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346 Otology and neuro-otology

ears than control ears; ilomastat and recombinant alpha 1 antitrypsin (rAAT) inhibited 60% of MMP and 98% of HNE activity. The authors speculate on the therapeutic potential of these protease inhibitors [34]. Finally, in a randomized, double-blind, placebo-controlled trial, bac teriophage (virus that infects and kills bacteria) therapy was well tolerated and effective, significantly improving patient symptom score and physician assessment com pared with placebo therapy for patients with COE due to antibiotic-resistant P. aeruginosa [35 ]. Conclusion Chronic otitis externa, a condition we share with our feline and canine friends, can be caused by many factors, with otorrhea, pruritis, discomfort, and fullness as the final common symptompathway. Treatment is aimed at remov ing all potential irritants to the skin of the canal, quelling the inflammation with medical management, reserving surgery for end-stage disease, and investigating the under lying source, whether exogenous (e.g. contact dermatitis) or endogenous (e.g. autoimmune/atopic). Frustrating for both patient and doctor, a ‘truce’ – stabilization and control of the disease process – is often the best we can hope for. Acknowledgements The author wishes to thank Dr Kenneth Greer, Division of Dermatology, Department of Internal Medicine, University of Virginia and Dr Prashant Raghavan, Department of Radiology, University of Virginia for the images used in this article. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 411). 1 Ali R, Burns P, Donnelly M. Otitis externa: quality of life assessment. Ir J Med Sci 2008; 177:221–223. 2 Toh A, De R. Spontaneous cerebrospinal fluid otorrhoea presenting as otitis externa. Eur Arch Oto-Rhino-Laryngol 2007; 264:689–691. 3 De Zoysa N, Vasani S, Kaniyur S, Frosh A. Gustatory otorrhoea: a rare case of congenital external ear salivary fistula. J Laryngol Otol 2009; 123:1371– 1374. Case report of a salivary fistula diagnosed by sending the otorrhea for amylase and treated by superficial parotidectomy. 4 Klemens JJ, Recant W, Baron JM, Saadia-Redleaf MI. Amyloidosis of the external auditory canal. Ear Nose Throat J 2010; 89:219–220. Case report; diagnosed by ear canal biopsy. 5 Lang EE, el Zaruk J, Colreavy MP, et al. An unusual case of external ear inflammation caused by sarcoidosis. Ear Nose Throat J 2003; 82:942–945. 6 Konttinen YT, Ramsay H, Hietanen J, et al. Otitis externa sicca/fibrotising external otitis (FEO) as a complication of Sjogren’s syndrome. Clin Experiment Rheumatol 2000; 18:746–748. 7 Illum P, Thorling K. Otological manifestations of Wegener’s granulomatosis. Laryngoscope 1982; 92 (7 Pt 1):801–804. The work was not funded. Conflicts of interest None declared.

