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Di f thDi f thDiseases of the Diseases of the External Auditory External Auditory
CanalCanal
PETER ROLAND, MDPETER ROLAND, MDPETER ROLAND, MDPETER ROLAND, MD
UT SOUTHWESTERNUT SOUTHWESTERN
DALLAS TXDALLAS TX
AnatomyAnatomy
Only skin lined Only skin lined i i tii i tiinvaginationinvagination
Outer Outer 11//3 3 vs inner vs inner 22//33
SS--shapeshapepp
Fissures of SantoriniFissures of Santorini
Tragi hair cellsTragi hair cellsTragi hair cellsTragi hair cells
Glandular ElementsGlandular Elements
Sebaceous Sebaceous l dl dglandsglands
Modified apocrine Modified apocrine sweat glandssweat glands
Neuroendocrine Neuroendocrine controlcontrol
Genetic/racial Genetic/racial di ib idi ib idistributiondistribution
Both empty into Both empty into hair folliclehair follicle
CerumenCerumen
Mixture of sebacous, Mixture of sebacous, apocrine & epithelialapocrine & epithelialapocrine & epithelial apocrine & epithelial cellscellsLubrication/waterproLubrication/waterproLubrication/waterproLubrication/waterproofofMechanicalMechanicalMechanical Mechanical protectionprotectionAntiAnti bacterialbacterialAntiAnti--bacterialbacterial
LyzozymeLyzozymeFatty acidsFatty acidsFatty acidsFatty acidspH ≈pH ≈66..11
Cerumen: hearing lossCerumen: hearing lossgg
Percent occlusion of EAC correlated with hearing loss in decibels
CerumenCerumen
CleansingCleansing
Normal radial Normal radial t ff TMt ff TMmovement off TMmovement off TM
Keeps drum thinKeeps drum thin
Out canalOut canalEpithelial Epithelial releasing releasing substance??substance??
Declines with Declines with agingaging
TM MigrationTM Migration
DefinitionDefinition
11) Causes symptoms ) Causes symptoms 22) Prevents assessment of the ear) Prevents assessment of the ear))
PEPEAudiovestibular testingAudiovestibular testingAudiovestibular testing Audiovestibular testing
33) both ) both
A strong recommendation that:(1) li i i h ld CI h(1) clinicians should treat CI that
causes symptoms expressed by thecauses symptoms expressed by the patient or prevents clinical examination
h t dwhen warranted.
Recommendations that clinicians h ldshould:
(1) Diagnose CI when cerumen causes symptoms; or t d d t f thprevents needed assessment of the ear
(2) Assess the pt with CI by history and/or physical examination for factors that modify managementexamination for factors that modify management
(3) Examine patients with hearing aids for the presence of CI during a healthcare encounter g
(4) Assess patients after treatment and document the resolution of CI. If the CI is not resolved, the clinician h ld ib dditi l t t t If tshould prescribe additional treatment. If symptoms
persist despite resolution of CI, alternative diagnoses should be considered
Option that clinicians may:1) Observe patients when cerumen is asymptomatic and1) Observe patients when cerumen is asymptomatic and
does not prevent an adequate assessment of the ear2) Evaluate the need for intervention in the patient who2) Evaluate the need for intervention in the patient who
may not be able to express symptoms but presents with cerumen obstructing the ear canal
3) May treat the patient with CI with cerumenolytic agents, irrigation, or manual removal other than irrigation
4) May educate/counsel patients with cerumen4) May educate/counsel patients with cerumen impaction/excessive cerumen regarding control measures.measures.
