ONLINE EXCLUSIVE Kristen Grine, DO; A guide to managing disorders Mark Stephens, MD Department of Family and Community Medicine, Penn of the ear pinna and canal State College of Medicine, University Park mstephens3@ This review will help you troubleshoot everything from pennstatehealth.psu.edu infections and foreign bodies to trauma and neoplasm. The authors reported no potential conflict of interest relevant to this article. hich antibiotics are most useful for infection follow- PRACTICE ing ear piercing? When is it safe to attempt removal RECOMMENDATIONS of a foreign body from the ear canal, and which ceru- ❯ Prescribe topical antibiotics W menolytic agent may be best for ear wax? This review covers com- for uncomplicated otitis externa, reserving systemic mon ailments of the outer ear, which are often readily diagnosed agents for infection given a patient’s history and thorough physical examination. We extending outside the ear also address more complicated matters such as deciding when canal, necrotizing otitis to refer for treatment of suspected malignant otitis externa, and externa, or patients who which lab markers to follow when managing it yourself. are immunodeficient. C ❯ Avoid clearing cerumen if A (very) brief review of ear anatomy a patient is asymptomatic Understanding the unique embryology and intricate anatomy and advise patients/parents of the external ear informs our understanding of predictable on Do’s and Don’ts for ear infections, growths, and malformations. wax accumulation. C The external ear is composed of the external auditory ❯ Consider flooding the canal and auricle. The external auditory canal has a lateral ear canal with xylocaine, (external) cartilaginous portion and a medial (internal) bony alcohol, or mineral oil before portion. The auricular structure is complex and formed by the attempting insect removal. C helix, antihelix (crura; scaphoid fossa), tragus, antitragus, con- Strength of recommendation (SOR) chae, and lobule. The auricle is composed of elastic cartilage A Good-quality patient-oriented covered by skin. The lobule is composed of skin, adipose tis- evidence sue, and connective tissue. B Inconsistent or limited-quality Embryologically, the auricle, auditory canal, and middle patient-oriented evidence ear form from ectoderm of the first 2 branchial arches during C Consensus, usual practice, opinion, disease-oriented early gestation. The auricle forms from the fusion of soft-tissue evidence, case series swellings (hillocks). Three hillocks arise from the first branchial arch and 3 from the second branchial arch during the fifth and sixth weeks of gestation. Tissues from the second branchial arch comprise the lobule, antihelix, and caudal helix. The cartilage of the tragus forms from the first branchial arch. The ear canal forms from an epithelial invagination of the first branchial arch that also occurs during the fifth week of gestation.1 Infections Perichondritis Inflammation or infection of the connective tissue layer sur- MDEDGE.COM/FAMILYMEDICINE VOL 69, NO 6 | JULY/AUGUST 2020 | THE JOURNAL OF FAMILY PRACTICE E1 rounding the auricular cartilage (perichon- due to allergic conditions, and placement of drium) results in perichondritis. Further hearing-aid devices.6 extension of infection can lead to an auricu- ❚ What you’ll see. Suspect AOE when lar abscess. Both of these conditions can have signs or symptoms of ear canal inflamma- serious consequences. tion have appeared rapidly (generally within ❚ What you’ll see. The most common 2 days) over the past 3 weeks.7 Findings in- risk factor for perichondritis is the popular clude otalgia, itching, fullness, tragal ten- practice of cosmetic transcartilaginous pierc- derness, ear canal edema, erythema with or ing.2 Piercing of the helix, scapha, or anti- without otorrhea, lymphadenitis, or cellulitis helix (often referred to as “high” ear piercing) of the pinna or adjacent skin.7 AOE must be causes localized trauma that can strip the ad- distinguished from other causes of otalgia jacent perichondrium, decrease blood sup- and otorrhea, including dermatitis and viral ply, create cartilaginous microfractures, and infection. lead to devascularization. Rates of infection ❚ How to treat. Topical therapy is rec- as high as 35% have been reported with high- ommended for the initial treatment of un- ear piercing.3 complicated AOE, usually given over 7 days. The most common microbes associated Multiple topical preparations are available, with perichondritis and pinna abscess for- such as ciprofloxacin 0.2%/hydrocortisone mation are Pseudomonas and Staphylococcus 1.0%; neomycin/polymyxin B/hydrocorti- Rates of species.2 P aeruginosa accounts for a majority sone; ofloxacin 0.3%; or acetic acid 2.0%.7 infection as high (87%) of