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