Cerumen removalCerumen removal
IrrigationIrrigation CerumenolyticsCerumenolyticsSyringeSyringe
WaterWater--picpic
Peroxide basedPeroxide based
Cerumenex®Cerumenex®
ManualManual NaHCONaHCO33
OtherOther
Ear candlesEar candles
Ear candles SealyEar candles SealyEar candles -- Sealy 1996Ear candles -- Sealy 199619961996
No neg pressureNo neg pressure
Burnt paraffinBurnt paraffin
Injuries Injuries (n=(n=122122))::jj (( ))
13 13 burnsburns
7 7 paraffin occlusionsparaffin occlusionspa a occ us o spa a occ us o s
2 2 TM perfsTM perfs
33 otitis externaotitis externa3 3 otitis externaotitis externa
6 6 CHLCHL
FurunculosisFurunculosis
Lateral Lateral 11//33
Staph aureusStaph aureus
Systemic antibiotics Systemic antibiotics yywith good gram + with good gram + coveragecoveragegg
Cephalosprin, clinda.,Cephalosprin, clinda.,
I&DI&DI&DI&D
Fungal External OtitisFungal External Otitis
Uncommon as a Uncommon as a primary diseaseprimary diseaseprimary disease. primary disease. Fungal organisms Fungal organisms may grow on may grow on y gy gdesquamated desquamated epithelium or epithelium or cerumen as simple cerumen as simple saprophytessaprophytes
T f l titi iT f l titi iTrue fungal otitis is True fungal otitis is almost always either almost always either Aspergillus orAspergillus orAspergillus or Aspergillus or Candida SpeciesCandida Species
Treatment of Fungal OtitisTreatment of Fungal Otitis
Mechanical debridmentMechanical debridment
Usually responds to reUsually responds to re--acidification acidification &/or the use of topical anti&/or the use of topical anti--septicsseptics&/or the use of topical anti&/or the use of topical anti septics septics (Gentian violet, mercurochrome, )(Gentian violet, mercurochrome, )
O l l ill tif lO l l ill tif lOnly rarely will antifungal Only rarely will antifungal antibiotics be requiredantibiotics be required
L t t l Th E t l ELucente et al: The External Ear
A t DiffA t DiffAcute Diffuse Acute Diffuse Bacterial External Bacterial External OtitisOtitis
AOEAOEAOEAOE
AOE: PathogenesisTemp and Temp and humidityhumidity
S lS lSeasonalSeasonal
pHpHpHpH
DermatitisDermatitis
TraumaTrauma
Fabricant et al. Arch Otorhinolaryngol: 201-9, 1949.
Diagnosis of AOEDiagnosis of AOE
History History Pain and DischargePain and Discharge
including predisposing factors suchincluding predisposing factors suchincluding predisposing factors such including predisposing factors such as diabetes and immunosuppresionas diabetes and immunosuppresion
Physical examinationPhysical examinationPhysical examination Physical examination tenderness, erythema and edematenderness, erythema and edema
Purulent DrainagePurulent Drainage
BACTERIOLOGY OFBACTERIOLOGY OFBACTERIOLOGY OF AOEBACTERIOLOGY OF AOEAOEAOE
55%
50%
60% % Incidence
30%40%
50%
15%20%
30%
0%
10%
0%Pseudomonas Staph Other gram neg
AOE: TreatmentAOE: Treatment
Removal of Removal of OtowickOtowick
debris debris (irrigation,suction)(irrigation,suction)
ReRe--acidificationacidification Appropriate pain Appropriate pain ReRe acidificationacidification
Appropriate Appropriate tibi titibi ti
pp p ppp p pmanagementmanagement
SystemicSystemicantibiotics antibiotics (Aminoglycosides, (Aminoglycosides, Quinolones)Quinolones)
Systemic Systemic antibiotics are antibiotics are rarely requiredrarely requiredQuinolones)Quinolones) rarely requiredrarely required
Problem #Problem #1 1 ScienceScience
• No good data on naturalNo good data on natural historyy–No modern studies with a ‘Placebo arm”
Problem #Problem #2 2 ScienceScience
• Impact of allergicImpact of allergic sensitization on outcome
HypersensitivityHypersensitivity
• Ear molds, chrome, i k l t hnickel, matches
• often iatrogenic– Aminoglycosides,
esp. Neomycin & S lfSulfas
– Other antibiotics
– Topical anesthetics and antihistamines
SensitizationSensitization
• 1st case of contact allergy to Neomycin was reported in l952 by Baer and Ludwig in a pt withreported in l952 by Baer and Ludwig in a pt with chronic OE!
