Evaluating the tympanic membrane can help support the clinical diagnosis and the patients left ear tympanic membrane is not visible
Introduction A middle age male patient presents with primary complaint of left earache, which has increased over the past two days and is now impacting his ability to hear. Patient concerned with pain and potential swelling of face on affected side. Patient has relevant comorbidities and is positive for diabetes, hypertension and hyperlipidemia. One additional consideration is patient’s known allergy to amoxicillin. Primary Diagnosis Based on patient complaints and physical examination it is determined the patient has otitis externa and will require antibiotics. Key supporting evidence includes the onset of symptoms, slight hearing loss, facial swelling, pinna pain and sensitivity and the obscured tympanic membrane observed through otoscope examination. Research indicates, “acute otitis externa presents with rapid onset of ear canal inflammation, resulting in otalgia, canal edema, erythema and otorrhea” (Schaefer, 2012, p. 1055). This patient presents with a two-day history of ear pain and is consistent with “the usual presentation of acute otitis media externa is pain of the affected ear developing over 48 hours or less” (Buttaro, 2017, p. 371). The pain in the left pinna is a significant finding to help support the diagnosis and is a classic finding of otitis externa (Schaefer, 2012). Evaluating the tympanic membrane can help support the clinical diagnosis and the patients left ear tympanic membrane is not visible. Ball, the author of Seidel’s Guide to Physical Examination, points out that obscured tympanic membrane is consistent with otitis externa (2019, p. 264). Differential Diagnosis Ear pain is a common occurrence in the primary care setting and can have many different underlying pathologies (Earwood, 2018). Pain originating from the ear is called primary otalgia and the most common causes include otitis media and otitis externa (Earwood, 2018). Other possible diagnosis that may present with otalgia include contact dermatitis, furunculosis or otomycosis (Schaefer, 2012). Otitis media is unlikely here as otitis media usually includes a clinical presentation with fever and a tympanic membrane with distinct erythema (Ball, 2019). Contact dermatitis is more commonly associated with allergic reaction to foreign materials (Schaefer, 2012). Foreign materials that may cause an allergic response include piercings, hearing aid, ear plugs and this patient has no corresponding medical history to support this finding. Furunculosis may cause isolated ear pain and the pustule is generally visible in the distal canal (Schaefer, 2012). The physical inspection of the ear canal did not support a furuncle. Otomycosis is another possible explanation but is quickly ruled out by a lack of itching as a symptom (Schaeffer, 2012). Treatment Otitis externa is “caused by bacterial infections (90%) and fungal infections (10%)” (Earwood, 2018, p. 25). Topical antimicrobials are the mainstay of treatment for uncomplicated acute otitis media externa (Schaefer, 2012). Suggested duration of 7-10 days. Topical antibiotics “should be supplemented by systemic antibiotics if the affected individual has a condition, especially diabetes that is associated with markedly increased morbidity” (Rosenfeld, n.d.). Given the patients age, history of hypertension, diabetes, and hyperlipidemia, an oral antibiotic is warranted. Fluoroquinolone antibiotics would be an excellent choice as they cover P. aeruginosa and S. aureus and the patient does not have an allergy to this drug class (Buttaro, 2017). References Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby Buttaro, T.M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier. Earwood, J., Rogers, T., Rathjen, N. (2018). Ear pain: diagnosing common and uncommon causes. American Family Physician. 97 (1): 20-27 Rosenfeld, R., Brown, L., Cannon, C., Dolor, R., Ganiates, T., Hannley, M., Kokemueller, P., Marcy, S., Roland, P., Shiffman, R., Stinnett, S., & Witsell, D. (n.d.). Clinical practice guideline: acute otitis externa. Otolaryngology – Head and Neck Surgery, 134 (4), S4-S23. https:/doi-org.ezp.waldenulibrary.org/10.1016/j.otohns.2006.02.014 Schaefer, P., Baugh, R. (2012). Acute otitis externa: an update. American Family Physician. 86 (11): 1055-1061 please response
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