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Retained Cotton Bud-induced Severe Otitis Externa That Mimics Malignant Otitis Externa
International Journal of Gerontology xxx (2015) 1e2
Contents lists available at ScienceDirect
International Journal of Gerontology journal homepage: www.ijge-online.com
Case Report
Retained Cotton Bud-Induced Severe Otitis Externa That Mimics Malignant Otitis Externa* Hyung Chae Yang, Yong Beom Cho, Hyong-Ho Cho* Department of OtolaryngologydHead and Neck Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, South Korea
a r t i c l e i n f o
s u m m a r y
Article history: Received 20 July 2014 Received in revised form 18 November 2014 Accepted 22 November 2014 Available online xxx
The potential complications of cotton bud use are not well known in the elderly population. Here, we presented a case of cotton bud misuse. An elderly man who had long-standing diabetes mellitus, chronic otorrhea, and right-sided otalgia was poorly responsive to empirical treatment at a primary hospital. He was misdiagnosed with malignant otitis externa and referred to a tertiary hospital. On treatment Day 7 at the tertiary hospital, when the swollen ear canal was somewhat resolved, a retained cotton swab was found in his ear canal. His symptoms rapidly resolved after removing the retained foreign body. A cotton bud can be retained as a foreign body in the ear canal. The guidance of health professionals is needed to clean the ear canal using cotton buds, especially for elderly patients with other chronic diseases. Copyright © 2015, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: chronic otitis media, otitis externa, retained foreign body
1. Introduction Cotton buds were developed in the early 1920 and are widely used globally. Although they are easily acquired and easy to use, their misuse and complications, such as tympanic membrane perforation by direct penetration, otitis externa by external auditory canal (EAC) injury, and cerumen impaction by pushing ear wax deeper into the canal, have often been reported1e6. Many cotton bud manufacturers display warnings against the use of these buds3. However, misuse problems persist. Otitis externa is one of the major medical issues caused by cotton bud misuse. It is mainly due to the mechanical injury of the EAC. However, a report of otitis externa caused by a retained cotton
* Conflicts of interest: All contributing authors declare that they have no conflicts of interest. * Correspondence to: Dr Hyong-Ho Cho, Department of OtolaryngologydHead and Neck Surgery, Chonnam National University Medical School and Chonnam National University Hospital, 42 Jebong-ro Dong-gu, Gwangju 501-757, South Korea. E-mail address: [email protected] (H.-H. Cho).
bud is rare. To the best of our knowledge, this is the first report of a cotton bud retained as a foreign body in the canal. The retained cotton bud caused severe otitis externa that mimicked malignant otitis externa in an elderly man.
2. Case report A 73-year-old man was brought to a tertiary hospital with the suspicion of malignant otitis media. He had been taking an oral hypoglycemic agent for 30 years. Otorrhea and otalgia were intractable despite medication. A physical examination revealed that the EAC was completely obliterated. An aural polyp was found in the inferior portion of the EAC (Fig. 1A). Pure tone audiometry revealed a mixed-type profound hearing impairment. Temporal bone computed tomography was performed. The EAC was obliterated with soft tissue density without erosive change of the underlying bony EAC wall. Right-side middle ear cavity and mastoid antrum showed opacification. Mastoid air cells showed a sclerotic change (Fig. 1B). Due to the ineffectiveness of oral antipseudomonal fluoroquinolones, ceftazidime 2 g was administered intravenously every 12 hours and the EAC was packed with antibiotic-soaked gauze. On Day 7, a strange object was found in the left ear canal
http://dx.doi.org/10.1016/j.ijge.2014.11.001 1873-9598/Copyright © 2015, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.
Please cite this article in press as: Yang HC, et al., Retained Cotton Bud-Induced Severe Otitis Externa That Mimics Malignant Otitis Externa, International Journal of Gerontology (2015), http://dx.doi.org/10.1016/j.ijge.2014.11.001
2
H.C. Yang et al.