• Cross reactivity between Neomycin and otherCross reactivity between Neomycin and other Aminoglycosides is common. Cf tobra in the Netherlands
• The reaction time of the aminoglycosides in patch testing almost always exceeds 3 days and often takes 7 daysoften takes 7 days
• The routine use of Neomycin is not recommended because of the high risk of sensitizationbecause of the high risk of sensitization
HypersensitivityHypersensitivity
• WARNING: THE MANIFESTATION OFMANIFESTATION OF SENSITIZATION TO
NEOMYCIN IS USUALLY A LOW
GRADE REDDENING WITH SWELLING,
DRY SCALING AND ITCHING; IT MAYITCHING; IT MAY
SIMPLY MANIFEST AS FAILURE TO HEAL
Problem # Problem # 3 3 ScienceScience
• What is theWhat is the pathophysiology?p p y gy– Bacterial exposure?
pH?– pH?
– Host factors? I.e. blood group, cerumen?
– Virulence factors? Adhesion?
– Temp and pressure variablesp p
Problem #Problem #4 4 EducationEducation
• Continued use of systemicContinued use of systemic agentsg– Halpern: 40% prescribed both
M C 39% t i l 25% l– McCoy: 39% topical; 25% oral
Halpern et al J Am Board Fam Pract 1999 McCoy et al Pediatr Infect
Di J 2004
Problem # Problem # 5 5 EducationEducation
• Irrelevance of “MIC”Irrelevance of MIC
Problem #Problem #7 7 EducationEducation
• Frequency of fungal AOEFrequency of fungal AOE at initial presentationp
Controversy #Controversy #11
• Do you need an antibiotic?o you eed a a t b ot cOr is a steroid, antiseptic &/or an
idif i l ti d t ?acidifying solution adequate?
Controversy #Controversy #11
• To what extent should cost o at e te t s ou d costbe a consideration?
Controversy # Controversy # 22
• Does the addition of a topical steroid make a clinicallysteroid make a clinically relevant difference? Is it worthrelevant difference? Is it worth the added cost?
Controversy #Controversy #33Controversy #Controversy #33
• Does topical therapy t ib t t thcontribute to the emergence
of resistant strains either:of resistant strains either:– A) Locally?
– B) Distal to site of administration (NP) or
) ( )• (I.e “Collateral Damage”)?
Roland et al Laryngoscope 2004
Resistance Resistance
• In 1125 patients treated with ototopical fluoroquinolones for either AOMT or AOE
• 27 persisting isolates had pre-treatment and post treatment MIC data availableand post-treatment MIC data available for comparison .
RESULTSRESULTSRESULTSRESULTSOrganism No. of Pretreatment MIC Pretreatment Persisting Post-treatment
isolates range MIC50 MIC range MIC50
Pseudomonas aeruginosa
13 0.06 – 0.25 0.13 0.06 – 0.25 0.13
Streptococcus pneumoniae
4 0.5 – 2.0 1.0 0.5 – 2.0 1.5
Staphylococcus aureus 3 0.5 – 8.0 1.0 1.0 – 8.0 1.0Staphylococcus aureus 3 0.5 8.0 1.0 1.0 8.0 1.0
Coryneform microbacterium
3 1.0 – 32 32 1.0 – 32 32
Staphylococcus epidermidis
2 2.0 – 4.0 3.0 2.0 – 4.0 3.0
Haemophilus 1 0 016 0 016 0 016 0 016Haemophilus influenzae
1 0.016 0.016 0.016 0.016
Streptococcus agalactiae
1.0 1.0 1.0 1.0 1.0
Roland et al submitted for publication
ResistanceResistance
• No evidence that treatment with a topical quinolone resulted in i d MIC t i lincreased MIC to quinolones
• MIC did not predict treatment• MIC did not predict treatment success vs treatment failure
Rosenfeld et al OTO HNS MayRosenfeld et al OTO-HNS May 2006
Strong RecommendationStrong Recommendation
• Management of AOE should include assessment of pain and a recommendation for analgesic gtreatment based on the severity of pain
RecommendationsRecommendations
• 1) Distinguish diffuse AOE from other causes
• 2) Assess the patient for factors that2) Assess the patient for factors that modify treatment
N i t t TM TT di b t– Nonintact TM, TT, diabetes, immunocomprimised state, prior radiation ththerapy
• 3) Use topical therapy for initial ) p pymanagement
RecommendationsRecommendations
• 4) The choice of topical agent should be based on:based on:– Efficacy
Low incidents of adverse events– Low incidents of adverse events– Likelihood of adherence– CostCost
• 5) Clinicians should inform pts how to administer the dropsadminister the drops
• 6) When the TM is nonintact, a non-ototoxic topical preparation should be prescribedtopical preparation should be prescribed
• 7) If the patient fails to respond within 48 to 72hrs, the clinician should reassess the pt.
