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Description : DISEASES OF EXTERNAL EAR

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Published on : Dec 01, 2021 | Views : 3800 | Downloads : 24

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Slide 1-

DISEASES OF EXTERNAL EAR
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ANATOMY- PINNA
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ANATOMY- PINNA(cont) Average adult female ear is 59 mm tall and the average male is 63mm tall. 85 % of height of ear is achieved by 3 years of age and almost 100% by 10 years of age. The size of ear remains the same size till the age of 60 when it gradually enlarges particularly the lobe. The average adult ear protrudes 19 mm from the mastoid skin The ear lies between the level of the eyebrow and a line of few millimetres beneath the nasal columella. The distance between the lateral canthus of the eye to the front of the ear is just over the length of the ear.
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CONGENITAL CONDITIONS CAUSES : Heridity , Drugs , Irradiation , Viral Infection etc. Darwin’s tubercle : an inherited Wildermuth’s ear : Prominence condition.Presence as a small antihelix and under- development elevation in post-sup part of helix. of helix & a/w CHL & SNHL.
Slide 5-

CONGENITAL CONDITIONS(cont) Mozart’s Ear : An dominant inheritance condition of the auricle, characterized by the bulging appearance of the antero-superior portion of the auricle due to fusion of the crura of the antihelix, an inversion in the normal form of the cavum conchae resulting in its convexity and a slit-like narrowing of the orifice of the external auditory meatus. Wolfgang Amadeus Mozart
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CONGENITAL CONDITIONS(cont) Bat Ears: Prominence is due to an absent anti-helical fold but in some cases, the conchal bowl is excessively deep Recommended to do surgery only after 5 years of age.
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Lop Ear Crux anhihelics is poorly formed CONGENITAL CONDITIONS(cont)
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Cup Ear Antihelix is undeveloped CONGENITAL CONDITIONS(cont)
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CONGENITAL CONDITIONS(cont) ACCESSORY AURICLES: Small elevation of skin containing a bar of elastic cartilage. Anterior to tragus or ascending crus of helix , but may extend along a line joining the tragus and angle of mouth. Excision
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CONGENITAL CONDITIONS(cont) Mirror Ear or Polyotia: Persistent pre-auricular tissues lying on posterior cheek resembling extra ear.
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CONGENITAL CONDITIONS(cont) Cryptotia (The Hidden Ear): Lower two thirds of ear visible, upper auricular sulcus seems lost. Upper pole is tethered and lower lobe is prominent. When ear is pulled away from the side of the head, the upper pole cartilage becomes evident, having hidden beneath scalp skin.
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CONGENITAL CONDITIONS(cont) Pre Auricular Sinus: Faulty fusion of 1st & 2nd arch Opening : Anterior border of ascending limb of helix Line extending b/w tragal notch & angle of mouth Pinna (or) Lobule Extend upto the level of tympanic ring. C/F : Asymptomatic , If infected – chronic discharge , recurrent abscess & calculus Treatment : Excision ( careful for facial nerve)
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CONGENITAL CONDITIONS(cont) Anotia Microtia Macrotia
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PERICHONDRITIS/CHONDRITIS Infection or inflammation of perichondrium or cartilage of Auricle & EAC Classification Erysipelas of External ear ( Inf. of overlying skin) Cellulitis of External ear (Inf. of soft tissue ) Perichondritis ( Inf. Involving perichondrium) Chondritis ( Inf. Involving cartilage ) Org : Pseudomonas Aeruginosa , Staph. Aureus. Signs & Symptoms: Pain over auricle and deep canal, Pruritus, Induration. Edema Advanced cases- Crusting & weeping, Involvement of soft tissues
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PERICHONDRITIS/CHONDRITIS(cont) Aetiology: Result of trauma to auricle Laceration of auricle , Surgery to ext.ear , frostbite , burns , chemical injury , inf. of hematoma of pinna , high piercing of auricle for insertion of ear rings Spontaneous (overt diabetes) Connective Tissue Disease Treatment: Antibiotics-Topical & oral antibiotics I & D (if abscess) Irrigating with 1.5 % acetic acid & gentamycin Sequelae: Cauliflower ear
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PERICHONDRITIS/CHONDRITIS(cont) Prevention: By careful ear piercings away from cartilaginous pinna. Avoid Surgery in and around ear – to prevent from trauma Hematoma of auricle to drain properly. Meticulous management of burn injuries with prophylatic antibodies against gram negative bacteria. Removal of eschars and crusts.
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PSEUDOCYST/SEROMA OF PINNA A soft cystic swelling may develop on pinna due to collection of fluid under the skin. There is no definite cyst wall. The exact aetiology is not known but possibly this extravasation of fluid is due to trauma of which the patient may be unaware. Treatment Aspiration or incision drainage under aseptic precautions is done followed by pressure bandage. In case of recurrence, removal of the necrosed cartilage and painting of the wound with a weak solution of iodine is recommended Aspirated Serous Fluid
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HEMATOMA OF PINNA Hematoma of pinna is usually seen in fights where due to trauma a fluctuant swelling appears under the skin. Usually, there are no constitutional symptoms unless an infection supervenes. Its persistence deprives blood supply to perichondrium, leading to infection and necrosis. If not treated may lead to cauliflower ear also called Boxer’s ear Treatment is by incision and drainage and proper compression of the wound to prevent accumulation of blood or fluid. This can be done by applying quilting sutures and/ or a tight bandage. Antibiotics to prevent secondary infection and anti-inflammatory are also given.
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FROST BITE OF PINNA The pinna being exposed to variations in temperature and the blood vessels being superficial (deep only to the skin), extremes of cold affect it readily. Frost bite occurs particularly in the upper and outer portions of the pinna. Treatment involves slow thawing. Vasodilator drugs like nicotinic acid and nylidrine are also prescribed. As a preventive measure, exposure to cold should be avoided.
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KELOID OF PINNA It is common after pinna injury/prick. Prone for recurrence even after excision. repeated excision may lead to huge mass. It is common near the ear and on the neck. Triamcinolone injected at the base repeatedly in small lesions, may help Large lesions may be excised, followed by Triamcinolone locally or Radiotherapy to reduce the recurrence rate.
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BENIGN SKIN PATHOLOGY OF PINNA Seborrhoeic Keratosis Gouty Tophi Solar keratosis
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REFERRED OTALGIA WITH NORMAL TM
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REFERRED OTALGIA WITH NORMAL TM(cont) Via Trigeminal Nerve • Teeth: infection, impacted 3rd molar, malocclusion • Oral cavity: infection, ulcer, malignancy, Ludwig’s angina, sialadenitis, salivary calculus • Temporo-mandibular joint: arthritis, dysfunction • Nose & PNS: impacted DNS, sinusitis, neoplasm • Nasopharynx: infection, post- adenoidectomy, adenoiditis, tumor • Trigeminal neuralgia Via Glossopharyngeal Nerve • Tonsil: tonsillitis, peritonsillar abscess, posttonsillectomy, neoplasm • Oropharynx: infection, ulcer, retropharyngeal +parapharyngeal abscess, trauma, neoplasm • Eagle’s syndrome (stylalgia) • Glossopharyngeal neuralgia
Slide 24-

