CLINICAL PRESENTATION AND TREATMENT OF

OTITIS EXTERNA IN SIERRA LEONE

Hassan Al-Husban, MD*, Mefleh Al-Serhan, MD*, Ahmad Al-Gudah, MD*

ABSTRACT

Objective: To describe clinical presentation and treatment patterns of otitis externa in Sierra Leone.
Methods: This is a retrospective review of 75 patients with otitis externa treated by Ear Nose & Throat (ENT)
specialist who supported the Jordan Peace Keeping Forces Level II Medical Hospital in Sierra Leone between J uly 2000
and J anuary 2001. All patients were treated as an outpatient day-cases and given an appointment for follow-up after
two days to two weeks. Patients age, sex, type of otitis externa, and its response to treatment were assessed.
Results: The commonest type of otitis externa in Sierra Leone was otomycosis. Forty-seven percent were found to
have fungal infection. Diffuse otitis externa was found in 34%, 6 patients (8%) were treated for eczematous otitis
externa, one patient was suspected to have malignant otitis externa and the remaining eight patients (11%) were treated
for other types of otitis externa.
Conclusion: Appropriate topical treatment of otitis externa should eliminate the need for systemic medications;
decrease the cost of treatment with less side effects and better patient compliance.
Key words: Otitis externa, Otomycosis, Tropical countries, Malignant otitis externa.

JRMS Dec 2004; 11(1): 65-67


I nt r oduc t i on
Sierra Leone is a tropical country on the West Coast
of Africa. Besides poverty, the country has been torn by
civil war for 10 years. The Royal Medical Services of
the J ordan Armed Forces participate in the United
Nations Peace Keeping Forces in Sierra Leone by clinics
that provide medical help not only for UN military staff
but also to civilian population in need for this help.
Otitis externa (OE) is a broad term for a disease state
that includes inflammation or infection of the auricle,
external auditory canal, and eardrum. It can range from
mild inflammation and discomfort to a life - threatening
disease
(1)
. OE is a common condition in warm humid
climates, hence the term tropical ear. It is more likely to
occur in population where swimming is popular
(2)
.
Otorrhoea, or discharge from the ear, may be
associated with otitis media or OE. Each episode of
otorrhea requires examination of the external ear canal
and eardrum to determine the origin and extent of the
disease
(3)
. Types of OE are either localized OE e.g.
furuncle or diffuse OE. The causes of OE are either
infective e.g. bacterial viral and fungal or reactive to
atopic eczema or external sensitizing agent or mixed of

viral, bacterial and fungal. Causes include trauma to
external auditory meatus (finger nail, match stick, hair
clip, key.), irritation by chemicals, exposure to water
(swimming), excessive sweating and allergic reaction to
topical medications. The most common causative
organism is Staphylococcus aureus; while in otomycosis,
Candida albicans is the commonest fungus isolated
followed by Aspergillus niger
(4)
.

Met hods
This is a retrospective review of 75 cases of otitis
externa treated by ENT specialists in the Jordan Peace
Keeping Force Level II Medical Hospital in Sierra Leone
between J uly 2000 and J anuary 2001. All the patients
were treated as an outpatient day-cases and given an
appointment for follow-up after two days to two weeks,
but only 25 patients returned to outpatient clinic. The
remaining 50 patients were lost for follow up because
they either improved or missed their appointments
(which indicates poor follow up of patients in this
country). Patients age, sex, type of otitis externa, and its
response to treatment were assessed.
*Fromthe Department of ENT, King Hussein Medical Center, (KHMC), Amman J ordan
Correspondence should be addressed to Dr. H. Al-Husban, (KHMC)
Manuscript received J uly 1, 2001. Accepted September 23, 2001


Resul t s
The commonest type of otitis externa in Sierra Leone
was otomycosis. Thirty-five out of seventy-five patients
(47%) were found to have fungal infection. Diffuse
otitis externa was found in only twenty-five patients with
a frequency of 34%. Six patients (8%) were treated for
eczematous otitis externa. One patient was suspected to
have malignant otitis externa. The remaining eight
patients (11%) were treated for other types of otitis
externa. There is a high percentage of otitis externa in
Sierra Leone among females (44% of patients).
As only twenty-five out of seventy-five patients
(33%) came for follow up, it was recommended to
depend mainly on a one- visit treatment for otitis externa
in this country. There is a dramatic and complete
response to medical treatment in this area. Twenty-two
out of twenty-five patients (88%), who came for follow-
up were found to be completely cured from the first
treatment trial, and only three patients received a second
session of treatment.

