Case Report

Furunculosis External Otitis

Presentator: Pradhana Fajar Wicaksana

Moderator :Dr.dr. Sagung Rai Indrasari.,Mkes.Sp.T.H.T.K.L (K) FICS

Department ofHealthEarNoseThroat-HeadNeck Surgery

Faculty ofMedicine, Universitas GadjahMada /Dr.SardjitoHospital
Yogyakarta
2017

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CHAPTER I aureus. Damage to the hair follicle
allows these bacteria to enter deeper
INTRODUCTION
into the tissues of the follicle and the

Inflamatory changes in the tissue underneath. Furuncle/boils may

external ear are common and often occur in the hair follicles anywhere on

treated initially by a primary care the body. They are most common on

physician and otologist. It is important, the face, neck, armpit, buttocks, and

therefore, to be familiar with the thighs. There can be one or many

various type of external ear boils.2

inflammations, their hazards, and their Bacterial otitis externa is a

appropriate management. Different common problem for the otologist as

inflammatory conditions of the well as general practitioner. Thats why

external ear are interrelated to their as a medical professional we must

pathogenesis, sometimes making it understand how to diagnose the

difficult to differentiate the various disease and how to treat it with a

forms.1 reasonable therapy because disease

Inflamations of the external ear extention can produce intratemporal

may manifest acutely with severe pain, and intracranial complications through

subacutely, or may present with involvement neurovasculer pathway.3

chronic complaints. Acute

inflammations are often caused by
bacterial infection. The term otitis
externa usually refers to inflammation
of the external auditory canal. One
example of inflammations of the
external ear is furuncle.1 Furuncles are
very common. They are generally
caused by the bacteria Staphylococcus

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CHAPTER II constrictions, one near the medial
end of the cartilaginous part, the
OVERVIEW
other, the isthmus. The tympanic
membrane, which closes its medial
A. ANATOMY EXTERNAL EAR end, is obliquely set and
The external ear consists of the consequently the floor and the
auricle or pinna and the external anterior wall of the meatus are
acoustic meatus/external auditory longer than its roof and posterior
canal. The external acoustic wall. The lateral, cartilaginous part
meatus extends from the concha to is about 8 mm long. It is
the tympanic membrane. Its length continuous with the auricular
is 2.5 cm – 3 cm from the floor of cartilage and attached by fibrous
the concha and 4 cm from the tissue to the circumference of the
tragus. It has two structurally osseous part. This meatal cartilage
different parts; the lateral third is is deficient posterosuperiorly, and
cartilaginous and the medial two- the gap is occupied by a sheet of
thirds is osseous. It forms an S- collagen.3,4
shaped curve, directed at first The skin of the auricle
medially, anteriorly and slightly up continues into the external acoustic
(pars externa), then meatus and covers the external
posteromedially and up (pars surface of the tympanic membrane.
media) and lastly anteromedially It is thin, has no dermal papillae,
and slightly down (pars interna). It and is closely adherent to the
is oval in section, its greatest cartilaginous and osseous parts of
diameter is obliquely inclined the tube. Inflammation here is
posteroinferiorly at the external therefore very painful. The thick
orifice, but is nearly horizontal at subcutaneous tissue of the
its medial end. There are two cartilaginous part of the meatus
contains numerous ceruminous

3
glands which secrete ear wax or
cerumen. Their coiled tubular
structure resembles that of sweat
glands. The secretory cells are
columnar when active, but
cuboidal when quiescent. They are
covered externally by
myoepithelial cells. Ducts open
either on to the epithelial surface or
into the nearby sebaceous gland of
Figure of Coronal section of the ear canal. The
a hair follicle. Cerumen prevents skin of the cartilaginous and osseous canals
are magnified.
the maceration of meatal skin by (From Lilwani, 2008)
trapped water. Overproduction or
accumulation of wax may Two branches of the external
completely block the meatus or carotid artery provide most of the
obstruct the vibration of the arterial supply to the ear. The
tympanic membrane. Although superficial temporal artery supplies
ceruminous glands and hair the anterior portion of the external
follicles are largely limited to the canal and auricle, and the posterior
cartilaginous part, a few small auricular artery provides blood to
glands and fine hairs also occur in the mastoid region and the
the roof of the lateral part of the posterior portions of pinna and
osseous meatus.4,5 canal.6 Lymphatic drainage of
auricular are: 1) Pre-auricular
lymph nodes ( Parotid lymph
nodes ) anteriorly 2). Post-
auricular lymph nodes ( Posterior
lymph nodes ) posteriorly 3).