REFERRED OTALGIA WITH NORMAL TM(cont) Via Facial Nerve: Herpes zoster oticus, vestibular schwannoma Via vagus nerve: Larynx + hypopharynx: neoplasm, infection, tuberculosis, trauma, foreign body Via second & third cervical nerves: Herpes zoster, cervical spondylosis & arthritis
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FURUNCULOSIS Acute localized infection of single hair follicle. Lateral 1/3 of posterosuperior canal Obstructed apopilosebaceous unit Signs: Edema, Erythema, Tenderness, Occasional fluctuance Symptoms: Localized pain, Ear blockage, Pruritus Exudates a scanty sero-sanguinous discharge Hearing loss (if lesion occludes canal) The lymph nodes adjacent to the pinna are enlarged with a furuncle or furunculosis, and a tender mastoid node may mimic a cortical mastoid abscess.
Slide 26-

FURUNCULOSIS (cont) Pathogen: S. aureus Treatment: Local heat, Analgesics, Topical antibiotics /Hygroscopic Dehydrating agents. Oral antibiotics, IV antibiotics for soft tissue extension. Incision and drainage reserved for localized abscess For recurrent : Eradication therapy with oral flucloxacillin (14 days), nasal mupirocin , as the organism may be transferred by the patient’s finger from the nasal vestibules. Nasal swab becomes a relevant investigation, particularly with recurrent furuncles.
Slide 27-

