External Otitis (Otitis Externa)

External otitis, or otitis externa, refers

to an inflammation of the external
auditory canal. Otitis externa is an
inflammation/infection of the external
ear, pinna, and/or ear canal.
 Causes
• Include water in the ear canal (swimmer’s ear)
• Trauma to the skin of the ear canal, permitting entrance
of organisms into the tissues
• systemic conditions, such as vitamin deficiency and
endocrine disorders.
• Bacterial or fungal infections
• The most common bacterial pathogens,Staphylococcus
aureus and Pseudomonas species.
• The most common fungus isolated in both normal and
infected ears is Aspergillus.
• dermatosis such as psoriasis, eczema, or seborrheic
dermatitis.
• allergic reactions to hair spray, hair dye, and permanent
wave lotions can cause dermatitis, which clears when the
offending agent is removed.
 NURSING MANAGEMENT
Nurses should instruct patients not to clean the
external auditory canal with cotton-tipped
applicators
to avoid events that traumatize the external canal
such as scratching the canal with the fingernail or
other objects.
Patients should also avoid getting the canal wet
when swimming or shampooing the hair. A cotton
ball can be covered in a water insoluble gel such as
petroleum jelly and placed in the ear as a barrier to
water contamination.
Infection can be prevented by using antiseptic otic
preparations after swimming (eg, Swim Ear, Ear
Dry), unless there is a history of tympanic
membrane perforation or a current ear infection.
 Nursing Interventions and Patient Education
1. Demonstrate proper application of eardrops.
2. Advise the patient that otitis externa can be prevented or
minimized by thoroughly drying the ear canal after coming into
contact with water or moist environment.
3. Teach the patient to use prophylactic eardrops after
swimming to assist in preventing swimmer’s ear, as directed by
health care provider.
4. Advise the use of properly fitting earplugs for recurrent cases.
5. Teach proper ear hygiene: clean auricle and outer canal with
washcloth only; do not insert anything smaller than finger
wrapped in washcloth in ear canal. Avoid inserting cotton swabs
or sharp objects into ear canal because:
a. Cerumen may be forced against the tympanic membrane,
causing impaction.
b. The canal lining may be abraded, making it more susceptible
to infection. c. The tympanic membrane may be injured.
 Cerumen Impaction

Definition
Impacted Cerumen and Foreign Bodies Cerumen
impaction is defined as accumulation of cerumen,
or “ear wax,” that causes symptoms of ear pain,
fullness, or hearing loss and/or prevents
visualization of the tympanic membrane.
 Management
• Cerumen can be removed by irrigation, suction, or instrumentation.
Unless the patient has a perforated eardrum or an inflamed external ear
(ie, otitis externa), gentle irrigation usually helps remove impacted
cerumen, particularly if it is not tightly packed in the external auditory
canal.
• To prevent injury, the lowest effective pressure should be used. However,
if the eardrum behind the impaction is perforated, water can enter the
middle ear, producing acute vertigo and infection.
• If irrigation is unsuccessful, direct visual, mechanical removal can be
performed on a cooperative patient by a trained health care provider.
• Instilling a few drops of warmed glycerin, mineral oil, or half-strength
hydrogen peroxide into the ear canal for 30 minutes can soften cerumen
before its removal.
• Ceruminolytic agents, such as peroxide in glyceryl (Debrox), are available;
Using any softening solution two or three times a day for several days is
generally sufficient.
• If the cerumen cannot be dislodged by these methods, instruments, such
as a cerumen curette, aural suction, and a binocular microscope for
magnification, can be used.
Nursing Interventions and Patient
Education
1. Teach proper ear hygiene, especially not putting
anything in ears.
2. Explain the normal protective function of cerumen.
3. If patient has a problem with cerumen buildup and
has been advised by health care provider to use a
ceruminolytic periodically, make sure that patient is
getting cerumen out of ear before more medication is
instilled. A bulb syringe may be used by the patient at
home to help remove softened cerumen.
4. Advise patient to report persistent fever, pain,
drainage, or hearing impairment.
 Tympanic Membrane
Perforation

