Congenital Abnormality
1. Preauricular sinuses and cysts. 2. Anotia: Complete absence of the pinna. 3. Microtia: Small pinna. 4. Accessory auricles. 5. Atresia of the external auditory meatus. 6. Protruding ear (Bat ear).Acquired Disorders
The Pinna Injuries to the pinna Simple laceration or partial or complete avulsion. Haematoma of the auricle (Haematoma auris).Cauliflower ear
Infections of the pinnaPerichondritis Definition; is inflammation of the perichondrium which cover the auricular cartilage Causes; Infection of haematoma or other injury. Complication of severe otitis externa. Complication of mastoid surgery. Clinical Picture: The pinna is uniformly enlarged and thickened and its surface is red and shiny. Severe pain and tenderness.
Treatment of Perichondritis
Broad spectrum antipseudomonal antibiotic. Application of soothing dressing such as glycerin and ichthamol. A subperichondrial abscess may present and should be incised and drained if fluctuation is definitely present (premature incision may result in further spread of infection and more extensive cartilage necrosis).Infections of the pinna (cont.)
B. Skin infections: Impetigo: ( infection of superficial layers of skin by staphylococci )most commonly occurs in young children secondary to an episode of otorrhoea. Treatment; topical antibiotic and control of otorrhea Erysipelas : Streptococcal infection Dermatitis: may complicate severe otitis externa. Furunculosis: (a staphylococcal infection of the hair follicle).Tumors of The Pinna
Squamous cell and basal cell carcinomas occur on the pinna often on the edge. Predisposing factor: Sun exposure with hyperkeratosis.
Diseases of The external auditory meatus
1. Impacted Wax (Cerumen) Definition: Wax is a mixture of secretions of ceruminous and sebaceous glands with desquamated skin cells. Normally, it is expelled outside the canal by movement of chewing and by underlying epithelial migration. Function Protects the skin by : Acidic reaction Lyzozyme activity - Removal of dust and foreign bodies from EAMEtiology:Excessive wax formation and its retention by stiff hairs.Attempts of the patient to clean his ear push the wax mediallySymptoms:Deafness and discomfort Pain and irritation Tinnitus and disturbance of balanceReflex coughSigns: Brown, yellowish or black plug obscuring the tympanic membrane.Treatment:Removal by:Ear wash: if the wax is hard it should be softened by glycerin/ bicarbonate drops before ear wash Instruments Suction
2. Keratosis Obturans Mass of wax+ desquamated epithelium + cholesterol. Blocking deep portion. This mass causes excessive erosion and expansion of the bony meatus (resembles a cholesteatoma of the middle ear). Frequently associated with bronchiectasis and sinusitis in young patients. Aetiology; unknown ? hyperaemia of the meatal skin and instability of the epidermis.
Clinical Picture: Pain and deafness. Tinnitus and discharge. In severe cases , facial palsy. Examination: Pearly-white glistening mass occluding the bony meatus. Treatment: Removal of the keratotic mass under G.A. Regular observation.
3. Foreign Body in The Ear
Type of patient: Commonly children Mentally retaded adult Type of FB: Animate FB: Flies, larvae, fleas, mosquito Inanimate FB: Non vegitable: bead, button, disc battery Vegetable: bean and peaSymptoms History Hearing loss Severe irritation and noise in the ear with animate FB Signs: The FB can be seen by otoscopy
FB
Treatment:Animate FB:Kill by alcohol or oil remove by ear wash or instrumentsInanimate FB:- Non vegetable: remove by ear wash or instruments BUT PLEASE DO NOT WASH IF THE FB IS DISC BATTERY- Vegetable: Remove by instruments and avoid ear washbecause it may swell by water and become more impactedGeneral anesthesia may be needed in impactedFB and uncooperative children Complications:Injury of the external canal or drum by the FB or during removal So donn’t wash if:The FB is vegetable The FB is disc battery FB
Inflammatory conditions of the external auditory canal
Bacterial: 1- Diffuse OE 2- Localised OE: frunculosis 3- Malignant OE ( Necrotizing OE) Viral ( bullous- Herpes) Fungal: (Otomycosis) Non infective ( allergic OE, Seborrhoic OE)Inflammatory: Bacterial Diffuse otitis externa
Definition: Diffuse inflammation of the skin lining of the extenal auditory canal Pridisposing factors: - Skin laceration: Self inflicted Iatrogenic:- Ear wash or instruments - Skin maceration: Hot humid atmosphere Swimmer ear Discharge of chronic suppurative otitis mediaSymptoms: Earache:Severe Why?Increase on moving the jaw Why? Deafness when edema is severe obstruct the canal SignsExternal exam:Tragal tendernessTender pre and postauricular LN Otoscopic exam :Redness, edema, tenderness of the skin of the external canalScanty discharge, serous or purulentTREATMENTMETICULOUS CLEANINGPACK WITH ANTIBIOTICCULTURE Because the skin is tightly adherent to the underlying perichondrium & periostium
Because the external canal Lies immediately behind Temporomandibular joint
Definition Localized suppurative inflammation of a hair follicle in the skin of the external auditory canal Organism Staph aureus PP factors: - scratching of ear canal - DM
Inflammatory: Bacterial Frunculosis
Symptoms:Earache:Severe Why?Increase on moving the jaw Why? Deafness when edema is severe obstruct the canalSigns: External:Tenderness on moving the auricle orpressure on the tragusTender pre and postauricular LN Otoscopic:It is difficult to examine the external canalBy Otoscope because there is localisedarea of tenderness in the skin of the outerpart of the external canalNo or scanty purulent otorrhea ( never mucoid as there is no mucous glands )
Investigations: Blood glucose level especially in: Recurrent cases Bilateral cases DD acute mastoiditis Treatment Antibiotics Analgesics and heat application Aural toilet. Incision of a boil should be delayed until it is clearly pointing to the skin. Aural pack.