OTITIS EXTERNA Is an inflammation of the EAC skin that is characterized by general edema & erythema a/w itchy discomfort and ear discharge. Can be Acute or Chronic (Lasts <6 weeks, Bacterial infection ) (Lasts >6 weeks, Allergies/Autoimmune Diseases.)
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OTITIS EXTERNA(cont) Predisposing factors : Anatomical ( narrow / obstructed ear canal) , Dermatological ( Eczema , Sebhorrhoeic dermatitis ) Allergic ( Atopy , Non–atopy , Exposure to top.med) Physiological ( Humid environment , Imm.compramised) Traumatic ( Skin maceration , ear probing , rad.theraphy ) Microbiological ( P.aeruginosa , Active COM , Fungi infection ) Bathing : In fresh water lakes containing Pseud.aeruginosa ”swimmer’s ear” Any condition that disturbs the lipid/acid balance of the ear will predispose.
Slide 29-

OTITIS EXTERNA(cont) Aetiology: Bacterial – Staph. aureus, Pseudomonas, Proteus Fungal – Aspergillus niger, Candida albicans Viral – Herpes simplex,Herpes zoster Reactive – Eczema, Psoriasis Clinical Menifestations: Red, swollen ear canal • Foul discharge from ear. Itchiness, Fever Ear pain( Pain worsened when external ear is touched). Temporary conductive loss. Severe cases : Ear canal narrowed through exudates/ Lumen obliteration. Involvement of periauricular soft tissue: fullness of post auricular sulcus
Slide 30-

OTITIS EXTERNA(cont) Treatment : Systemic antibiotics, anti-inflammatory drugs. Local treatment- removal of debris and wick soaked in antibiotic steroid cream. Avoidance of any predisposing factors. COMPLICATIONS: Abscesses. Narrowing of ear canal- in Chronic Inflamed or perforated eardrum Cellulitis. Malignant otitis externa: Mostly occur with person with diabetes mellitus.
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Malignant Otitis Externa Malignant otitis externa was described by Meltzer and Kelemen in 1959. It is a fulminating severe form of otitis externa caused by pseudomonas seen in elderly diabetic patients, male preponderance. It may also be seen in those patients suffering from acquired immune deficiency syndrome (AIDS) or malignancy and are on immunosuppressive drugs like azathioprine, methotrexate, cyclophosphamide and cyclosporine. Patients using steroids or having hypogammaglobulinemia may also be affected by this disease. The disease has also been called as skull base osteomyelitis. History of trivial trauma to the ear often by ear buds
Slide 32-

Malignant Otitis Externa (cont)
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Malignant Otitis Externa (cont) Clinical Features: It is called malignant as it behaves like a malignant process by causing destruction of tissues of canal, pre- and post auricular region by various enzymes such as lecithinase and hemolysin. Spread of this disease occurs through the fissures of Santorini and osteo - cartilaginous junction. Granulation tissue at the bony cartilaginous junction Posteroinferior wall of external auditory meatus shows granulations and lower cranial nerves involvement such as VII, IX, X, XI. Facial nerve may be paralyzed more frequently than other nerves. Common Pathogens: Pseudomonas aeruginosa, Staphylococcus aureus, Aspergillus & rarely Proteus Differential Diagnosis: Paget’s disease Carcinoma of external auditory meatus Granulomatous disorders
Slide 34-

Malignant Otitis Externa (cont) Differential Diagnosis: Paget’s disease Carcinoma of external auditory meatus Granulomatous disorders Diagnostic Work Up: Pus swab. Hb, TLC, DLC. CT scan, bone scan to rule out osteomyelitis Serial Gallium-67 scans, which indicates active inflammation at the site. Brush cytology & Biopsy – to exclude neoplasm Syphillis & TB should be excluded.
Slide 35-

Malignant Otitis Externa (cont) Treatment: Heavy doses of antibiotics such as gentamicin/ tobramycin/ cefotaxime 1 gm IM/IV and ciprofloxacin 750 mg twice daily for a period of 6 to 8 weeks. Hyperbaric oxygen therapy is very effective and helps by improving phagocytic action due to higher tissue oxygen tension levels. Local debridement of necrotic tissues and bone. Packing of a wick soaked in antibiotic cream. Strict control of diabetes is most important. Wide surgical excision of infected tissue and bone may be required sometime. Mortality is 67 percent in patients with facial nerve palsy, while it is 80 percent in patients with multiple cranial nerve involvement.
Slide 36-

OTOMYCOSIS Is a fungal infection of external auditory canal usually caused by Aspergillus fumigatus, Aspergillus niger or Candida albicans. Common in hot , humid climates & is often secondary to prolonged use of topical Antibiotics. Occur because the protective lipid/acid balance of the ear is lost. It is confirmed by microscopic examination Aspergillus Candida
Slide 37-