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 superficial cervical lymph nodes cartilaginous portion of the ear
inferiorly.7 canal. The infection occurs most
The innervations of the pinna commonly at the junction of the
and external auditory canal derives concha and canal skin.1,8
from the auriculotemporal branch
of trigeminal nerve which B.2.Etiology
innervates the anterior canal wall Furunculosis is conditions
and tympanic membrane, as well resulting from gram positive
as the anterior aspect of the pinna. infections, usually staphylococcal,
The greater auricular nerve of the hair follicles.8
supplies the mastoid process and
both lateral and medial of the B.3.Pathogenesis
posterior pinna and tympanic The two factors that are
membrane. The auricular branch of required for external otitis to
the vagus innervates the inferior develop are (1) the presence of
bony canal and tympanic germs that can infect the skin and
membrane, the posterosuperior (2) impairments in the integrity of
cartilaginous canal, and the cymba the skin of the ear canal that allow
concha. Branches of the facial and infection to occur. Inflammation of
chorda tympani nerves innervate the ear canal skin typically begins
the posterosuperior bony external with a physical insult, most often
auditory canal.3 from injury caused by attempts at
self-cleaning or scratching with
B. FURUNCULOSIS cotton swabs, pen caps, finger
B.1.Definition nails, hair pins, keys, or other
Furuncle (also known as small implements.9 Glandular
circumscribed otitis externa) is a secretions from the
circumscribed lesion caused by an apopilosebaceous unit combine
acute bacterial infection of the with sloughed squamous

5
epithelium (cerumen) to coat the water-filled balloon. Pain gets
external ear canal and maintain an worse as it fills with pus and dead
acidic pH. Local mechanical tissue. Is usually pea-sized, may
trauma and contamination of the develop white or yellow centers
ear canal lead to obstruction of the (pustules).11 The primary lesion is
hair follicles or glandular ducts, usually a small well circumscribed
followed by staphylococcal pustule that may enlarge to become
infection of the pilosebaceous a furuncle or merge with several
units.1 similar lesion to form a carbuncle.
Pushing the tragus, the tablike
B.4.Diagnosis portion of the auricle that projects
Diagnosisof out just in front of the ear canal
furunculosisexternal otitis derives opening, so typically causes pain in
from signs/symptoms of the patient this condition as to be diagnostic of
and physical examinations. Pain external otitis on physical
(otalgia) is the most presenting examination. For additional
symptom which may be severe examination to ensure the
particularly when the ear is diagnosis, we can use the infected
touched, that is because the skin is skin or mucous biopsy culture, that
intimately adherent to the may show the specific germ
underlying cartilage. Other include staphylococcal or other
symptoms of furunculosis can be bacteria. The differential diagnosis
hearing loss, tinnitus, otorhea when of furunculosisexternal otitis are
the furuncle ruptures so purulent diffuse external otitis and
discharge starts flowing, even otomycosis.8,11
trismus.10 Based on physical
examination a furuncle may begin B.5.Treatment
as a tender, pinkish-red, swollen For treatment to be successful,
nodule but ultimately feel like a any accumulated infectious

6
 material must be removed.
Spontaneous drainage can often be
encouraged by the use of warm
soaks, supplemented by topical and
oral antibiotics. If this fails to
relieve obstruction of the canal,
incision and drainage under local
anesthesia are indicated.6,8
when she touched on tragus. The
pain was felt constantly and become
more severe. She also
complainedlump in her left ear
canal. Initially the patient felt water
got enter into her ear canal after she
took a bath about a week ago, then
she manipulated her ear using her
finger and cotton bud until several

CHAPTER III days after that she felt pain in her

ear and there was no fever. She
CASE REPORT
denied discharge from the ear, there
is no complaint buzzing in the ear,
A. Identity
hearing loss, dizziness or vertigo.
Name : Mr. F
No complaint on the right ear, nose,
Age : 19 years old
or throat.
Gender : Laki - laki
History of past illness:
 History of the same complains (-
Address : Yogyakarta
)
 No MR : 1.86.32.22
 History of alergy (-), Diabetic (-)
History of illness in family
members:
B. Anamnesis
 History of the same complains (-
Chief complaint : earache in the )

left ear..  History of alergy (-) Diabetic (-)

History of present illness:
Since 2 days ago, patient complain
her left ear so painful especially C. Physical Examination

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 General status : well conscious, pulled. NRS
adequatly nourished. Score is 8. It is
 Vital sign : Blood Pressure difficult to
: 110/70 mmHg examine the
Pulse : 80 x/min left canal and
Respiration : 20 x/min tympanic
Temperature : 370C membrane
 Otorhinolarygology because of the
examination: swelled area
and earache
Left Ear : The inspection
when we touch
of the left ear
the left ear. No
at left meatus
discharge from
acusticus
the left ear
externus
canal.
(posterior the
RightEar :
tragus) there is
Auricle,CAE,ty
circumscribed
mpanic
lesion,swelled,
membrane
with a pustule,
were within
hyperemicarea
normal limits.
surround it and
Nose : Within normal
have
limits
punctum.Patien
Throat : Within normal
t feels pain if
limits
the tragus is
being pressed
and the auricle D. Diagnosis
was being

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 Based on the result from anamnesis
and physical examinations, this
patient was diagnosed with the
FurunculosisExternal Otitis or
LocalizedExternal Otitis at Left
Ear.

