1. Diseases of the External Ear الدكتور سعد يونس سليمان

2. Diseases OF EXT. EAR wax congenital acquired Diseases of pinna
injuries
infections
tumors
EAM
wax
obturans
Keratosis
body
Foreign
Inflammatory
conditions

3. 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).

4. Acquired Disorders The Pinna Injuries to the pinna
Simple laceration or partial or complete avulsion.
Haematoma of the auricle (Haematoma auris).
Cauliflower ear

6. Infections of the pinna
Perichondritis
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.

7. 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).

8. 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).

9. Tumors of The Pinna
Squamous cell and basal cell carcinomas occur on the pinna often on the edge.
Predisposing factor: Sun exposure with
hyperkeratosis.

10. 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 EAM

11. Excessive wax formation and its retention by stiff hairs.
Etiology:
Excessive wax formation and its retention by stiff hairs.
Attempts of the patient to clean his ear push the wax medially
Symptoms:
Deafness and discomfort
Pain and irritation
Tinnitus and disturbance of balance
Reflex cough
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 glycerin/ bicarbonate drops before ear wash
Instruments
Suction

12. 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.

13. 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.

14. 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 pea

15. Severe irritation and noise in the ear with animate FB Signs:
Symptoms
History
Hearing loss
Severe irritation and noise in the ear with animate FB
Signs:
The FB can be seen by otoscopy

16. So donn’t wash if: The FB is vegetable The FB is disc battery
Treatment:
Animate FB:
Kill by alcohol or oil  remove by ear wash or instruments
Inanimate 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 wash
because it may swell by water and become more impacted
General anesthesia may be needed in impacted
FB 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

17. 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)

18. 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 media

19. Symptoms: Signs TREATMENT Earache: Severe Why?
Increase on moving the jaw Why?
Deafness when edema is severe  obstruct the canal
Signs
External exam:
Tragal tenderness
Tender pre and postauricular LN
Otoscopic exam :
Redness, edema, tenderness of the skin of the external canal
Scanty discharge, serous or purulent
TREATMENT
METICULOUS CLEANING
PACK WITH ANTIBIOTIC
CULTURE
Because the skin is tightly
adherent to the underlying
perichondrium & periostium
Because the external canal
Lies immediately behind
Temporomandibular joint

21. Inflammatory: Bacterial Frunculosis
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

22. Symptoms: Signs: Earache: Severe Why? Increase on moving the jaw Why?
Deafness when edema is severe  obstruct the canal
Signs:
External:
Tenderness on moving the auricle or
pressure on the tragus
Tender pre and postauricular LN
Otoscopic:
It is difficult to examine the external canal
By Otoscope because there is localised
area of tenderness in the skin of the outer
part of the external canal
No or scanty purulent otorrhea ( never mucoid as there is no mucous glands )

23. Blood glucose level especially in: Recurrent cases Bilateral cases
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.

24. 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

25. 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

26. 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).

27. 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

28. 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 nerve

29. Fungal:Otomycosis Itching is usually the only symptom
Fungal infection of the skin of the exernal canal
Etiology:
organism:
Aspirigillus Niger
Candida albicans
Symptoms:
Itching is usually the only symptom
Pain if there is secondary infection
Deafness if the external canal is obstructed
Signs:
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 fungicidal

30. Neoplasm: 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.

31. Incidence
The commonest tumor of the external canal
More common in swimmers
Symptoms:
Asymptomatic
Hearing loss.
Signs:
Bilateral smooth bony swelling
Treatment:
- If obstructing the canal excision

32. 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 LN

33. Investigations: Treatment:
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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