(Fig. 2A). The object was identified as a retained cotton bud (Fig. 2B). Following its removal, EAC swelling and otorrhea resolved rapidly. 3. Discussion
Figure 1. (A) Endoscopic photograph of the ear canal at Day 3 post-treatment showing a completely obliterated ear canal. An aural polyp was seen at the posteroinferior portion of the ear canal. (B) Axial view of high-resolution computed tomography demonstrating soft tissue density of the obliterated left-sided ear canal and sclerotic mastoid.
Gossypiboma is the technical term for a surgical complication resulting from retained foreign materials, such as a surgical sponge, which are accidentally left inside a patient's body. A retained foreign body can trigger a granulomatous reaction and may result in a mass within the body7. A cotton tip was left inside the ear canal of our patient. This retained foreign material caused inflammation in the canal. The discharge from the ear of the patient helped the cotton tip remain attached to the canal, where it invoked severe otalgia and inflammation. Additionally, due to the long-standing diabetes mellitus of the patient, otitis externa was poorly responsive to the initial treatment. Intractable otorrhea, otalgia, old age, and diabetes mellitus are common causes of malignant otitis externa. The patient was misdiagnosed to have malignant otitis externa and referred to a tertiary hospital. However, unlike malignant otitis externa, temporal bone computed tomography revealed no evidence of osteitis in the temporal bone. Additionally, intractable symptoms in the patient who did not respond to 7 days' administration of intravenous ceftazidime were rapidly resolved after the removal of the retained foreign body. Manufacturers warn against the use of cotton buds in the EAC on the product packaging. However, the warnings may be discounted or ignored by the consumer3. Despite the warning, only 5% of cotton ball users actually use the product in the ear canal on the advice of doctors or nurses3. Nussinovitch et al5 reported that 70.1% in the otitis externa group had their ears cleaned with cotton buds during the 10 days preceding the diagnosis of otitis externa. Kravitz et al4 reported that cotton buds were a major cause of ear injury and hearing loss. Despite cotton bud manufacturers' explicit warning on their product, the most common use of cotton swabs is to clean or scratch the ear canal, and misuse of cotton buds is common. Here, we presented another case of cotton swab misuse. A stronger warning against the use of cotton buds and consumer education on their proper use are recommended. The guidance of health professionals is needed for using cotton buds to clean the ear canal, especially in case of elderly patients with other chronic diseases. 4. Conclusion This case demonstrated the risk of using a cotton bud in the ear canal of a patient with chronic otorrhea or a chronic disease. References
Figure 2. (A) Endoscopic photograph of the ear canal at Day 7 post-treatment revealing a foreign body in the widened ear canal. (B) Photograph of foreign material extruded from the ear canal. A cotton tip of about 1.5 cm in size was found.
1. Russell JD, Donnelly M, McShane DP, et al. What causes acute otitis externa? J Laryngol Otol. 1993;107:898e901. 2. Hawke M, Wong J, Krajden S. Clinical and microbiological features of otitis externa. J Otolaryngol. 1984;13:289e295. 3. Hobson JC, Lavy JA. Use and abuse of cotton buds. J R Soc Med. 2005;98: 360e361. 4. Kravitz H, Neyhus AI, Dale DO, et al. The cotton-tipped swab: a major cause of ear injury and hearing loss. Clin Pediatr (Phila). 1974;13:965e970. 5. Nussinovitch M, Rimon A, Volovitz B, et al. Cotton-tip applicators as a leading cause of otitis externa. Int J Pediatr Otorhinolaryngol. 2004;68: 433e435. 6. Robertson MS. The misuse of cotton wool buds. N Z Med J. 1972;75:1e2. 7. Kim HS, Chung TS, Suh SH, et al. MR imaging findings of paravertebral gossypiboma. AJNR Am J Neuroradiol. 2007;28:709e713.
