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Diseases of the Pinna Congenital Abnormality

Protruding ear (Bat ear, Lop ear): abnormally protruding ear. The concha is large with poorly developed antihelix. It can be corrected surgically around 6 years.

Congenital Abnormality

Preauricular ppendages: They are skin-covered tags that appear in front of the tragus. They may contain small pieces of cartilage(accessory auricle).

Congenital Abnormality

Preauricular sinuses and cysts. root of helix due to incomplete fusion of tubercles repeatedly infected causing abscess Treatment is antibiotic and repeated needle aspiration until abscess disappear ,then surgical excision of the track and cyst.

Congenital Abnormality

Microtia major developmental anomaly. Degree may vary. unilateral or bilateral. may be associated with meatal atresia and ossicular abnormalities. Treatment is difficult by multi-stage surgery or prosthetic ear and bone anchored hearing aid BAHA.

Acquired Disorders of Pinna

Haematoma of the auricle (Haematoma auris). extravasation of blood between the cartilage and perichondrium. pinna appears swollen and blue. Aspiration or drainage under local anesthesia followed by a firm pressure for 48 hours In recurrent hematoma, surgical drainage UGA with mattress suturing over buttons.

ComplicationsIf untreated, the pinna may become distorted and thickened due to replacement of necrosed cartilage with fibrous tissue. A "cauliflower ear" – often seen in wrestlers- may result.

Keloid of auricle

It may follow trauma or piercing of ear for ornament. Usual sites are the lobule or helix. Surgical excision usually results in recurrence. Some prefer local injection of steroid after excision (other treatment: 5 FU, LASER, or cryosurgery.


Perichondritis:
Infection of the auricular cartilage and perichondrium, resulting from infected hematoma, extension of infection from ear boil or high ear piercing. Pinna is uniformly enlarged and thickened and its surface is red and shiny, except ear lobule. There is severe pain and tenderness.

Perichondritis:

Treatment: Empiric antipseudomonal antibiotic ( ceftazidime, ciprofloxacin,..). A subperichondrial abscess may present and should be incised and antibiotic given according to sensitivity result. Wick insertion and daily dressing, sometimes with local antibiotic irrigation.

Relapsing polychondritis

Rare autoimmune disorder involving cartilage of the ear. Other cartilages may also be involved as laryngeal cartilage. The entire auricle except its lobule becomes inflamed and tender. External ear canal becomes stenotic. Treatment consists of high doses of systemic steroids and azathioprine

Congenital Aural Atresia

Congenital atresia of the meatus may occur alone or in association with microtia, due to failure of canalization of the ectodermal core that fills the first branchial cleft. The atresia is fibrous or bony.

WE REMEMBER 10% of what we read 20% of what we hear 30% of what we see 50% of what we see and hear 70% of what we discuss with others 80% of what we personally experience 95% or what we teach others - Edgar Dale

Otitis Externa

I / Infective OE: Bacterial: 1- Diffuse OE 2- Localized OE: frunculosis 3- Malignant OE (Necrotizing OE) Viral: 1- Bullous Myringitis ( Otitis Externa hemorrhagica). 2- Herpes Zoster Oticus. Fungal: (Otomycosis) II / Reactive: Eczematous OE. Seborrhoeic OE. Neurodermatitis.

Diffuse Otitis Externa

Diffuse inflammation of meatal skin. Hot and humid climate and in swimmers. Pseudomonas aeruginosa , Staphyllococus aureus and Proteus but more often the infection is mixed. Hot burning sensation in the ear, followed by pain which is aggravated by movements of jaw. Serous discharge, Meatal inflamation, LN. Chronic phase: constant itching, pain and the meatal skin shows fissuring and scaling.


Diffuse Otitis Externa
Treatment Ear toilet: dry mopping or suction. Medicated wicks: Wick soaked with antiseptic or antibiotic/steroid cream, changed daily for few days, then drops. Antibiotics: Systemic antibiotics are used when there is cellulitis or lymphadenitis. Analgesics.

Frunculosis

Localized staphylococcal infection of a hair follicle in the skin of the cartilaginous part of EAC. Severe otalgia which increases on moving the jaw, and tenderness on pressure of tragus. Deafness due to canal obstruction. Preauricular LN may enlarge. Otoscopy is difficult and painful.

Frunculosis

Treatment: Antistaph ( flucloxacillin) 5 days. Analgesics and heat application. Aural toilet: removal of ear discharge. Incision of a boil should be delayed. Aural pack: gauze soaked in ichthammol/ glycerin. Diabetes should be excluded in recurrent cases.

Malignant otitis externa (Necrotizing otitis externa)

“Osteomyelitis of skull base”. Invasive potentially fatal infection of EAC, extends to skull base, Ps Aeurug.Clinical features: Elderly diabetic complaining of severe deep otalgia mainly at night not responding to analgesics.Scanty sanguineous ear discharge. Otoscopy reveals granulations at the floor of the external canal at the attachment of bony and cartilaginous part.

Malignant otitis externa (Necrotizing otitis externa)

Investigations: Blood glucose level. CT scan + MRI.
The CT scan shows bony destruction of the right temporal bone. Note the missing posterior wall of the external auditory canal . Mastoid air cells are secondarily involved and are opacified compared with the well-aerated left side.

