A 20-year-old woman comes to the physician with pain and itching in her left ear. She has been swimming frequently and first noticed some itching a few days ago. She tried using cotton swabs in the canal and subsequently developed pain with malodorous discharge from that ear. Her hearing is also diminished on that side. The patient has no fever or chills. Her balance and coordination are normal. She does not wear earrings and has no known skin disorders.
Vital signs are within normal limits. Examination shows ear pain elicited with movement of her left tragus. There is no warmth or redness around the ear and no pain to percussion of the mastoid area. There is a moderate amount of debris blocking 50% of the auditory canal. Removal of the debris shows an erythematous and edematous external canal. The tympanic membrane appears slightly red but is intact and mobile with a pneumatic otoscope.
Which of the following is the most appropriate management for this patient?

Question

A 20-year-old woman comes to the physician with pain and itching in her left ear.  She has been swimming frequently and first noticed some itching a few days ago.  She tried using cotton swabs in the canal and subsequently developed pain with malodorous discharge from that ear.  Her hearing is also diminished on that side.  The patient has no fever or chills.  Her balance and coordination are normal.  She does not wear earrings and has no known skin disorders.
Vital signs are within normal limits.  Examination shows ear pain elicited with movement of her left tragus.  There is no warmth or redness around the ear and no pain to percussion of the mastoid area.  There is a moderate amount of debris blocking 50% of the auditory canal.  Removal of the debris shows an erythematous and edematous external canal.  The tympanic membrane appears slightly red but is intact and mobile with a pneumatic otoscope.
Which of the following is the most appropriate management for this patient?

Quizplus · Accepted Answer

11ec193a_979d_2ac7_853d_596913654c93_MD0002_00 This patient has acute otitis externa (OE), likely from swimming. The most common organisms causing OE are Pseudomonas and Staphylococcus species. Initial treatment includes thoroughly cleaning the ear canal to remove cerumen and other debris and nonsteroidal anti-inflammatory drugs for pain control. An otoscope can directly visualize the canal, and a wire loop can gently remove debris and cerumen. Irrigating the ear canal with a 1:1 dilution of 3% hydrogen peroxide is also effective in patients with intact tympanic membranes. Mild OE (pruritus with minimal canal edema) usually improves with combined acidifying agent (eg, acetic acid) to inhibit bacterial growth in the ear canal and topical glucocorticoids to decrease inflammation. Moderate (pain, pruritus, partial canal occlusion) to severe (intense pain, canal occlusion, fever) OE requires combined topical antibiotics (eg, quinolones, polymyxin B, neomycin), antiseptics, and glucocorticoids with possible wick placement. Both ofloxacin and ciprofloxacin have excellent coverage against P aeruginosa and S aureus. Oral antibiotics do not significantly improve uncomplicated OE but are added in immunocompromised patients and for deep-tissue infections beyond the ear canal. These patients are also at risk for malignant OE, with the infection spreading to the skull base, and usually need otolaryngology referral. This patient with moderate OE may first be treated with a topical antibiotic and glucocorticoid (Choices B and C). If she does not improve within 3 days, she requires culture of the ear canal or referral to an otolaryngologist (Choices A and D). Educational objective: Otitis externa is most commonly due to Pseudomonas and Staphylococcus infections. Treatment involves cleaning the ear canal and treating the inflammation and infection with a combination of ototopical steroid and antibiotic. Patients not responding to initial therapy after 3 days require culture of the ear canal or otolaryngology referral. __________ References: Systemic review of topical antimicrobial therapy for acute otitis externa. (http://www.ncbi.nlm.nih.gov/pubmed/16638474) Interventions for acute otitis externa. (http://www.ncbi.nlm.nih.gov/pubmed/20091565)

A 20-Year-Old Woman Comes to the Physician with Pain and Itching