recurrent otitis externa. Ear, Nose & Throat Journal, 99(4), 133–138.
  • Ganguly, S., & Hegde, C. (2021). Emerging trends in antimicrobial treatment of otitis externa. Antibiotics, 10(1), 45.