8 Ghaffar SA, Todd PM. Chronic recurrent otitis externa secondary to allergic contact dermatitis to nickel and phosphorus sesquisulfide. Contact Derm 2009; 61:124–125. 9 Sood S, Strachan DR, Tsikoudas A, Stables GI. Allergic otitis externa. Clin Otolaryngol Allied Sci 2002; 27:233–236. 10 Yariktas M, Yildirim M, Doner F, et al. Allergic contact dermatitis prevalence in patients with eczematous external otitis. Asian Pac J Allergy Immunol 2004; 22:7–10. 11 Derebery J, Berliner KI. Foot and ear disease: the dermatophytid reaction in otology. Laryngoscope 1996; 106:181–186. 12 Yariktas M, Doner F, Dogru H, Demirci M. Asymptomatic food hypersensitivity prevalence in patients with eczematous external otitis. Am J Otolaryngol 2004; 25:1–4. 13 Lum CL, Jeyanthi S, Prepageran N, et al. Antibacterial and antifungal proper ties of human cerumen. J Laryngol Otol 2009; 123:375–378. In culture, human cerumen has potent antibacterial activity against S. aureus , P. aeruginosa , and C. albicans but not as potent against E. coli . 14 Pata YS, Ozturk C, Akbas Y, et al. Has cerumen a protective role in recurrent external otitis? Am J Otolaryngol 2003; 24:209–212. 15 Gray RF, Sharma A, Vowler SL. Relative humidity of the external auditory canal in normal and abnormal ears, and its pathogenic effect. Clin Otolaryngol 2005; 30:105–111. 16 Martinez Devesa P, Willis CM, Capper JW. External auditory canal pH in chronic otitis externa. Clin Otolaryngol Allied Sci 2003; 28:320–324. 17 Ho T, Vrabec JT, Yoo D, Coker NJ. Otomycosis: clinical features and treatment implications. Otolaryngol Head Neck Surg 2006; 135:787–791. 18 Vennewald I, Klemm E. Otomycosis: diagnosis and treatment. Clin Dermatol 2010; 28:202–211. Excellent review of antifungal agents for otomycosis with thorough yet concise tables. Article addresses the evidence regarding ototoxicity of antifungals as well. 19 Yenisehirli G, Bulut Y, Guven M, Gunday E. In vitro activities of fluconazole, itraconazole and voriconazole against otomycotic fungal pathogens. J Lar yngol Otol 2009; 123:978–981. Solid ‘translational’ study looking at in-vitro activity of antifungal agents against fungal isolates from 92 otomycosis patients. Interestingly, all Aspergillus isolates were resistant to fluconazole. Voriconazole was most potent. 20 Becker GD. Treatment of chronic otitis externa with trichophyton, oidiomy cetes, epidermophyton antigen. Otolaryngol Head Neck Surg 1980; 88: 293–294. 21 Hopsu E, Pitkaranta A. Idiopathic inflammatory medial meatal fibrotizing otitis presenting in children. Otol Neurotol 2008; 29:350–352. 22 Slattery WH 3rd, Saadat P. Postinflammatory medial canal fibrosis. Am J Otol 1997; 18:294–297. 23 Selesnick S, Nguyen TP, Eisenman DJ. Surgical treatment of acquired external auditory canal atresia. Am J Otol 1998; 19:123–130. 24 Becker BC, Tos M. Postinflammatory acquired atresia of the external auditory canal: treatment and results of surgery over 27 years. Laryngoscope 1998; 108:903–907. 25 Suzukawa K, Karino S, Yamasoba T. Surgical treatment of medial meatal fibrosis. Report of four cases. Auris Nasus Larynx 2007; 34:365–368. 26 Golder J. Oral steroids in the treatment of otitis externa. Aust Fam Physician 1999; 28:775. 27 Caffier PP, Harth W, Mayelzadeh B, et al. Tacrolimus: a new option in therapy-resistant chronic external otitis. Laryngoscope 2007; 117:1046– 1052. 28 Hughes RG, Courteney-Harris RG, Wilson PS. Longer term follow up for treatment of chronic otitis externa by KTP/532 laser. J Laryngol Otol 2001; 115:862. 29 Farnan TB, McCallum J, Awa A, et al. Tea tree oil: in vitro efficacy in otitis externa. J Laryngol Otol 2005; 119:198–201. 30 Kumar PJ, Smelt GJ. A long term follow up of conchal flap meatoplasty in chronic otitis externa. J Laryngol Otol 2007; 121:1–4. 31 Sharp HR, Oakley RJ, Padgham ND. The Canterbury technique for canalplasty via an endaural approach in the surgical management of chronic refractory otitis externa. J Laryngol Otol 2003; 117:195– 197. 32 Savastano M, Ferraro SM, Marioni G. Perichondritis with or without external otitis and intradermal injection: a new therapeutic approach. J Otolaryngol Head Neck Surg 2009; 38:568–572. A case series without long-term data presenting another method (intradermal) of delivering drug to the inflamed ear. Note: ‘flogosis’ means inflammation in Spanish.

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