OTOMYCOSIS(cont) Symptoms : Often indistinguishable from bacterial OE, Dull pain Pruritus deep within the ear, Mild edema. Canal erythema Hearing loss (obstructive), Tinnitus White, grey ,green , yellow or black fungal debris Treatment: Thorough aural toilet, removal of debris and Topical antifungals. Local application of gentian violet. Use of amphotericin B is sometimes done in resistant cases Resistant otomycosis – Exclude fungal inf. anywhere including Athelete’s foot . Immunotheraphy with Trichophyton , Epidermophyton & oidomycetes extracts and dust mite , is the treatment of choice.
Slide 38-

WAX/CERUMEN Wax is secreted by ceruminous and sebaceous glands in the cartilaginous part of external auditory canal. To these secretions are added desquamated keratin, debris and dust to form the wax. Ceruminous glands produce watery secretions, while sebaceous glands produce fatty secretions. Due to oxidative processes, it becomes brown in color. The wax is excreted out due to movements of jaw, while eating or talking. It collects in excessive amount in dry hot humid or dusty occupation or if there is excessive desquamation from canal. Wax performs antibacterial function and it is a nature’s way for removal of dust and foreign material
Slide 39-

WAX/CERUMEN(cont) Clinical features: Sense of blockage, itchiness, Impaired hearing, earache, Tinnitus and vertigo. Treatment: If hard, it should be softened by wax solvents, i.e. soda glycerin, etc. and then removed by syringing with sterile normal saline water at body temperature or may be with wax hook or suction.
Slide 40-

SYRINGING A proper sized syringe is filled with warm water and the jet of water from the nozzle is directed along the posterosuperior canal wall. If the wax or foreign body is directly hit by the stream of water it moves deeper and may get impacted. Excessive force used while syringing may damage the canal wall or the tympanic membrane. If the water used is not at body temperature, it produces caloric stimulation with symptoms of giddiness and vomiting.
Slide 41-

HOOKING
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FOREIGN BODIES OF EAR Non living Living Can be removed by: Forceps Syringing Suction Microscopic removal Post aural approach Buttton Batteries – may spontaneously leak alkaline electrolyte solution on exposure to moisture – liquefaction necrosis – removed in urgency.
Slide 43-

KERATOSIS OBTURANS Keratosis obturans is also called cholesteatoma of external auditory canal. It is a condition seen in 5 to 20 years of age, in which there is a firm mass consisting of wax, desquamated keratinized epithelium and cholesterol granules. Exact etiology is not known, but hyperemia of canal skin and irritability of epidermis may contribute. The mass causes erosion and widening of bony canal. Failure of epithelial migration may lead to accumulation of epithelial debris.
Slide 44-

KERATOSIS OBTURANS(cont) Clinical Features: Pain, deafness, granulation tissue formation, symptoms and signs of chronic sinusitis and bronchiectasis. On examination, pearly white mass of keratin material is seen. Treatment: Mass is softened by soda glycerin solution and removed periodically under anesthesia. Gram (-) ve infection – treated topically Refractory cases – Canaloplasty
Slide 45-

HERPES ZOSTER OTICUS Is a viral infection of the inner, middle, and external ear. Manifests as severe otalgia and associated cutaneous vesicular eruption, usually of the external canal and pinna. When associated with facial paralysis, the infection is called Ramsay Hunt syndrome as Antibiotics to prevent secondary infectionit was described in 1907 by Hunt James. In its severe form, there may be sensorineural hearing loss and disturbed vestibular function and even signs and symptoms of viral encephalitis
Slide 46-

HERPES ZOSTER OTICUS(cont)
Slide 47-

HERPES ZOSTER OTICUS(cont) Pathophysiology: Reactivation of the Varicella Zoster Virus along the geniculate ganglion. Transmission of the virus via direct proximity of cranial nerve (CN) VIII to CN VII at the cerebellopontine angle. Transmission via vasa vasorum that travel from CN VII to other nearby cranial nerves. Cranial nerves V, IX and X may also be involved.
Slide 48-

HERPES ZOSTER OTICUS(cont) Clinical Features: Burning blisters in and around the ear, on the face, in the mouth, and/or on the tongue. Severe otalgia , hearing loss , hyperacusis , tinnitus, dysgeusia (alteration in taste) Vertigo, nausea, vomiting Eye pain, lacrimation, In patients with Ramsay Hunt syndrome, vesicles may appear before, during, or after facial palsy. Vesicles seen over external auditory canal, concha,and pinna , post-auricular skin .
Slide 49-