E. Treatment
 Antibiotic tampon
 Fluocinolon acetonid +
Neomycinsulfat 3 times a
daysapplied to herleft ear.
 Na Diclofenac 2 x 50mg a day
take if only feel pain after
meal. CHAPTER IV
 Advise the patient not to DISCUSSION
manipulate her ear without
medication purposes, take the
The diagnosis of this patient
medication regularly.
derives from anamnesis and
physical examination. The main
F. Problem
complain of the patient is pain in
Treatmentand Recurency
the ear (otalgia) after
G. Planning shemanipulates her ear using her
Control again after 3 days of finger and cotton bud. Her left ear
treatment to evaluate the boil. is so painful especially when she
touches on auricular area. Then
from physical examination we find

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at left meatus acusticus externus evaluated its accuracy as a
there is circumscribed screening test to identify patients
lesion,swelled, with a pustule, with clinically important pain. This
hyperemic area surround it, and patient mention the NRS Score 8
have punctum. Patient feels pain if so it means relative worst
the tragus is being pressed and the pain.With this relative worst pain
auricle is being pulled. According patientrefuse to be perform
to Cummings and Ballenger incision and drainageat her
(2005),clinical manifestations furuncle.We hope spontaneous
include localized pain, particularly drainage can often be encouraged
to touch and the examination may by the use of warm soaks,
be difficult because of pain and supplemented by topical and oral
swelling. According to Bhargava antibiotic.
(2002) pain is presenting symptom To reduce her suffering from
which may be severe as the skin is the pain, we must use appropriate
intimately adherent to the analgesic and for this patient we
underlying cartilage. can use dicofenac. According to
Based on Barclay (2008), the Laurence (2006), diclofenac has
NRS on which patients rate their analgesic, antipyretic, and
pain as 0 ("no pain") to 10 ("worst antiinflammatory activities and has
pain") has become the most widely rapid absorption, extensive protein
used instrument for pain screening. binding..
The potential advantages of the This patient is diagnosed as
NRS are it is short, easy to furunculosis external otitis or
administer, and is validated as a localized external otitis, based on
measure of intensity of pain in Probst et al(2006), circumscribed
populations with known pain. otitis externa is also known as a
However, no studies have furuncle, this is a circumscribed
lesion caused by an acute bacterial

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infection of the cartilaginous In this case we also use
portion of the ear canal. According fluocinolone acetonidecombined
to Habif TM (2009), furuncles are with neomycin sulfate is a
generally caused by the bacteria member of aminoglycosides.
Staphylococcus aureus. Furuncle According to Mayer (2010),
may occur in the hair follicles aminoglycosides are active against
anywhere on the body including many gram-negative and some
cartilaginous part of external gram-positive bacteria. They are
auditory canal. Staphylococcal not useful for anaerobic bacteria,
infections are related to since oxygen is required for uptake
pathological conditions such boil, of the antibiotic, or for intracellular
acne, pneumonia, meningitis, and bacteria. Fluocinolone is member
arthritis. According to Todar of steroid. Acording to Katzung
(2011) and Laurence (2006), (2006), steroid dramatically reduce
staphylococci (staph) are gram- the manifestations of
positive spherical bacteria so the inflammation. This is due to their
appropriate treatment is using suppressive effects on the
antibiotic which sensitive with inflammatory cytokines and
gram positif bacteria.According to chemokines and on other mediators
Laurence (2006),antibiotic which of inflammation.
sentitive with gram positive The problem of this patient is
bacteria are beta lactam, recurrency because she has habit
quinolone,cotrimoxazole, manipulating her ear using her
tetracycline, and macrolide. finger and cotton bud so she must
According to Habif TM(2009), be educated no to manipulate her
antibacterial soaps and antibiotics ear and keep the hygiene of the ear.
placed on the skin are little help But in this moments we also use
once a boil has formed. topical ointment that needs for
manipulating her ear so we can

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educate that she can manipulate
her ear just for medication
pusposes.If there is any complaint
in the ear during the treatment she
must come to the otolaryngologist
to examine it.
CHAPTER V
CONCLUSSION

Have been reported a patient,

female, 19 years old, with chieft
complaint is pain in the left ear
(otalgia) and diagnosed as
furunculosisexternal otitis at left
ear. The patient had being gotten a
treatment, but still must be
followed up to evaluate our
treatment, manage soon if the
complication was happened,
educate the patient not to
manipulate her ear without
medication purposes, to take the
medication regularly. If there is
any complaint in the ear she better
come to the otolaryngologist.

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