OTOLOGY 2

Lecture(2) ENT Dr. Haitham Alnori

8/1/2020 Assistant Professor
OTOLOGY
Diseases of the External Ear
Diseases of the Pinna
Congenital Abnormality:
Bat ear(prominent or lop ear): This is an abnormally protruding ear. The concha is large with poorly developed antihelix. It can be corrected surgically around 6 years.

Preauricular appendages: They are skin-covered tags that appear in front of the tragus. They may contain small pieces of cartilage(accessory auricle).
Preauricular pit or sinus: This is commonly seen at the root of helix and is due to incomplete fusion of tubercles. It may get repeatedly infected causing purulent discharge or abscess formation. Treatment is antibiotic and repeated needle aspiration until abscess disappear ,then surgical excision of the track and cyst.
Microtia: It is a major developmental anomaly. Degree of microtia may vary. The condition may be unilateral or bilateral. It may be associated with meatal atresia and ossicular abnormalities. Treatment of severe microtia and anotia is difficult specially when associated with aural atresia, by multi-stage surgery or prosthetic ear and bone anchored hearing aid BAHA.

Acquired Disorders:

Haematoma of the auricle (Haematoma auris):
Trauma to the pinna may cause swelling results from haematoma (extravasation of blood between the cartilage and overlying perichondrium). The pinna appears swollen and blue. The ear may be slightly tender with a feeling of heat and discomfort. If 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.
Treatment; under aseptic technique, aspiration or drainage of the swelling usually under local anesthesia followed by a firm pressure dressing for 48 hours, in attempt to discourage more blood from collecting. + prophylactic Antibiotic. In recurrent hematoma, surgical drainage UGA with mattress suturing over buttons.
Keloid of auricle:
It may follow trauma or piercing of the ear for ornament. Usual sites are the lobule or helix. Surgical excision of the keloid usually results in recurrence. Some prefer local injection of steroid after excision (other treatment: 5 FlouroUrasil, 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.
Clinical Picture:
Pinna is uniformly enlarged and thickened and its surface is red and shiny, except ear lobule. There is severe pain and tenderness.
Treatment:
Empiric antipseudomonal antibiotic ( ceftazidime, ciprofloxacin,..).
A subperichondrial abscess may present and should be incised if fluctuation is present and antibiotic given according to sensitivity result.
Wick insertion and daily dressing, sometimes with local antibiotic irrigation.

Relapsing polychondritis:

It is a 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.

Diseases of The External Auditory Meatus

Congenital Disorders
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.

Otitis Externa

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


Diffuse Otitis Externa
It is diffuse inflammation of meatal skin. The disease is commonly seen in hot and humid climate and in swimmers. Excessive sweating changes the pH of meatal skin from acid to alkaline which favours growth of pathogens. Common organisms are Pseudomonas aeruginosa , Staphyllococus aureus and Proteus but more often the infection is mixed. It is characterized by hot burning sensation in the ear, followed by pain which is aggravated by movements of jaw. Ear starts oozing thin serous discharge. Meatal lining becomes inflamed and swollen. In severe cases, regional lymph nodes become enlarged and tender with cellulitis of the surrounding tissues. Chronic phase may occur characterized by constant itching with mild pain and the meatal skin shows fissuring and scaling.
Treatment
Ear toilet: It is the cornerstone of treatment of diffuse otitis externa. It can be done by dry mopping or suction clearance.
Medicated wicks: Wick soaked with antiseptic or antibiotic/steroid cream is changed daily for few days, then substituted by ear 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 external auditory canal. There is severe otalgia which increases on moving the jaw, and tenderness on pressure of tragus. Deafness occurs due to canal obstruction. Preauricular lymph nodes may enlarge. Otoscopy is difficult and painful.
Treatment:
Antistaph Antibiotics ( flucloxacillin) for 5 days.
Analgesics and heat application.
Aural toilet: removal of ear discharge when the furuncle has burst.
Incision of a boil should be delayed until abscess is formed.
Aural pack: by gauze strip soaked in ichthammol and glycerin.
Diabetes should be excluded in recurrent cases.
Malignant otitis externa (Necrotizing otitis externa)
The new name is osteomyelitis of skull base. It is invasive potentially fatal infection of the external canal which extends to the base of the skull, caused by Pseudomonas Aeuruginosa.
Clinical features:
elderly diabetic complaining of severe deep otalgia mainly at night not responding to analgesics, with scanty sanguineous ear discharge. Otoscopy reveals granulations at the floor of the external canal at the attachment of bony and cartilaginous part.
Investigations:
Blood glucose level.
CT scan with contrast of the temporal bone and skull base. MRI is also useful.
Radio-isotope scan ( Gallium &Technetium) to assess severity and prognosis.
Biopsy of granulation tissue to exclude malignancy.
Culture and sensitivity.
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.
Treatment:
It is mainly medical and consists of high dose I.V. antibiotic according to sensitivity result ( usually flouroquinolone or third generation cephalosporin or aminoglycoside) for 6-8 weeks. Systemic antifungal is added if there is fungal infection. Strict control of diabetes is essential. Local treatment consists of repeated medicated wick. Strong analgesia is given. Surgical treatment is limited to local debridement and excision of granulation tissue.


