1. Diseases of the External Ear
Dr. Haitham Alnori

2. Perichondritis
Definition: Is infection and inflammation of the perichondrium of auricular cartilage.
Causes:
Infection of haematoma auris.
Complication of severe otitis externa.
Laceration, mastoid surgery.
High ear peircing.
Clinical Picture:
The pinna is uniformly enlarged and thickened and its surface is red and shiny.
Severe pain and tenderness.
Bacteriology:
Pseudomonus aeruginosa

3. Treatment of Perichondritis
Vigorous parenteral antibiotic treatment.
Application of soothing dressing such as ichthamol in glycerin.
If subperichondrial abscess is formed it must be incised and drained with removal of all necrotic cartilage, followed by daily dressing.

4. Cauliflower deformity may result if the condition is not treated early.

5. Impacted Wax (Cerumen)
Wax is a mixture of secretions of ceruminous and sebaceous glands with desquamated skin cells.
Cartilaginous portion of the EAM.
Expelled outside the canal by movement of chewing and epithelial migration.
Cerumen protects the ear from various bacterial and fungal infections, helps in cleaning and lubrication, and also protects the sensitive skin of the ear canal.

6. Symptoms:
Deafness and discomfort
Tinnitus and disturbance of balance
Reflex cough: Arnold nerve
Signs:
Brown, yellowish or black plug obscuring the tympanic membrane.
Treatment:
Removal by:
Ear wash: if the wax is hard it should be softened by 5% bicarbonate before ear wash
tap water 27 C
Jobson-Horn probe: hard piece of wax
Suction: if there is TM perforation.

7. Keratosis Obturans
The meatus on one or both sides become blocked in its deep portion by a mass consisting of wax, desquamated epithelium and cholesterol.
This mass causes excessive erosion and expansion of the bony meatus and in this, it resembles a cholesteatoma of the middle ear.
Aetiology
unknown but it may be associated with bronchiectasis and sinusitis in young patients

8. Clinical Picture:
Pain deafness and tinnitus.
White glistening mass occluding the bony meatus.
Treatment:
Removal of the keratotic mass under G.A.
Regular observation is advised as keratosis may reform.

9. 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)

10. Diffuse otitis externa
Diffuse inflammation of the skin lining of the extenal auditory canal
Pridisposing factors:
- Skin laceration:
Self inflicted
Iatrogenic
- Skin maceration:
Hot humid atmosphere
Swimmer ear

11. Increase on moving the jaw Why? Deafness Signs
Symptoms:
Earache:
Severe Why?
Increase on moving the jaw Why?
Deafness
Signs
Tenderness on moving the auricle or pressure on the tragus
Tender pre and postauricular LN
Otoscopic exam :
Redness, edema, tenderness
Scanty discharge
TREATMENT
Meticulous cleaning
Packing of canal
Antibiotic/ steroid drops
Because skin is tightly
adherent to underlying
perichondrium
Because the EAC
Lies immediately behind
Temporomandibular joint

13. Frunculosis 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

14. Symptoms:
Earache…. Why?
Deafness
Signs:
External:
Tenderness on moving the auricle or
pressure on the tragus
Tender pre and postauricular LN
Otoscopic:
Localised area of tenderness: difficult to examine the external canal by Otoscope
No or scanty purulent otorrhea

15. Investigations:
Blood glucose level especially in:
Recurrent cases
Bilateral cases
DD acute mastoiditis
Treatment
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 it is clearly pointing to the skin.
Aural pack: by gauze strip soaked in ichthamol and glycerin and changed daily.

16. 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 and increase at night
Necrotizing otitis externa should be suspected when patients with DM complain of persistent external otitis that causes severe pain, especially at night

17. Signs
External examination:
Tenderness on pulling the AURICLE OR PRESSURE
ON THE TRAGUS
Otoscopic examination:
Granulations at the floor of the external canal at the
attachment of bony and cartilagenous part
Scanty, sanginous and purulent otorrhea

18. CT scan of the temporal bone& skull base
Investigations:
Blood glucose level
CT scan of the temporal bone& skull base
Radio-isotop scan ( Gallium99) to assess severity & prognosis
Axial computed tomographic (CT) scan in a 65-year-old male patient with diabetes mellitus who had severe nocturnal otalgia for two months. This patient was referred because of facial nerve paralysis that developed despite oral treatment with ofloxacin (Floxin). The CT scan shows bony destruction of the right temporal bone. Note the missing posterior wall of the external auditory canal (short arrow). Mastoid air cells are secondarily involved and are opacified (long arrow) compared with the well-aerated left side.

19. Complications Treatment Osteomyelitis of the temporal bone &skull base
Facial nerve paralysis at the stylomastoid foramen
Last 4 cranial nerves paralysis at the jagular foramen
Treatment
Control of diabetes
amikacin
Ciprofloxacin 6 wk !
Analgesics
Aural toilet+ topical AB
Surgical excision or mastoidectomy is to be avoided or postponed.

20. (Otitis externa haemorrhagica)
Bullous myringitis
(Otitis externa haemorrhagica)
painful condition characterized by formation of haemorrhagic blebs on the TM.
caused by viral infection.
Clinical picture
Severe extreme pain preventing sleep or work with almost normal hearing.
Otoscopy: haemorrhagic bullae are found on the drum, dark bluish or red in colour. The bullae are prone to spontaneous rupture, with blood stained aural discharge.
Treatment
Analgesia and keeping the ear dry. Incision of the bullae is not indicated.

21. 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 nerve

22. Otomycosis Fungal infection of the skin of the exernal canal Etiology:
Aspirigillus Niger
Candida albicans
Symptoms and signs:
Itching is usually the only symptom
Pain if there is secondary bacterial infection
Deafness if the external canal is obstructed
whitish mass with black spots like wet newspaper
Treatment:
Aural toilet: removal of the fungal mass by suction.
Antifungal: nystatin, or salicylic acid (2%) as a keratolytic in alcohol as fungicidal

23. Osteoma and Exostosis
Osteoma is a single tumor composed of cancelous bone located at outer part of bony canal.
Exostosis is multiple growth composed of ivory bone located at deep meatus.
Aetiology cold water swimmers.
Symptoms: Hearing loss if the external canal is obstructed by large osteoma or wax.
Treatment
Asymptomatic: observation.
If obstructing the canal: excision.

24. THANK YOU