Case history

Case history

A 35-year-old man presents with a 2-day history of rapid-onset severe ear pain and fullness. The patient complains of otorrhea and mild decreased hearing. He reports that his symptoms started after swimming. No fever is reported. On physical exam, the external ear canal is diffusely swollen and erythematous. He has tenderness of the tragus and pain with movement of the auricle. The tympanic membrane was partially visualized because of the swelling. The concha and the pinna look normal. Neck exam fails to reveal any lymphadenopathy.

Other presentations

Necrotizing otitis externa (also called malignant otitis externa) is a form of otitis externa that is more common in older patients with uncontrolled diabetes or in patients with immunodeficiency.[1][4]​​ In necrotizing otitis externa, the infection and the inflammatory process involve not only the skin and soft tissue of the external auditory canal but also the bone tissue of the temporal bone.[5] Early symptoms and signs are the same as acute otitis externa (AOE), but, if left untreated, osteomyelitis of the petrous part of the temporal bone and/or skull base could result, which may invade soft tissue, the middle ear, inner ear, or brain.[1][5][6]​​ The facial nerve may be affected, and less frequently, the glossopharyngeal and spinal accessory nerves.[1] Necrotizing otitis externa is a medical emergency.[7]​​ Pseudomonas aeruginosa is implicated in most patients.[1][7]​​​​ Patients usually present with severe ear pain, otorrhea, and fullness, and are not responding to the conventional treatment of AOE. Depending on the stage of presentation and the extent of invasion, patients may have facial weakness and other cranial nerve abnormalities.[1] On physical exam, the external auditory canal is swollen, with evidence of granulation tissue on the floor of the canal and at the bony-cartilaginous junction.[1] The diagnosis is usually made by computed tomography or magnetic resonance imaging scans, which show presence of soft tissue and bone destruction.[5] 

Otomycosis is a fungal infection of the external ear caused by molds and yeasts.[8]​ Fungal otitis externa accounts for approximately 9% of total otitis externa.[8]​ It presents in a similar way to acute bacterial otitis externa, with ear pain, itching, aural fullness, and otorrhea. It is common in tropical countries, humid locations, after long-term topical antibiotic therapy, and in people with diabetes, HIV/AIDS, or other immunocompromised states.[1] The most common fungal pathogens are Aspergillus species (60% to 90%) and Candida species (10% to 40%).[1] Stepwise multiplex polymerase chain reaction is more sensitive, rapid, and efficient than culture technique in differentiating bacterial otitis externa from fungal otitis externa.[9]

Tympanic membrane perforation may occur secondary to fungal otitis externa; a perforation rate of 6.75% has been reported.[8][10]​​​ Perforation is common in otomycosis caused by Aspergillus flavus, Aspergillus tubingensis, and Candida albicans.[8]​ The perforation of tympanic membrane due to fungal otitis externa is smaller in size and may resolve with treatment. Some cases may require tympanoplasty.​​[10]​​​ 

Physical exam reveals swollen ear canal skin and discharge. Ear discharge may be thickened and black, gray, bluish green, yellow, or white.[1] The presence of black spores indicates Aspergillus niger as the causative organism.[1][3]​​ White filamentous hyphae can often be seen. Microscopic exam and ear cultures can help establish the definitive diagnosis of otomycosis. Otomycosis should be suspected in patients who fail treatment with antibacterial agents.[3] Secondary fungal infection of the external auditory canal is well known after prolonged treatment with topical antibacterial agents.[11]

Chronic otitis externa is chronic inflammation of the ear canal skin for 3 months or longer.[12]​ It usually presents with diffuse low-grade infection of months' or, at times, years' duration.[13] It is the result of recurrent otitis externa, bacterial or fungal infections, underlying skin conditions, or otorrhea from middle ear infections.[3] Patients usually present with itching and scant otorrhea but no pain.[13]

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