Di sc ussi on
Otitis externa is a common otological disease. It has
been found that up to 10% of the population were
affected by this condition at some stage in their life
(5)
.
Otalgia constitutes the most prominent of the symptoms
in OE
(6)
, followed by itching, hearing loss, otorrhea,
tinnitus, and fullness
(7)
. Patients with otomycosis are
usually present with ear itching, serous fluid, and
otalgia
(8)
.


It has been noticed that many cases of otitis externa in
that country followed external ear trauma and war
injuries. There was also a high frequency of severe
cases of otitis externa involving both ears (Fig. 1), but on
the other hand, there was a good and dramatic response
to treatment (88% of the patients improved from the first
treatment trial).
The widespread use of antibiotics (mainly without
being prescribed by a doctor) led to antibiotic-resistant
organisms, and this may be the main cause of delayed
and incomplete response to the treatment of otitis externa
here in Jordan compared to the cases in Sierra Leone.
Aural toilet is the mainstay of treatment in OE. It is
usually performed by gentle suction of all secretions and
debris from the external ear meatus, especially from the
antero-inferior recess where pus and debris may
collect
(9)
. After aural toilet we usually prescribed the
patients with bacterial otitis externa topical antibiotic
drops. Oral antibiotics with analgesics were prescribed
only in severe cases. In fungal otitis externa we usually
use solvent violent reactant (S.V.R) with oral
antihistamines to decrease ear itching, or econazole-
neomycin-hydrocortisone ointment introduced deep in
external ear meatus.
In case of severe edema and stenosis of external ear
canal it is usually very painful to do aural toilet and
eardrops could not enter the stenosed canal, so the best
way to decrease edema and deliver antibiotics deep in
external ear meatus was found to be aural packing. A
ribbon gauze wick soaked with ichthammol 10%
in glycerin or polymyxin-B sulfate-neomycin-
hydrocortisone acetate cream placed into the external ear
meatus and replaced after 24-48 hours
(10)
was found to
be the treatment of choice. J oseph Rakover et al
(11)

found that the concentration of gentamicin began to
decrease only after 12 hours so they recommended using
gentamicin eardrops twice a day on a wick as a routine
therapy for external otitis. They stated that the wick
serves two purposes: It keeps the solution in contact with
the bacteria in the ear, which is particularly useful in an
inflamed edematous meatus, and it prevents conscious
and unconscious scratching of the ear by the patient.

Patients with localized OE (furuncle) were treated by
drainage of the abscess and packing of the external ear
meatus as previously described with oral antibiotic
support and analgesics.
The second cornerstone in the management of OE
was compliance since successful treatment depends not
only on medications. All patients with OE were
instructed to prevent water from entering the ear by
closing the external ear meatus using a small piece of
cotton soaked with few drops of olive oil. Patients
should also avoid scratching the ear to prevent flare-up
of the condition
(12)
.
Malignant otitis externa is a severe penetrating
infection usually found in immune compromised patients
where Pseudomonas aeruginosa is usually found which
can spread outside the external auditory meatus to
involve the temporal bone, mastoid air cells and perioral
soft tissues. It is a rare but important condition having a
mortality rate between 23-75%. Clinical diagnosis is
difficult because the symptoms are similar to acute otitis
externa
(13)
, mastoiditis, and even parotitis. The presence
of granulation tissue is a leading sign and a positive
finding of bone erosion on CT scan will confirm the
diagnosis of malignant otitis externa, especially in
diabetics and old patients.
Only one patient was suspected to have malignant OE
aged 60 years with 12 years history of diabetes mellitus
and was referred to a regional hospital for further
evaluation and treatment.
For individual prophylactic measures (where intensive
exposure to water is required) topical application of
paraffin-oil and aqueous solution of alcohol and acetic
acid after exposure are recommended
(14)
.

Conc l usi on
Tropical climate, extensive exposure to water, sweating,
infection, trauma (including war injuries), and allergy
play an important role in the etiology of otitis externa.
Fungal infection is the most common type of otitis
externa in tropical countries and appropriate topical
treatment of otitis externa is the treatment of choice.
This decreases the cost of treatment with fewer side
effects and better patient compliance. Systemic
medications should be reserved only to severe cases of
otitis externa.




Fig. 1. Sierra Leone women with left Otitis externa

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