post-piercing infections of the au- Avoid these agents, though, if you suspect as 35% have ricular cartilage.2 tympanic membrane rupture. Quinolone been reported ❚ How to treat. The cornerstone of treat- drops are the only topical antimicrobials ap- with high-ear ment is early detection and antimicrobial proved for middle ear use.7 piercing. coverage with antipseudomonal antibiotics. Systemic antibiotics are not recommend- Ciprofloxacin is the oral antibiotic of choice ed for the initial treatment of AOE. Topical because of its ability to penetrate the tis- agents deliver a much higher concentration sue.4 Other options include clindamycin and of medication than can be achieved systemi- third- or fourth-generation cephalosporins. cally. Consider systemic antibiotics if there is If the wound becomes abscessed, perform extension outside the ear canal, a concern for (or refer for) early surgical incision and necrotizing otitis externa (more on this in a drainage.5 A failure to promptly recognize bit), or the patient is immunodeficient.8 perichondritis or to mistakenly prescribe non- Patient (or parent) education is impor- antipseudomonal antibiotics contributes to tant to ensure proper medication adminis- increased rates of hospitalization.2 Cosmetic tration. The patient should lie down with the deformity is the most common complication affected ear facing up. After the canal is filled of perichondritis. This may require recon- with drops, the patient should remain in this structive surgery. position for 3 to 5 minutes. Gently massag- ing the tragus can augment delivery. Patients Otitis externa should keep the ear canal as dry as possible Acute otitis externa (AOE; “swimmer’s ear”) and avoid inserting objects (eg, hearing aids, is cellulitis of the skin and subdermis of the ear buds, cotton-tipped applicators) into the external ear canal. It is most prevalent in canal for the duration of treatment. The deliv- warm, moist climates and almost always as- ery of topical antibiotics can be enhanced by sociated with acute bacterial infection, most wick placement. Prescribe analgesics (typi- commonly P aeruginosa or S aureus.6 There is cally nonsteroidal anti-inflammatory agents) also an increased association with poor water based on severity of pain.7 quality (containing higher bacterial loads). Have patients abstain from water sports Anything breaching the integrity of the ear for 7 to 10 days. Showering is acceptable canal can potentially predispose to the de- with minimal ear exposure to water; bath- velopment of AOE. This includes trauma ing is preferred when possible. If there is no from cleaning, cerumen removal, scratching clinical improvement in 48 to 72 hours, ask E2 THE JOURNAL OF FAMILY PRACTICE | JULY/AUGUST 2020 | VOL 69, NO 6 EAR DISORDERS patients to return for re-evaluation.8 Preven- (particularly if CT findings are normal and tion is essential for patients with a history of clinical suspicion is high) and for follow-up recurrent otitis externa. Acetic acid solutions with treatment. create an acidic environment within the ca- ❚ How to treat. Management involves a nal to help prevent recurrent AOE. Ear plugs team approach with otolaryngology, radiolo- and petroleum jelly–soaked cotton plugs pri- gy, neurology, endocrinology, and infectious or to water exposure may also help prevent disease specialists. Long term (6-8 weeks) recurrent AOE. antipseudomonal antibiotic treatment is typical. Malignant otitis externa Let culture results guide the choice of Malignant, or necrotizing, otitis externa is an antibiotic. Fluoroquinolone therapy, usually aggressive disease form of otitis externa that ciprofloxacin, is used most often.12 Surgical is most common in individuals with diabetes intervention may be required for local de- or other immunodeficiency disorders.9 Most bridement and drainage of abscesses. Close cases are due to infection with P aeruginosa.10 follow-up is necessary due to reports of re- Prior to the availability of effective antibiot- currence up to 1 year after treatment. If left ics, mortality rates in patients with necrotiz- untreated, necrotizing otitis externa can lead ing otitis externa were as high as 50%.11 to osteomyelitis, meningitis, septic thrombo- ❚ What you’ll see. Patients typically sis, cerebral abscess, and death.11 present with severe ear pain, otorrhea, con- In head-to- ductive hearing loss, and a feeling of fullness head laboratory in the external ear canal. Physical examina- Cerumen impaction comparisons, tion reveals purulent otorrhea and a swollen, The relatively small diameter of the external distilled water tender ear canal. Exposed bone may be vis- auditory canal increases the risk for impac- appears to ible, most often on the floor of the canal. The tion of cerumen and foreign