Please cite this article in press as: Yang HC, et al., Retained Cotton Bud-Induced Severe Otitis Externa That Mimics Malignant Otitis Externa, International Journal of Gerontology (2015), http://dx.doi.org/10.1016/j.ijge.2014.11.001
Contents lists available at ScienceDirect
International Journal of Gerontology journal homepage: www.ijge-online.com
Case Report
Retained Cotton Bud-Induced Severe Otitis Externa That Mimics Malignant Otitis Externa* Hyung Chae Yang, Yong Beom Cho, Hyong-Ho Cho* Department of OtolaryngologydHead and Neck Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, South Korea
a r t i c l e i n f o
s u m m a r y
Article history: Received 20 July 2014 Received in revised form 18 November 2014 Accepted 22 November 2014 Available online xxx
The potential complications of cotton bud use are not well known in the elderly population. Here, we presented a case of cotton bud misuse. An elderly man who had long-standing diabetes mellitus, chronic otorrhea, and right-sided otalgia was poorly responsive to empirical treatment at a primary hospital. He was misdiagnosed with malignant otitis externa and referred to a tertiary hospital. On treatment Day 7 at the tertiary hospital, when the swollen ear canal was somewhat resolved, a retained cotton swab was found in his ear canal. His symptoms rapidly resolved after removing the retained foreign body. A cotton bud can be retained as a foreign body in the ear canal. The guidance of health professionals is needed to clean the ear canal using cotton buds, especially for elderly patients with other chronic diseases. Copyright © 2015, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: chronic otitis media, otitis externa, retained foreign body
1. Introduction Cotton buds were developed in the early 1920 and are widely used globally. Although they are easily acquired and easy to use, their misuse and complications, such as tympanic membrane perforation by direct penetration, otitis externa by external auditory canal (EAC) injury, and cerumen impaction by pushing ear wax deeper into the canal, have often been reported1e6. Many cotton bud manufacturers display warnings against the use of these buds3. However, misuse problems persist. Otitis externa is one of the major medical issues caused by cotton bud misuse. It is mainly due to the mechanical injury of the EAC. However, a report of otitis externa caused by a retained cotton
* Conflicts of interest: All contributing authors declare that they have no conflicts of interest. * Correspondence to: Dr Hyong-Ho Cho, Department of OtolaryngologydHead and Neck Surgery, Chonnam National University Medical School and Chonnam National University Hospital, 42 Jebong-ro Dong-gu, Gwangju 501-757, South Korea. E-mail address: [email protected] (H.-H. Cho).
bud is rare. To the best of our knowledge, this is the first report of a cotton bud retained as a foreign body in the canal. The retained cotton bud caused severe otitis externa that mimicked malignant otitis externa in an elderly man.
2. Case report A 73-year-old man was brought to a tertiary hospital with the suspicion of malignant otitis media. He had been taking an oral hypoglycemic agent for 30 years. Otorrhea and otalgia were intractable despite medication. A physical examination revealed that the EAC was completely obliterated. An aural polyp was found in the inferior portion of the EAC (Fig. 1A). Pure tone audiometry revealed a mixed-type profound hearing impairment. Temporal bone computed tomography was performed. The EAC was obliterated with soft tissue density without erosive change of the underlying bony EAC wall. Right-side middle ear cavity and mastoid antrum showed opacification. Mastoid air cells showed a sclerotic change (Fig. 1B). Due to the ineffectiveness of oral antipseudomonal fluoroquinolones, ceftazidime 2 g was administered intravenously every 12 hours and the EAC was packed with antibiotic-soaked gauze. On Day 7, a strange object was found in the left ear canal
http://dx.doi.org/10.1016/j.ijge.2014.11.001 1873-9598/Copyright © 2015, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.
Please cite this article in press as: Yang HC, et al., Retained Cotton Bud-Induced Severe Otitis Externa That Mimics Malignant Otitis Externa, International Journal of Gerontology (2015), http://dx.doi.org/10.1016/j.ijge.2014.11.001
2
H.C. Yang et al.
