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ORIGINAL ARTICLE
Year : 2016  |  Volume : 19  |  Issue : 3  |  Page : 146-149

Risk factors of acute otitis externa seen in patients in a Nigerian tertiary institution


Department of Otorhinolaryngology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Web Publication14-Oct-2016

Correspondence Address:
Mohammed Abdullahi
Department of Otorhinolaryngology, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
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DOI: 10.4103/1118-8561.192395

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  Abstract 


Background: Acute otitis externa is a common clinical problem which is associated with preventable risk factors. Objective: The aim of this study is to determine the practices that are risk factors in patients with acute otitis externa in a Nigerian tertiary institution. Patients and Methods: This was a 6-month cross-sectional study of patients with acute otitis externa carried out between April and September 2013 at the Ear, Nose, and Throat Clinic of the Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. Results: A total of 2350 patients were seen during the study period, of which 88 (3.7%) were diagnosed with acute otitis externa. The males and females were 32 (36.4%) and 56 (63.6%), respectively, with a ratio of 1:1.8 The age range was 3 months to 70 years, with the mean age of 18.9 years. Self-ear cleaning with cotton bud 65 (73.9%) constituted the majority of object introduced into the ear canal(s) and the reasons for self-ear cleaning were because of itching of the ear(s) in 47 (53.4%), habitual 9 (10.2%), and perceiving that the ears were dirty 32 (36.4%). The introduction of extraneous moisture into the ears was seen in 46 (52.3%) including self-medication with topical antibiotic, instilling plain and soapy water in the ear canal(s), and swimming. The comorbid conditions which are known risk factors for otitis externa were seen in 35 (39.8%) patients, of which allergy was the most frequent with 22 (25%), followed by diabetic mellitus 7 (8%) and AIDS 6 (6.8%). Only 14 (16%) of these patients had their comorbid conditions diagnosed at their first presentation. Conclusion: Self-ear cleaning with cotton bud was the major risk factor seen in our patients with otitis externa, followed by the introduction of extraneous moisture into the ear canals and untreated comorbid risk factors for acute otitis externa. These risk factors are preventable through creation of awareness and prompt treatment of other associated disease conditions.

Keywords: Acute otitis externa, prevention, risk factors


How to cite this article:
Abdullahi M, Aliyu D. Risk factors of acute otitis externa seen in patients in a Nigerian tertiary institution. Sahel Med J 2016;19:146-9

How to cite this URL:
Abdullahi M, Aliyu D. Risk factors of acute otitis externa seen in patients in a Nigerian tertiary institution. Sahel Med J [serial online] 2016 [cited 2019 Oct 18];19:146-9. Available from: http://www.smjonline.org/text.asp?2016/19/3/146/192395




  Introduction Top


Otitis externa is an inflammation or infection of the external auditory canal.[1] This condition can be acute or chronic, with the acute form affecting 4 in 1000 persons annually.[2] Acute otitis externa is unilateral in 90% of patients, and it is uncommon below the age of 2 years. The peak age incidence is from 7 to 12 years and declines after 50 years of age.[3],[4]

Otitis externa usually represents an acute bacterial infection of the skin of the ear canal which is commonly attributable to Pseudomonas aeruginosa or Staphylococcus aureus.[5] The infections can also be due to other bacteria, viruses, or fungal agents.

Several factors can contribute to external auditory canal infection and the development of otitis externa: Absence of cerumen, high humidity, retained water in the ear canal, increased temperature, local trauma (e.g., use of cotton swabs), anatomical anomaly of the external auditory canal, dermatological conditions, etc.[6],[7]

Otitis externa is a clinical diagnosis based on the symptoms and signs such as pain, itching, edema, and erythema of the external auditory canal with purulent otorrhea and debris in the meatus.[7]

Risk factors for otitis externa are well documented in the literature;[6],[7],[8] there is dearth of information on the risk factors practiced by patients with acute otitis externa in our environment.

The aim of this study is to determine the practices that are risk factors for acute otitis externa and the influence of the known comorbid conditions usually associated with it in patients seen in the Ear, Nose, and Throat (ENT) Clinic, of the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, and to create awareness on prevention of the disease in our environment.


  Patients and Methods Top


This was a 6-month cross-sectional study using self- and interviewer-administered questionnaires (for patients with no educational background). The study population was all consecutive patients who presented for treatment at the ENT Clinic of the UDUTH, Sokoto, Nigeria (a tertiary institution with a referral from other centers in the neighboring states of Northern Nigeria: Kebbi, Niger, and Zamfara), from August 2013 to January 2014. This study was carried out after the approval from the Ethical Committee of the reference institution.