Inflammatory: Bacterial Malignant otitis externa (Necrotizing otitis externa)
Def: invasive potentially fatal infection of the external canal which extends to the base of the skull Incidence: elderly uncontrolled diabetic patient Organism: pseudomonas aeuruginosa Symptoms: Ear discharge and severe earache which does not respond to analgesics
Necrotizing otitis externa should be suspected when patients with diabetes mellitus (or another condition that compromises the immune system) complain of persistent external otitis that causes severe pain, especially at night
Signs External examination: Similar to other OE Otoscopic examination: Granulations at the floor of the EAM at the attachment of bony and cartilaginous part. Scanty, sanguineous and purulent otorrhea
Investigations: Blood glucose level CT scan of the temporal bone& skull base Radio-isotop scan ( Gallium &Tecnetium) to assess severity & prognosis Biopsy Culture &sensitivity
. the left temporal bone shows enhanced uptake of Ga (arrow).
Complications: Osteomyelitis of the temporal bone &skull base Facial nerve paralysis at the stylomastoid foramen Last 4 cranial nerves paralysis at the jagular foramen Treatment: Medical: Control of diabetes Antibiotics; - Gentamycin (be aware of possibility of ototoxicity) - Quinolones 3rd generation cephalosporins Local antibiotic ear drops Analgesics Aural toilet Surgical: Removal of granulations and debridement of necrotic tissue up to mastoidectomy
Inflammatory:Viral: Herpes Zoster Oticus
Etiology: Herpes zoster virus Clinically: Pain in and around the ear Vesicles on the auricle and external canal Ramsay-Hunt syndrome: Vesicles+ facial nerve palsy+SNHL& Vertigo Treatment: - Antiviral - Corticosteroid if there is affection of VII nerve or VIII nerveFungal:Otomycosis
Fungal infection of the skin of the exernal canal Etiology:organism:Aspirigillus NigerCandida albicans Symptoms:Itching is usually the only symptomPain if there is secondary infectionDeafness if the external canal is obstructedSigns:The external canal contains whitish mass with black spots like wet newspaper مثل قطعة صغيرة مبللة من ورق جرائد Treatment:Aural toilet: removal of the fungal mass by suction.Antifungal: nystatin, or salicylic acid (2%) as a keratolytic in alcohol as fungicidalNeoplasm: Benign Exostosis
Definition: is a bony outgrowth from the wall of the EAM. It may be composed of cancellous or compact bone. They are usually multiple and bilateral affecting chiefly the anterior and posterior wall.IncidenceThe commonest tumor of the external canalMore common in swimmers Symptoms: Asymptomatic Hearing loss.Signs:Bilateral smooth bony swellingTreatment:- If obstructing the canal excision
Neoplasm: Malignant Squamous cell carcinoma
Incidence Rare More common in elderly males Clinical Picture: Otological: Deep seated earache Bloody stained discharge Fleshy friable mass in the external canal Progressive hearing loss, initially CHL then SNHL Neurological: paralysis of VII& last 4 cranial nerves Cervical: - Enlarged preauricular, postauricular and upper deep cervical LNInvestigations: CT scan and MRI to assess tumor extension and lymph nodes involvement Biopsy Metastatic work up Treatment: Surgical resection of the temporal bone + postoperative radiotherapy + Radical neck dissection prosthesis
Chest X ray
Abdominal ultrasound
Bone scan
CT scan Of brain
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