AOE: Treatment FailureAOE: Treatment Failure
Ineffective deliveryIneffective delivery
SensitizationSensitization
Poor compliance with therapyPoor compliance with therapyPoor compliance with therapyPoor compliance with therapy
Selection of an antibiotic with poor Selection of an antibiotic with poor of coverage for causative pathogen of coverage for causative pathogen
Resistant pathogen?Resistant pathogen?Resistant pathogen?Resistant pathogen?
Chronic External OtitisChronic External Otitis
a low grade , diffuse infection of a low grade , diffuse infection of the external canal that persist for the external canal that persist for months or yearsmonths or yearsyy
It i h t i d li i ll bIt i h t i d li i ll bIt is characterized clinically by It is characterized clinically by pruritits, scanty otorrhea and pruritits, scanty otorrhea and progressive narrowing of the lumen progressive narrowing of the lumen of the EAC.of the EAC.of the EAC. of the EAC.
Pathology:Pathology:
Mild to mod Mild to mod ddedemaedema
Chronic Chronic inflammatory cell inflammatory cell infiltrateinfiltrate
Often focalOften focal
Microabscess Microabscess formationformation
Areas of Areas of calcificationcalcification
Pathology:Pathology:
PathologyPathology
Progressive Progressive b ith li lb ith li lsubepithelial subepithelial
fibrosis leading to fibrosis leading to t it istenosisstenosis
Post inflammatory Post inflammatory di l ldi l lmedial canal medial canal
fibrosisfibrosis
PathologyPathology
Clinical PresentationClinical PresentationHearing loss is a Hearing loss is a more common more common
titipresenting presenting symptom than symptom than otorrheaotorrheaotorrheaotorrhea
Females Females 22::11Exacerbated by Exacerbated by hearing aidshearing aidsOft t t iOft t t iOften starts in Often starts in anterior sulcus anterior sulcus
Bilateral in Bilateral in 5050%%
Physical examinationPhysical examination
Absent cerumenAbsent cerumen
Raw epithelial Raw epithelial surfacesurface——erythemaerythema
ElephantiasisElephantiasis
Scant milkyScant milkyScant, milky Scant, milky otorrheaotorrhea
shinnyshinnyshinnyshinny
Narrowing of the Narrowing of the lllumenlumen
InfectiousInfectious
BacterialBacterialGram negative, especially Gram negative, especially Pseudomonas Pseudomonas StaphyloccusStaphyloccus
MycoticMycoticyyNot common pathogens in AOE but Not common pathogens in AOE but role in COE unclearrole in COE unclear------probably probably p yp ygreatergreaterAspergillus & CandidaAspergillus & Candidap gp gSlow growing fungi may be missedSlow growing fungi may be missed“Id” reactions“Id” reactions
DermatologicalDermatological
Seborrheic dermatitisSeborrheic dermatitis⊕⊕ fam history, scalp (“dandruff”), fam history, scalp (“dandruff”), flexures (retroflexures (retro--auricular) auricular) (( ))
PsoriasisPsoriasisOccasionally is isolated to earsOccasionally is isolated to earsOccasionally is isolated to earsOccasionally is isolated to ears
May develop from seborrheaMay develop from seborrhea
NeurodermatitisNeurodermatitis
Sensitization in Sensitization in COECOE
• Rasmussen: 35% of 98 chronic OE. N i @ 8%Neomycin @ 8%. (Rasmussen Acta Otolaryngol. 1974)
• Fraki: 40% 0f 142 chronic OE. Neomycin and framycetin most common @ 16.2% (Fraki JE et al: Act Otolaryngol. 1985)
• Smith: 58% 0f 49 pts w chronic OE• Smith: 58% 0f 49 pts w chronic OE. Neomycin commonest @ 32%. Cross sensitization among aminoglycosides @ 17-sensitization among aminoglycosides @ 1750% (Smith et al: Clin. Otolaryngol. 1990.)