Perforation of the tympanic membrane is

usually caused by infection or trauma. Sources
of trauma include skull fracture, explosive
injury, or a severe blow to the ear.
Less frequently, perforation is caused by foreign
objects (eg, cotton tipped applicators, bobby
pins, keys) that have been pushed too far into
the external auditory canal.
 Medical Management
Although most tympanic membrane
perforations heal spontaneously within weeks
after rupture, some may take several months to
heal.
Some perforations persist because scar tissue
grows over the edges of the perforation,
preventing extension of the epithelial cells across
the margins and final healing. In the case of a
head injury or temporal bone fracture, a patient
is observed for evidence of cerebrospinal fluid
otorrhea or rhinorrhea—a clear, watery drainage
from the ear or nose, respectively. While healing,
the ear must be protected from water.
 Surgical Management
Perforations that do not heal on their own may
require surgery. The decision to perform a
tympanoplasty (surgical repair of the tympanic
membrane) is usually based on the need to
prevent potential infection from water entering
the ear or the desire to improve the patient’s
hearing. Performed on an outpatient basis,
tympanoplasty may involve a variety of surgical
techniques. In all techniques, tissue (commonly
from the temporalis fascia) is placed across the
perforation to allow healing. Surgery is usually
successful in closing the perforation
permanently and improving hearing.
 Acute Otitis Media
Acute otitis media is an inflammation and
infection of the middle ear caused by the
entrance of pathogenic organisms, with rapid
onset of signs and symptoms.
Acute otitis media or acute suppurative otitis
media is infection of the middle ear caused by
contamination from bacteria from the middle ear
fluid through the eustachian tube.
 Clinical Manifestations

1. Pain is usually the first symptom.

2. Fever may rise to 104° F to 105° F (40° C to 40.6°
C).
3. Purulent drainage (otorrhea) is present if
tympanic membrane is perforated.
4. Irritability may be noted in the young person.
5. Headache, hearing loss, anorexia, nausea, and
vomiting may be present.
6. Purulent effusion may be visible behind tympanic
membrane or tympanic membrane may be
reddened and bulging on otoscopic examination.
 Management
Antibiotic treatment—amoxicillin is first-line treatment;
cephalosporins, macrolides, or trimpethoprim- sulfamethoxazole
may be used in patients with penicillin allergy.
Amoxicillin/clavulanate and cephalosporins are used for treatment
failure due to increasing rate of beta-lactamase- producing bacteria
that inactivate penicillin and other antibiotics. Usual treatment
course is 10 days.
Nasal or topical decongestants and antihistamines have a limited
role in promoting eustachian tube drainage.
Surgery—myringotomy with placement of pressure-equalizing
tubes.
a. An incision is made into the posterior inferior aspect of the
tympanic membrane for relief of persistent effusion. A pressure-
equalizing tube may be inserted to prevent recurrent episodes.
b. Performed in selected patients to prevent recurrent episodes or in
patients with middle ear effusion for 3 months or more.
c. May be done because of failure of patient to respond to
antimicrobial therapy; for severe, persistent pain; and for persistent
conductive hearing loss.
Chronic Otitis Media and Mastoiditis

Definition-
Chronic otitis media is a chronic inflammation of
the middle ear with tissue damage, usually
caused by repeated episodes of acute otitis
media.
It may be caused by an antibiotic-resistant
organism or a particularly virulent strain of
organism. It may be associated with tympanic
membrane perforation. Mastoiditis is
inflammation of the mastoid air cells of the
temporal bone adjacent to the ear.
 Management
Medical Therapy
1. Antibiotic and steroid eardrops may control middle
ear infection and inflammation, but when mastoiditis
develops, parenteral antibiotic therapy is necessary.
2. Eardrops containing neomycin, garamycin,
tobramycin, and quinolones, such as ciprofloxacin, are
instilled into the middle ear when the tympanic
membrane is ruptured. Otic drops containing
antibiotics or antibiotic powder preparations may be
used for infection and otorrhea. Local cleaning using
microscope and instrumentation is mainstay of
treatment and done by ENT specialist.
3. IV antibiotics must cover beta-lactamase-producing
organisms—ampicillin-sulbactam, cefuroxime—based
on culture results.
 Surgical Interventions
1. Indicated when cholesteatoma is present.
2. Indicated when there is pain, profound deafness,
dizziness, sudden facial paralysis, or stiff neck (may
lead to meningitis or brain abscess).
3. Types of procedures:
a. Simple mastoidectomy—removal of diseased bone
and insertion of a drain; indicated when there is
persistent infection and signs of intracranial
complications.
b. Radical mastoidectomy—removal of posterior wall
of ear canal, remnants of the tympanic membrane, and
the malleolus and incus.
c. Posteroanterior mastoidectomy—combines simple
mastoidectomy with tympanoplasty (reconstruction of
middle ear structures).