HERPES ZOSTER OTICUS(cont) Treatment: Antibiotics to prevent secondary infection. Antiviral drugs such as acyclovir in the form of tablets (800 mg 4-5 times a day) and cream. Anti-inflammatory drugs Corticosteroids in the form of tablets and local cream Facial nerve palsy is managed in the usual way.
Slide 50-

BULLOUS MYRINGITIS Myringitis bullosa is a viral infection characterized by formation of vesicles on the tympanic membrane and on the adjacent skin of the deep meatus. Self-limiting Confined b/w outer epithelium & lamina propria of tympanic membrane. Inflammation limited to TM & nearby canal. Viral infection ( Influenza ) , Mycoplasma pnuemoniae. Primarily involves younger children.
Slide 51-

BULLOUS MYRINGITIS(cont) Multiple reddened inflamed blebs, Hemorrhagic vesicles Severe throbbing pain in the ear. Otoscopy reveals a congested tympanic membrane with vesicles on its surface, commonly in the upper part. The membrane is mobile. Blood stained discharge & Hearing loss Treatment: Analgesics Topical antibiotics to prevent secondary infection Incision of blebs is unnecessary
Slide 52-

BENIGN TUMOURS Lipoma – post-auricular sulcus Papilloma Viral Papilloma - outer meatus Removal – curetting under L.A / laser Diffuse Papilloma Typical papilliferous apperance Extend to deep meatus & obscure TM Remove permanently but recur
Slide 53-

BENIGN TUMOURS Exostosis/ Osteomas: Exostosis occur in bony meatus and are usually multiple. Exostosis is a bony outgrowth from bony meatus, which may be single pedunculated or multiple of sessile type. It may be bilateral. Osteomas are single and occur at the junction of bony and cartilaginous meatus. Etiology is not known, but may be due to cold water bathing or trauma and infection. Clinical features Asymptomatic when small, but if large may occlude the meatus causing irritation and deafness. Treatment No treatment if asymptomatic, but if large, electric drill is used to remove it avoiding injury to VII nerve.
Slide 54-

BENIGN TUMOURS(cont) Adenoma: 1. Sebaceous adenoma arises from sebaceous glands of cartilaginous meatus and is treated by excision. 2. Ceruminoma (Hydradenoma) arises from ceruminous glands and is a rare tumor resembling sweat gland tumors and may become malignant. Smooth innervated polypoidal swelling in outer EAC
Slide 55-

MALIGNANT TUMOURS Squamous Cell Ca Squamous cell carcinoma can occur on pinna or in external auditory canal. Indurated ulcer with everted margins. Commonly an elderly patient, bleeding from ear or blood-stained discharge, bleeding polyp or granulation and enlarged lymph nodes. Facial nerve may beinvolved. Biopsy under L.A Cancer of pinna requires radical excision (i.e. total auriculectomy) and cancer of external auditory canal (EAC) needs wide excision of tumor by extended radical mastoid operation followed by radiotherapy.
Slide 56-

MALIGNANT TUMOURS(cont) SQUAMOUS CELL CA
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MALIGNANT TUMOURS(cont) Basal cell carcinoma (rodent ulcer): Basal cell carcinoma arises from basal layer of epidermis and starts as a nodule on pinna. Margins of ulcer are not everted and no lymph node metastasis. Seen in tragus , border of helix , meatal entrance. Later cases – whole auricle is involved , with underlying bone and parotid gland involvement. Resection of tumor if small and localized, but if extensive, complete excision followed by plastic reconstruction. Radiotherapy is for inoperable tumours only.
Slide 58-

MALIGNANT TUMOURS(cont) Basal cell carcinoma
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MALIGNANT TUMOURS(cont) Malignant Melanoma: Nodular pigmented leision which tends to enlarge rapidly and eventually to ulcerate. Regional L.N Involement & Diatant metastasis Local Disease – Excision & Skin Graft Large Tumours – Wedge (or) Wide Excision Radical excision involves complete excision of pinna & and dissection of regional L.N
Slide 60-

MALIGNANT TUMOURS(cont) Malignant Melanoma

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HarjitpalSingh

About : Associate Professor (ENT) at Dr Radhakrishnan Govt Medical College, Hamirpur(H P)
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