• Ginkel: 56% 0f 34 pts w chronic OE and• Ginkel: 56% 0f 34 pts w chronic OE and CSOM. Neomycin & framycetin most common @ 35% (Van Ginkel et al: Clin Otolaryngol 1995)common @ 35% (Van Ginkel et al: Clin Otolaryngol 1995)
MixedMixed
The majority of cases of COE are The majority of cases of COE are probably in this categoryprobably in this category
TreatmentTreatment
MedicalMedicalEarly stage of disease. Ideally will Early stage of disease. Ideally will prevent stenosisprevent stenosispp
May only serve to slow progressionMay only serve to slow progression——no long term outcome datano long term outcome datano long term outcome datano long term outcome data
SurgicalSurgicalLate stage of disease. Late stage of disease.
Medical TherapyMedical Therapy
SteroidsSteroids: drops, : drops, creams, creams, injections?injections?
Single agents. Ie Single agents. Ie opthalmic drops opthalmic drops or dermatologicor dermatologicor dermatologic or dermatologic creamscreams
CombinationCombinationCombination Combination agentsagents
Medical TherapyMedical Therapy
AntibioticsAntibioticsU i lU i lUse sparinglyUse sparinglyQuinolone drops Quinolone drops PowdersPowders lastlastPowdersPowders----last last longer & can longer & can include multiple include multiple agentsagentsCultureCulture
“N T h” l“N T h” l“No Touch” aural “No Touch” aural toilettoilet
Surgical TherapySurgical Therapy
For hearing For hearing t tit tirestorationrestoration
To restore canal To restore canal patencypatency
Local flapsLocal flaps
PrePre--conchal, post auricular conchal, post auricular Tendency to contract may help pull Tendency to contract may help pull canal opencanal openpp
Decreased scarring because Decreased scarring because ↑↑vascularityvascularityvascularityvascularity
Hard to get enough length Hard to get enough length
B lkB lkBulkyBulky
FTSG vs STSGFTSG vs STSGGreater Greater resistance to resistance to traumatrauma
Most commonly Most commonly usedusedtraumatrauma
GlandularGlandularEasiest to obtainEasiest to obtain
Glandular Glandular elements provide elements provide lubricationlubrication
Less reLess re--stenosis?stenosis?
Less likely to Less likely to contractcontractcontractcontract
Successful operationsSuccessful operations
Completely remove cicatrixCompletely remove cicatrix
Include a canalplastyInclude a canalplasty
Resurface the bony canalResurface the bony canalResurface the bony canalResurface the bony canal
Surgical resultsSurgical results
≈ ≈ 8080% patent canal % patent canal b tb tbut recurrences but recurrences occur late occur late
earliest @ earliest @ 33yrs in yrs in Slattery’s seriesSlattery’s series
Hearing Hearing improvements range improvements range ff 1010dBdB 00dBdBfrom from 1010dB to dB to 5050dB dB
6161% with closure of % with closure of th ith i b ABG tb ABG tthe airthe air--bone ABG to bone ABG to 20 20 dB (Beckers dB (Beckers ---- 53 53 pts)pts)
COECOE
Be very cognizant of the role that Be very cognizant of the role that sensitization can playsensitization can playsensitization can playsensitization can playSteroids are a mainstay of medical Steroids are a mainstay of medical managementmanagementmanagementmanagementUse antibiotics(powder can be Use antibiotics(powder can be helpful) sparingly and culture forhelpful) sparingly and culture forhelpful) sparingly and culture for helpful) sparingly and culture for organismorganismAny manipulation of the canalAny manipulation of the canalAny manipulation of the canal Any manipulation of the canal seems to exacerbate the condition, seems to exacerbate the condition, including aggressive clearingincluding aggressive clearingincluding aggressive clearingincluding aggressive clearingSurgery is successful in Surgery is successful in 8080%%
Granular MyringitisGranular Myringitis
Proliferating granulation tissue Proliferating granulation tissue limited to TM and adjacent canal limited to TM and adjacent canal skin.skin.
