A 21-year-old man comes to the office due to pain and itching in his left ear. The symptoms began after a swimming party and have progressively worsened. The patient has also noted scant discharge on his pillow when waking in the morning. There is no associated hearing loss, tinnitus, or vertigo. Medical history is unremarkable and he takes no medications. Vital signs are normal without fever. Pain is elicited when the auricle is pulled superiorly or the tragus is pressed inward. The ear canal is edematous and erythematous, with soft cerumen and yellowish debris. There is no periauricular erythema or lymphadenopathy. Following gentle removal of debris from the canal under direct visualization, the tympanic membrane is fully inspected and appears normal. Which of the following is the most appropriate next step in management of this patient?

Question

A 21-year-old man comes to the office due to pain and itching in his left ear.  The symptoms began after a swimming party and have progressively worsened.  The patient has also noted scant discharge on his pillow when waking in the morning.  There is no associated hearing loss, tinnitus, or vertigo.  Medical history is unremarkable and he takes no medications.  Vital signs are normal without fever.  Pain is elicited when the auricle is pulled superiorly or the tragus is pressed inward.  The ear canal is edematous and erythematous, with soft cerumen and yellowish debris.  There is no periauricular erythema or lymphadenopathy.  Following gentle removal of debris from the canal under direct visualization, the tympanic membrane is fully inspected and appears normal.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bea7_efb3_8f63_29c628dfd531_MD0005_00 This patient with pain, erythema, and otic discharge has typical features of otitis externa (OE; also called "swimmer's ear"). OE often arises due to excess moisture and skin maceration or other factors that disrupt the skin-cerumen barrier (eg, excessive cleaning of the canal, hearing aids). The most common causative organisms in OE include Staphylococcus aureus and Pseudomonas aeruginosa. The diagnosis is based on history and examination findings (eg, pain with tragal pressure or traction on the auricle). The initial step in management of OE is to gently clear cerumen and debris. A wire curette or cotton swab can be used under direct visualization, and any remaining material can be removed with irrigation using dilute hydrogen peroxide. For mild OE with minimal erythema and edema, topical acidifiers (eg, acetic acid, Domeboro solution) for 7-10 days are usually adequate. For moderate OE with more significant pain, erythema, and edema (as in this patient), topical antibiotics (eg, ciprofloxacin, neomycin/polymyxin) are recommended. Patients should also be advised on preventive measures, including avoiding moisture in the ears, drying ears thoroughly after swimming or bathing, and using acidifiers at the onset of recurrent symptoms. (Choices B and C) Topical glucocorticoids can alleviate the pain and itching of OE, and products are available that contain both a glucocorticoid and an antimicrobial. If additional pain relief is needed, nonsteroidal anti-inflammatory drugs or opioids may occasionally be necessary. However, symptomatic therapy alone is not recommended and an antimicrobial should be provided. (Choice D) Systemic antibiotics are reserved for invasive infection (malignant OE) or for immunosuppressed patients. Uncomplicated OE will respond to topical therapy. (Choice E) Wick placement is indicated for patients with severe otitis, especially if swelling of the canal prevents penetration of antibiotic solutions. The wick allows for topical medications to reach deeper into the swollen ear canal. This patient has moderate OE with a patent canal; a wick is not necessary. Educational objective: Otitis externa ("swimmer's ear") is characterized by discomfort, erythema, edema, and discharge at the external ear canal. Mild cases can be managed with topical acidifying agents (eg, acetic acid). Moderate cases should be treated with topical antibiotics. Severe cases with edema that blocks antibiotic penetration may require placement of a wick. References: Acute otitis externa: an update. (http://www.ncbi.nlm.nih.gov/pubmed/23198673) Interventions for acute otitis externa. (http://www.ncbi.nlm.nih.gov/pubmed/20091565)

A 21-Year-Old Man Comes to the Office Due to Pain