(Fig. 2A). The object was identified as a retained cotton bud (Fig. 2B). Following its removal, EAC swelling and otorrhea resolved rapidly. 3. Discussion
Figure 1. (A) Endoscopic photograph of the ear canal at Day 3 post-treatment showing a completely obliterated ear canal. An aural polyp was seen at the posteroinferior portion of the ear canal. (B) Axial view of high-resolution computed tomography demonstrating soft tissue density of the obliterated left-sided ear canal and sclerotic mastoid.
Gossypiboma is the technical term for a surgical complication resulting from retained foreign materials, such as a surgical sponge, which are accidentally left inside a patient's body. A retained foreign body can trigger a granulomatous reaction and may result in a mass within the body7. A cotton tip was left inside the ear canal of our patient. This retained foreign material caused inflammation in the canal. The discharge from the ear of the patient helped the cotton tip remain attached to the canal, where it invoked severe otalgia and inflammation. Additionally, due to the long-standing diabetes mellitus of the patient, otitis externa was poorly responsive to the initial treatment. Intractable otorrhea, otalgia, old age, and diabetes mellitus are common causes of malignant otitis externa. The patient was misdiagnosed to have malignant otitis externa and referred to a tertiary hospital. However, unlike malignant otitis externa, temporal bone computed tomography revealed no evidence of osteitis in the temporal bone. Additionally, intractable symptoms in the patient who did not respond to 7 days' administration of intravenous ceftazidime were rapidly resolved after the removal of the retained foreign body. Manufacturers warn against the use of cotton buds in the EAC on the product packaging. However, the warnings may be discounted or ignored by the consumer3. Despite the warning, only 5% of cotton ball users actually use the product in the ear canal on the advice of doctors or nurses3. Nussinovitch et al5 reported that 70.1% in the otitis externa group had their ears cleaned with cotton buds during the 10 days preceding the diagnosis of otitis externa. Kravitz et al4 reported that cotton buds were a major cause of ear injury and hearing loss. Despite cotton bud manufacturers' explicit warning on their product, the most common use of cotton swabs is to clean or scratch the ear canal, and misuse of cotton buds is common. Here, we presented another case of cotton swab misuse. A stronger warning against the use of cotton buds and consumer education on their proper use are recommended. The guidance of health professionals is needed for using cotton buds to clean the ear canal, especially in case of elderly patients with other chronic diseases. 4. Conclusion This case demonstrated the risk of using a cotton bud in the ear canal of a patient with chronic otorrhea or a chronic disease. References
Figure 2. (A) Endoscopic photograph of the ear canal at Day 7 post-treatment revealing a foreign body in the widened ear canal. (B) Photograph of foreign material extruded from the ear canal. A cotton tip of about 1.5 cm in size was found.
1. Russell JD, Donnelly M, McShane DP, et al. What causes acute otitis externa? J Laryngol Otol. 1993;107:898e901. 2. Hawke M, Wong J, Krajden S. Clinical and microbiological features of otitis externa. J Otolaryngol. 1984;13:289e295. 3. Hobson JC, Lavy JA. Use and abuse of cotton buds. J R Soc Med. 2005;98: 360e361. 4. Kravitz H, Neyhus AI, Dale DO, et al. The cotton-tipped swab: a major cause of ear injury and hearing loss. Clin Pediatr (Phila). 1974;13:965e970. 5. Nussinovitch M, Rimon A, Volovitz B, et al. Cotton-tip applicators as a leading cause of otitis externa. Int J Pediatr Otorhinolaryngol. 2004;68: 433e435. 6. Robertson MS. The misuse of cotton wool buds. N Z Med J. 1972;75:1e2. 7. Kim HS, Chung TS, Suh SH, et al. MR imaging findings of paravertebral gossypiboma. AJNR Am J Neuroradiol. 2007;28:709e713.
Please cite this article in press as: Yang HC, et al., Retained Cotton Bud-Induced Severe Otitis Externa That Mimics Malignant Otitis Externa, International Journal of Gerontology (2015), http://dx.doi.org/10.1016/j.ijge.2014.11.001