Normal Middle Ear !!Normal Middle Ear !!
Granular Myringitis: clinicalGranular Myringitis: clinical
Focal Focal 2020%%
DiffDiffDiffuse Diffuse 1010%%
Segmental Segmental 7070%%7070%%
Blevins: Otol & Neurotol 2001, El-Seifi: AJO 2000
Granular Myringitis: clinicalGranular Myringitis: clinical
Otorrhea Otorrhea 8585%%8585%%Itching Itching gg5050%%Hearing lossHearing lossHearing loss Hearing loss 3535%%Aural fullnessAural fullnessAural fullness Aural fullness 2020%%
Blevins: Otol & Neurotol 2001, El-Seifi: AJO 2000
Granular Myringitis: pathGranular Myringitis: path
El-Seifi: AJO 2000
Granular Myringitis: RxGranular Myringitis: Rx
AntisepticsAntiseptics Ototopical Antibiotics Ototopical Antibiotics
FormaldehydeFormaldehyde
CurettageCurettage
w steroids: w steroids: eg eg tobradex®tobradex®
CurettageCurettageCauterization: Cauterization: egegsilver nitratesilver nitratesilver nitrate, silver nitrate, trichloroacetic acidtrichloroacetic acid
55 FUFU5 5 FU creamFU cream
Surgical resectionSurgical resectiongg
Canal CholesteatomaCanal Cholesteatoma
UnilateralUnilateral Multiple etiologiesMultiple etiologies
No ass systemic No ass systemic diseasedisease
congenitalcongenital
Post traumaticPost traumatic
OlderOlder
Rx: medical orRx: medical or
Post obstructivePost obstructive
Post inflammatoryPost inflammatoryRx: medical or Rx: medical or surgicalsurgical SpontaneousSpontaneous
IatrogenicIatrogenic
Keratosis ObturansKeratosis Obturans
BilateralBilateral SymptomsSymptoms
Ass w sinusitis & Ass w sinusitis & bronchiectasisbronchiectasis
CHLCHL
Otorrhea rareOtorrhea rare
Rx: regular office Rx: regular office debridementdebridement
Pain Pain
11st and st and 22nd nd decadesdecadesdecadesdecades
KeratosisKeratosisKeratosis CholesteatomaKeratosis CholesteatomaCholesteatomaCholesteatoma
Keratosis Keratosis CholesteatomaCholesteatoma
Keratosis Keratosis CholesteatomaCholesteatoma
Seborrheic DermatitisSeborrheic Dermatitis
Malassezia FurfurMalassezia Furfur
PruritisPruritis
FlakingFlakinggg
Increased Increased vulnerability tovulnerability tovulnerability to vulnerability to AOEAOE
ExostosisExostosisSuture linesSuture lines
1717 55 C canalC canal1717..5 5 C canal C canal erythemaerythema
7373% surfers% surfers7373% surfers% surfers
Lateral to isthmusLateral to isthmus
OsteomaOsteoma
True neoplasmTrue neoplasm
SingleSingle
UnilateralUnilateral
ExostosisOExostosisOOsteomaOsteoma
ReactiveReactive NeoplasticNeoplastic
Non occlusiveNon occlusive
BilateralBilateral
OcclusiveOcclusive
UnilateralUnilateral
MultipleMultiple
SessileSessile
SingleSingle
PeduculatedPeduculatedSessile Sessile
Lamellar boneLamellar bone
PeduculatedPeduculated
Trabecular boneTrabecular bone
Exostosis O
Exostosis OOsteomaOsteoma
Surgical TechniqueSurgical Technique
Skin flapsSkin flaps
ChiselChisel
DrillDrill
Facial Nerve!Facial Nerve!1414% Of FN% Of FN1414% Of FN % Of FN paralysis paralysis (Green)(Green)
Monitor?Monitor?Monitor?Monitor?