Herpes Zoster Oticus
Viral infection of the external, middle and inner ear caused by Herpes Zoster(= Varicella Zoster) virus, characterized by severe otalgia and vesicles on the ear canal, concha and postaural area. If the facial nerve is affected it is called Ramsay-Hunt syndrome which carry worse prognosis than Bell palsy. If vestibulocochlear nerve is involved there is SNHL and vertigo.
Treatment: Antiviral drugs (Valacyclovir), and high dose corticosteroid if facial or vestibulocochlear nerves are affected.

Otomycosis

It is fungal infection of the skin of the exernal canal that occurs due to Aspergillus niger (black), Aspergillus fumigatus (green) or Candida albicans (white). It is common in 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. The clinical features include: 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.
Treatment:
(a) Thorough repeated ear toilet by suction, mopping or syringing with normal saline.
(b) Antifungal: Nystatin is effective against Candida. Other broad spectrum antifungal agents include clotrimazole or 2% salicylic acid in alcohol. Treatment for 2-3 weeks.
(c) Ear must be kept dry.
(d) Bacterial infections may be associated with otomycosis, and treatment with antifungal/antibiotic/steroid preparation helps to reduce oedema.

Bullous Myringitis ( Otitis Externa hemorrhagica)

It is characterised by 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?). The condition causes very severe pain in the ear and blood-stained discharge when the bullae rupture. Examination reveals bluish or red bullae on the tympanic membrane. Hearing is usually normal. Treatment with analgesics and to keep ear dry. Complications include sensorineural deafness and viral labyrinthitis.

Neoplasm of External Auditory Canal

Osteoma and Exostosis
A bony outgrowth from the wall of the EAM. It may be composed of cancellous or compact bone. Osteoma is solitary and unilateral while exostosis is multiple and bilateral. Oateoma arises from suture lines in the bony canal, exostosis arises from anterior and posterior walls of deep bony canal and has characteristic wide base. Exostosis is more common in swimmers and surfers; and referred to as " surfer's ear". Both are asymptomatic early but causes conductive deafness when enlarges. Treatment surgical excision under the microscope.

Miscelaneous conditions of the External Auditory Canal

Impacted Wax
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, it is expelled outside the canal 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.
Plug formation is encouraged by excessive wax formation and its retention by stiff hairs. Also attempts of the patient to clean his ear will push the wax medially
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 with water at body temperature. If too hot or too cold, a caloric response may be induced causing vertigo. Jet of water is directed to postero-superior wall of EAC. It is contraindicated in cases of perforated tympanic membrane or laceration of EAC.
Removal with a ring probe or crocodile forceps is often better with old hard plugs.
Suction through the operating microscope when a perforation in the tympanic membrane is present or in previous ear surgery.
If the wax is hard then preliminary softening by 5% sodium bicarbonate in 30% glycerin, olive oil or diluted hydrogen peroxide.


Keratosis Obturans
In this condition the 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. Keratosis obturans may be associated with bronchiectasis and sinusitis in young patients.
Aetiology; failure of epithelial migration due to unknown factors.
Clinical Picture: Conductive deafness, pain and repeated otorrhea.
Examination: Otoscopy reveals 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. It is classified into:
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.
History is suggestive and FB is seen by otoscopy.
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.















1.Preauricular sinus and accessory auricle. 2.Auricular hematoma. 3.Perichondritis. 4.Impacted wax. 5.Keratosis obturans. 6.Ear syringing. 7. Ear hook and ear probe. 8. Ear Keloid 9. Furuncle EAC 10. Diffuse OE 11. Malignanat OE 12. Herpis Zoster Oticus 13. Otomycosis 14. Bullous Myringitis 15. Removal of piece of paper from ear by crocodile ear forceps.









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