The clinical diagnosis of acute otitis externa was based on the major presentations such as rapid onset (usually within 48 h) in the past 3 weeks of otalgia, itching of the ear canal or fullness in the ear canal, and the signs of ear canal inflammation: Tenderness of the tragus/pinna or both with or without otorrhea, regional lymphadenitis.[9]

The questionnaires completed consist of biodata and risk factors for otitis externa which includes use of cotton bud and other objects for self-ear cleaning, introduction of extraneous moisture into the ear canals: Use of topical ear drops, swimming, instilling of plain and soapy water, and the reasons for that history of comorbid conditions associated with acute otitis externa such as allergy, diabetic, AIDS, and others.

Inclusion criteria were patients with acute otitis externa who were first seen at the ENT Clinic and the exclusion criteria were patients with discharging ears from otitis media, chronic otitis externa, and referred otalgia from other causes.

Data were analyzed using Statistic Package for Social Science (SPSS) Version 18 (Chicago: SPSS Inc.) for mean, standard deviation, and frequency distributions.


  Results Top


A total of 2350 outpatients were seen during the study period, of which 88 (3.7%) were diagnosed with acute otitis externa. The males and females were 32 (36.4%) and 56 (63.6%), respectively, with male to female ratio of 1:1.8. The age range was 3 months to 70 years, with the mean age of 18.9 years. Majority of these patients were below the age of 10 years, with 30 (34.1%) patients [Figure 1]. Self-ear cleaning with the use of various objects were seen in all patients with acute otitis externa for which the use of cotton bud 65 (73.9%) constituted the majority of object introduced into the ear canals, and the other objects used for self-ear cleaning include use of both fingertip and cotton bud 8 (9.1%), broomstick 6 (6.8%), fingertips 4 (4.5%), pen covers 4 (4.5%), and matchstick 1 (1.1%) [Table 1]. The reasons for self-ear cleaning were because of itching of the ear canals 47 (53.4%), habitual 9 (10.2%), and perceiving that the ears were dirty 32 (36.4%) [Figure 2]. Other risk factors practiced by the patients with acute otitis externa include deliberate introduction of extraneous moisture into the ear canals such as self-medication with topical antibiotic ear drops 21 (23.9%), instilling plain water into the ear canal(s) 15 (17%), instilling soapy water into the ear canal(s) 6 (6.8%), and swimming 4 (4.5%) [Table 1]. The comorbid conditions which are risk factors for acute otitis externa are allergy 22 (25%), diabetic mellitus 7 (8%), and AIDS 6 (6.8%). Out of these 35 (39.8%) patients with comorbid conditions, 14 (40%) patients were not aware of their comorbid conditions. Forty (45.5%), 38 (43.2%), and 10 (11.4%) had right, left, and bilateral acute otitis externa, respectively.
Figure 1: Age distribution in percentages

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Table 1: Risk factors for acute otitis externa and the associated comorbid conditions

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Figure 2: Reasons for self-ear cleaning in percentages

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  Discussion Top


Acute otitis externa is a common clinical condition.[10] This study showed that this condition is more common in females, which agrees with the studies by Amutta et al. and Rowlands et al.[10],[11] Probably, the female preponderance may be explained by the early presentation and frequent habits of engaging in self-ear cleaning that predisposes to acute otitis externa.

The accessible location of the external ear will explain its susceptibility to various risk factors. These various risk factors are well enumerated in the previous studies on otitis externa.[1],[6],[7],[8],[12] This study showed that all patients with acute otitis externa practiced self-ear cleaning with cotton-tip application as the leading object introduced into the ear canal(s), which agrees with other previous studies.[1],[11]

Apart from the use of cotton-tip applicator and other objects for self-ear cleaning, 52.3% of the respondents introduced extraneous moisture into the ear canal(s); this can cause maceration of the canal skin and encourages destruction of the protective barrier and hence a favorable condition for bacterial growth and forming good environment for otomycosis.[12],[13],[14] Cerumen plays an important role in the protection of the external auditory canal by creating an acidic pH which is hostile to infection;[3],[15] this can be altered by extraneous moisture exposure, soapy deposit, and aggressive cleaning,[3] especially in the form of self-ear cleaning.

