PANCE Blueprint EENT (9%)

Otitis externa

Patient will present as → a 4-year-old girl who is brought to the clinic by her mother who states that the child has been complaining of progressively worsening ear pain and itchiness over the past week. Examination reveals left tragal tenderness and an edematous and closed canal. Weber lateralizes to the left.

Otitis externa is an infection of the external auditory canal secondary to trauma or a consistently moist environment, which favors the growth of fungi or bacteria. It generally presents with canal itching and pain with movement of the ear. If the canal is closed, Weber is expected to lateralize to the side of the blocked canal.

  • Painful, edema with cheesy white discharge, sometimes it is impossible to see the TM
  • Most common causes: Pseudomonas, Staph. Aureus, Proteus, Klebsiella, Herpes Zoster, aspergillus
  • Malignant otitis externa is commonly seen in diabetics
  • Fungal OM usually caused by aspergillus 90%

Diagnosis is clinical by otoscopy

Bacterial OM: 

  • If perforated or chance of peroration: Ciprofloxacin 0.3% and dexamethasone 0.1% suspension: 4 drops BID × 7 days or ofloxacin: 0.3% solution 10 drops once a day × 7 days
  • Cortisporin otic drops

Fungal otitis externa

  • Topical therapy, anti-yeast for Candida or yeast: 2% acetic acid 3–4 drops QID; clotrimazole 1% solution; itraconazole oral
Otitis Externa

Comparison of 6 different types of otitis externa

Question 1
A 24 year-old patient presents after a recent vacation. He complains of left ear pain. Physical examination reveals an inflamed external auditory canal and the tympanic membrane can not be visualized. Which of the following is the most appropriate treatment?
A
Oral penicillin
Hint:
Oral antibiotics are not indicated in acute otitis externa.
B
Ciprodex otic drops
C
VoSoL drops
Hint:
VoSoL drops are utilized as preventive treatment of otitis externa, but are not effective for treatment.
D
Oral prednisone
Hint:
Oral prednisone is not indicated in the treatment of acute otitis externa.
Question 1 Explanation: 
Topical steroid/antibiotic drops are most useful in acute bacterial otitis externa.
Question 2
A patient presents complaining of right ear pain and itching. On physical examination you note erythema and edema of the right ear canal with purulent exudate. Palpation of the tragus and manipulation of the auricle is painful. The tympanic membrane is not well visualized. Which of the following is the treatment of choice for this patient?
A
Amoxicillin
Hint:
Amoxicillin is the initial treatment of choice in acute otitis media, not otitis externa.
B
Aqueous irrigation
Hint:
Aqueous irrigation is not indicated in the treatment of otitis externa.
C
Tympanocentesis
Hint:
Tympanocentesis is not indicated in the treatment of otitis externa.
D
Polymyxin B sulfate
Question 2 Explanation: 
Polymyxin B sulfate is the treatment of choice for otitis externa.
Question 3
Otitis externa can be differentiated from uncomplicated otitis media by which of the following physical examination findings?
A
Erythematous tympanic membrane
Hint:
In otitis externa, the erythema is because the lateral surface of the tympanic membrane is ear canal skin, and therefore is often erythematous.
B
Mastoid tenderness
Hint:
Mastoid tenderness is not directly associated with otitis media or otitis externa.
C
Normal pneumatic otoscopy
D
Posterior auricular adenopathy
Hint:
Both otitis media and otitis externa may have posterior auricular adenopathy on examination.
Question 3 Explanation: 
In contrast to acute otitis media, the tympanic membrane moves normally with pneumatic otoscopy in a patient with otitis externa.
Question 4
A 54 year-old type 2 diabetic male presents for follow up evaluation of previously diagnosed persistent otitis externa. Early in the disease process, a CT scan was obtained secondary to non-improvement on antibiotics. Results showed osseous erosion of the floor of the ear canal. He has been on ciprofloxacin 1000 mg twice daily for two months since the CT scan and currently has no further edema, erythema, or exudate from the external auditory canal or surrounding tissue. Which of the following is an appropriate treatment plan?
A
Continue prophylactic antibiotics for an additional 6 weeks
Hint:
See C for explanation.
B
Immediately discontinue antibiotics
Hint:
See C for explanation.
C
Obtain gallium scan to ensure reduction of inflammatory process
D
Skin swab culture of healthy tissue
Hint:
See C for explanation.
Question 4 Explanation: 
Treatment of malignant external otitis requires prolonged antipseudomonal antibiotic administration often for several months. To avoid relapse, antibiotics should be continued even in the asymptomatic patient, until gallium scanning indicates a marked reduction in the inflammatory process.
Question 5
A 62 year-old male chronic smoker is examined for slowly progressive non-painful vision loss. Visual acuity showed 20/150 in both eyes. Extra-ocular muscles are intact. Pupils are responsive to direct and consensual stimuli however appear hazy. During funduscopic exam you are unable to visualize the optic cup, disk or the vessels. What is the most appropriate diagnosis?
A
Anterior uveitis
Hint:
See D for explanation.
B
Narrow angle glaucoma
Hint:
See D for explanation.
C
Retinal detachment
Hint:
See D for explanation.
D
Senile cataract
Question 5 Explanation: 
Patients with cataract have gradually progressive blurred vision without pain or redness. Lens opacification usually develops and can be grossly visible. Cataracts are the leading cause of blindness worldwide. They usually occur bilaterally. Senile cataracts is by far the most common type with most persons over the age of 60 having some degree of lens opacity. Cigarette smoking increases the risk of cataract formation.
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