Malignant otitis externa (Necrotizing otitis externa)

Investigations: Radio-isotope scan ( Gallium &Technetium) to assess severity and prognosis. Biopsy of granulation tissue to exclude malignancy. Culture and sensitivity.
. Gallium citrate Ga 67 scintigraphy in a 74-year-old male patient with diabetes mellitus and left-sided temporal bone osteitis. This patient was referred because of persistent otalgia and otorrhea after a prolonged course of systemic oral antibiotics. As a result of ongoing infection, the left temporal bone shows enhanced uptake of 67Ga .


Malignant otitis externa (Necrotizing otitis externa)
Treatment: mainly medical : high dose I.V. antibiotic according to sensitivity result ( usually flouroquinolone or third generation cephalosporin or aminoglycoside) for 6-8 weeks. Systemic antifungal. Strict control of diabetes. Local treatment consists of repeated medicated wick. Strong analgesia is given. Surgical treatment is limited to local debridement and excision of granulation tissue.

Malignant otitis externa (Necrotizing otitis externa)

Complications: Osteomyelitis of the temporal bone and skull base. Facial nerve paralysis at the stylomastoid foramen Extension of infection to jugular foramen causing paralysis of last 4 cranial nerves.

Herpes Zoster Oticus

Viral infection of external, middle and inner ear caused by Herpes Zoster(= Varicella Zoster) virus severe otalgia and vesicles on the ear canal, concha and postaural area. If VII affected, called Ramsay-Hunt syndrome which carry worse prognosis than Bell palsy. If VIII is involved there is SNHL and vertigo.


Treatment: Antiviral drugs (Valacyclovir), and high dose corticosteroid if facial or vestibulocochlear nerves are affected. Herpis Zoster( shingles)

Otomycosis

fungal infection EAC Aspergillus niger (black), Aspergillus fumigatus (green) or Candida albicans (white). Hot and humid climate of tropical and subtropical countries. Secondary fungal growth is also seen in patients using topical antibiotics ear drops. Systemic and topical steroid is another factor.

Otomycosis

intense itching, discomfort or pain in the ear, watery discharge and ear blockage. The fungal mass may appear white, green or black, and described as wet newspaper.

Bullous Myringitis ( Otitis Externa hemorrhagica)

Formation of haemorrhagic bullae on the tympanic membrane and deep meatus. It is probably viral in origin and may be seen in influenza epidemics (Mycoplasma pneumoniae?). Very severe pain in the ear and blood-stained discharge when the bullae rupture.


Bluish or red bullae on the tympanic membrane. Hearing is usually normal. Treatment with analgesics and to keep ear dry. Complications sensorineural deafness and viral labyrinthitis.

Neoplasm of External Auditory Canal Osteoma and Exostosis

Bony outgrowth from EAM, cancellous or compact bone. Osteoma is solitary and unilateral, arises from suture lines.Exostosis is multiple and bilateral, arises from deep bony canal and has characteristic wide base. Exostosis … " surfer's ear". Both are asymptomatic early but causes conductive deafness when enlarges. Treatment surgical excision under the microscope.

Wax (cerumin) is a mixture of secretions of ceruminous glands( which is modified sweat gland) and sebaceous glands with desquamated skin cells. The glands are situated in the cartilaginous portion of the EAM. Normally, expelled by movement of chewing and by underlying epithelial migration. Function: Protects the skin by: Acidic reaction Lysozyme activity Removal of dust and foreign bodies from EAM.


Excessive wax formation + retention by stiff hairs. Also attempts of the patient to clean his ear . Clinical Picture: Deafness and discomfort in the ear. Tinnitus and disturbance of balance; also caused by pressure of the wax. Reflex cough due to stimulation of auricular branch of the vagus (Arnold nerve). Examination: Otoscopic examination shows brown, yellowish or black plug obscuring the tympanic membrane.


Treatment:Syringing. If too hot or too cold? Jet of water is directed? It is contraindicated in…Removal with a ring probe or crocodile forceps…Suction through the operating microscope..5% sodium bicarbonate in 30% glycerin, olive oil or diluted hydrogen peroxide.

Keratosis Obturans

Meatus on both sides become blocked in its deep portion by a mass consisting of wax, and desquamated epithelium. This mass causes excessive erosion and expansion of the bony meatus and in this action, it resembles a cholesteatoma. may be associated with bronchiectasis and sinusitis. Aetiology; failure of epithelial migration due to unknown factors. Clinical Picture: Conductive deafness, pain and repeated otorrhea.


White glistening mass occluding the deep meatus. Treatment: Removal of the keratotic mass, usually under general anesthesia. The mass is sticky and adherent, and should be removed carefully to avoid ossicular damage. Regular observation is advised as the keratosis may reform.

Foreign Body in the Ear

Commonly in children and mentally retarded adult. Animate FB: insects as flies and ants enters through ear canal. Larvae of mosquito are born in chronic discharging ear with bad general hygiene. Inanimate FB: inorganic FB: beads, stones, buttons,.. Organic FB: bean, pea, sponge, paper, wood,.. Disc battery: special types of inanimate FB, it rapidly leaks alkali into canal causing liquifactive necrosis of skin and bone with excess crust formation.



Treatment: Animate FB are Killed by instilling alcohol or oil and removed by ear wash or crocodile forceps. Irregular FB as paper are also removed by crocodile forceps. Round FB should be removed by ear probe or syringing but not by forceps.

Organic FB should not be washed because they swell and get more impacted; they can be removed by ear probe. Disc battery is removed as emergency procedure by forceps or probe. General anesthesia may be needed in impacted FB and uncooperative children. Removal under the operating microscope is helpful. Postaural approach is occasionally required.




رفعت المحاضرة من قبل: Oday Duraid
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