Although the study showed respondent practices that predispose them to acute otitis externa, prospective studies are needed to determine if these practiced risk factors are actually responsible for this disease condition.

Acute otitis externa can progress to a chronic form either when the risk factors persist or when it is inadequately treated, especially the risk can be very significant when malignant otitis externa develops in patients with immunosuppressive conditions such as HIV and diabetes mellitus.[16] Therefore, we recommend public enlightenment programs, especially for mothers who frequently engaged in self-ear cleaning and introduction of extraneous moisture into the external auditory canal for the purpose of removing wax and early diagnosis and prompt treatment of patients with immunosuppression.


  Conclusion Top


Self-ear cleaning with various objects, especially with cotton bud, introduction of extraneous moisture into the ear canal(s), and untreated comorbid conditions are the risk factors practiced by our patients with acute otitis externa; they are preventable through creation of awareness, especially to mothers who frequently engage in self-ear cleaning for their children, and to promote routine medical checkup for early diagnosis and prompt treatment of associated comorbid condition(s).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Nussinovitch M, Rimon A, Volovitz B, Raveh E, Prais D, Amir J. Cotton-tip applicators as a leading cause of otitis externa. Int J Pediatr Otorhinolaryngol 2004;68:433-5.  Back to cited text no. 1
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2.
Osguthorpe JD, Nielsen DR. Otitis externa: Review and clinical update. Am Fam Physician 2006;74:1510-6.  Back to cited text no. 2
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3.
Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA, et al. Clinical practice guideline: Acute otitis externa. Otolaryngol Head Neck Surg 2014;150 1 Suppl: S1-24.  Back to cited text no. 3
    
4.
Beers SL, Abramo TJ. Otitis externa review. Pediatr Emerg Care 2004;20:250-6.  Back to cited text no. 4
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5.
Clark WB, Brook I, Bianki D, Thompson DH. Microbiology of otitis externa. Otolaryngol Head Neck Surg 1997;116:23-5.  Back to cited text no. 5
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6.
Hughes E, Lee JH. Otitis externa. Pediatr Rev 2001;22:191-7.  Back to cited text no. 6
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7.
Carney SA. Otitis externa and otomycosis. In: Gleeson M, Browning GG, Burton MJ, Clark R, Hibbert J, Jones NS, et al ., editors. Scott-Brown Otorhinolaryngology, Head and Neck Surgery. 7th ed., Vol 3. London: Hodder Arnold; 2008. p. 3351-6.  Back to cited text no. 7
    
8.
Sander R. Otitis externa: A practical guide to treatment and prevention. Am Fam Physician 2001;63:927-36, 941-2.  Back to cited text no. 8
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9.
Hui CP; Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Acute otitis externa. Paediatr Child Health 2013;18:96-101.  Back to cited text no. 9
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10.
Rowlands S, Devalia H, Smith C, Hubbard R, Dean A. Otitis externa in UK general practice: A survey using the UK General Practice Research Database. Br J Gen Pract 2001;51:533-8.  Back to cited text no. 10
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11.
Amutta SB, Mufutau AY, Iseh KR, Obembe A, Egili E, Aliyu D, et al. Sociodemographic characteristics and prevalence of self ear cleaning in Sokoto Metropolis. Int J Otolaryngol Head Neck Surg 2013;2:276-9.  Back to cited text no. 11
    
12.
Wang MC, Liu CY, Shiao AS, Wang T. Ear problems in swimmers. J Chin Med Assoc 2005;68:347-52.  Back to cited text no. 12
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13.
Jackman A, Ward R, April M, Bent J. Topical antibiotic induced otomycosis. Int J Pediatr Otorhinolaryngol 2005;69:857-60.  Back to cited text no. 13
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14.
van Asperen IA, de Rover CM, Schijven JF, Oetomo SB, Schellekens JF, van Leeuwen NJ, et al. Risk of otitis externa after swimming in recreational fresh water lakes containing Pseudomonas aeruginosa. BMJ 1995;311:1407-10.  Back to cited text no. 14
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15.
Sirigu P, Perra MT, Ferreli C, Maxia C, Turno F. Local immune response in the skin of the external auditory meatus: An immunohistochemical study. Microsc Res Tech 1997;38:329-34.  Back to cited text no. 15
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16.
Karaman E, Yilmaz M, Ibrahimov M, Haciyev Y, Enver O. Malignant otitis externa. J Craniofac Surg 2012;23:1748-51.  Back to cited text no. 16
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