Malignant Otitis Externa Malignant Otitis Externa
Osteomyelitis of the temporal boneOsteomyelitis of the temporal boneNecrotizing External OtitisNecrotizing External Otitis
ChandlerChandler 19681968Chandler Chandler 19681968≈ ≈ 5050% mortality% mortality
≈ ≈ 7575% CN VII involvement% CN VII involvement
Death from massive septic Death from massive septic ppthrombophlebitisthrombophlebitis
MOE- historyMOE- history
Male Male 22::11 Dull,boring otalgia Dull,boring otalgia d HAd HAElderly diabeticElderly diabetic
Immune def ?Immune def ?
and HAand HA
Scant otorrheaScant otorrhea
Is this a different Is this a different process?process?
CN paresisCN paresis
MOE physical examMOE physical exam
Granulations @ Granulations @ OO C j tiC j tiOO--C junctionC junction
TendernessTenderness
Erythema & Erythema & EdemaEdema
CN deficitsCN deficits
MOE etiologyMOE etiology
Cerumen pH= Cerumen pH= 77..44 RuberiRuberi: :
ZikkZikk: : 88//24 24 had had
aural irrigations:aural irrigations:6565% vs % vs 1515%%((88//1313))
previous aural previous aural irrigations for irrigations for
((88//1313))
Showering:Showering:100100% vs% vs 9696%%gg
cerumen removalcerumen removal100100% vs % vs 9696%%
Swimming:Swimming:2525% vs % vs 1919%%
Ear Cleaning:Ear Cleaning:9696% vs % vs 9696%%
MOE bacteriologyMOE bacteriology
Pseudomonas aeruginosaPseudomonas aeruginosa
AspergillusAspergillus ( ll f i ti )( ll f i ti )Aspergillus Aspergillus (usually fumigatis)(usually fumigatis)
Proteus, Staph , KlebsiellaProteus, Staph , Klebsiella
MOE diagnosisMOE diagnosis
ESRESR CTCTAb EACAb EACRadiologyRadiology
Tc Tc 9999mm
Abn EAC Abn EAC 100100%%ME/mastoidME/mastoid
Gallium Gallium 6767citratecitrateME/mastoid ME/mastoid 9090%%Dz Dz ---- ET ET 6565%%Mass NP Mass NP 5050%%5050%%Subtemp Subtemp 5050%%5050%%Paraphary Paraphary 5050%%
MOE RxMOE RxMOE RxMOE Rx
IV antibioticsIV antibiotics SurgicalSurgicalAminogllycosidesAminogllycosides
SS penicilinsSS penicilins
debridement debridement
DrainageDrainage
RefampinRefampin
CeftazadimeCeftazadimeHBOHBO
Stage III or Stage III or
Oral antibioticsOral antibioticsQuinolonesQuinolones
treatment failurestreatment failures
CombinationCombination
MOE oral quinolonesMOE oral quinolones
GiamarellouGiamarellou159 159 patientspatients
Ciprofloxacin Ciprofloxacin 8888//101101pp
Ofloxacin Ofloxacin 3838//46 46 ((5 5 resistant)resistant)
MOE stagingMOE staging
STAGE ISTAGE I: infection of canal and : infection of canal and contiguous soft tissue w/wo CN VII contiguous soft tissue w/wo CN VII involvementinvolvement
STAGE IISTAGE II: Extension to include : Extension to include osteitis of skull base and multipleosteitis of skull base and multipleosteitis of skull base and multiple osteitis of skull base and multiple cranial nervescranial nerves
STAGE IIISTAGE III: Intracranial : Intracranial complicationscomplicationscomplicationscomplications
MOE completion of RxMOE completion of Rx
Standard Standard 6 6 wkswksResolution of symptomsResolution of symptoms
Resolution of gallium or indium scanResolution of gallium or indium scanResolution of gallium or indium scanResolution of gallium or indium scan
RecurranceRecurranceOtalgia!Otalgia!
ESRESR
Gallium/indium scanGallium/indium scan