Diseases of External Ear Dr. Muhammed Al-Tuwaijry Senior Consultant and Head Deptt. Of...

Diseases of External Ear

Dr. Muhammed Al-Tuwaijry

Senior Consultant and Head

Deptt. Of Otorhinolaryngology

King Saud Medical City

Riyadh, K.S.A

04/19/23 Under Graduate ENT Lectures by Dr. M.Tuwaijry

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Anatomy and Physiology

• Consists of the auricle and EAM• Skin-lined apparatus• Approximately 2.5 cm in length• Ends at tympanic membrane


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• Auricle is mostly skin-lined cartilage• External auditory meatus

• Cartilage: ~40%, Bony: ~60%• S-shaped, Narrowest portion at bony-cartilage junction


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• EAC is related to various contiguous structures• Tympanic membrane• Mastoid• Glenoid fossa• Cranial fossa• Infratemporal fossa


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• Innervation: cranial nerves V, VII, IX, X, and greater auricular nerve

• Arterial supply: superficial temporal, posterior and deep auricular branches

• Venous drainage: superficial temporal and posterior auricular veins

• Lymphatics


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• Squamous epithelium

• Bony skin – 0.2mm• Cartilage skin

• 0.5 to 1.0 mm• Apopilosebaceous

unit


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Clasification of Ext. Ear Diseases

● Congenital

● Inflammatory/Infective

● Reactive

● Trauma

● Tumors.


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Congenital conditions

● Preauricular sinus

● Congenital swellings (Pinna)

● Collaural fistula

● Congenital anamolies (Pinna)

● Atresia external canal

● Congenital tumors of external canal


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Preauricular sinus


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Preauricular sinus (synonyms

● Preauricular pit

● Preauricular sinus

● Preauricular tract

● Helical fistula

● Preauricular cyst


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Pinna (Embryology)

• ● Begins during the 6th week of gestation• ● Begins from 6 hillocks (Hillocks of His)• ● 3 hillocks arise from caudal border of I arch• ● Other 3 arise from the cephalic border of II arch


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Preauricular sinus theories

● Embryological fusion: Incomplete fusion of Hillocks

● Ectodermal infolding: Isolated ectodermal infolding

● Incomplete closure of dorsal part of first pharyngeal groove: (accepted)


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Preauricular sinus clinical features

● Seen as a small pit along the anterior margin of ascending limb of helix

● The tract usually blends with the perichondrium of auricle

● Sinus tract is usually superior and lateral to facial nerve and parotid gland

● Subcutaneous cyst formation in the area is common


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Management

● Complete removal with the tract

● Leaving behind remanant leads to recurrence


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Congenital anamolies of pinna

● Anotia

● Microtia

● Melotia

● Polyotia


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Congenital atresia of external meatus

● Very rare congenital disorder

● Caused by failure of canalization of first branchial cleft

● Bony atretic plate may be present at the level of ear drum

● Ossicular malformations common


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Otitis Externa

• Bacterial, viral or fungal infection of external auditory canal

• Categorized by time course• Acute• Chronic


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Speculum findings:• the canal may be so swollen that a view into

the ear is impossible• In swimmers, divers and surfers, chronic water

exposure can lead to the growth of bony swellings in the canal known as exostoses. These can interfere with the drainage of wax and predispose to infection.


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Differential diagnoses:

• Otitis media• Ramsay Hunt syndrome • Furuncle• Skull base osteomyelitis• Preauricular cyst and fistula• Lacerations• Atopic dermatitis• Cerumen impaction• Exostosis and osteoma• Foreign body• Acute (bullous) and chronic (granular) myringitis


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Organisms

1. Pseudomonas species

2. Staphylococci

3. Streptococci/Gram negative rods

4. Fungi (Aspergillus/Candida species)


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Labs/workup

Usually after failed empiric therapy:• bacterial and fungal culture• Adults with otitis externa: screening blood

glucose and/or a urine dipstick test to rule out occult diabetes.

• Additional tests (if available):• Gram stain of d/c• KOH prep smear (within 10 min)


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Acute Otitis Externa (AOE)

• “swimmer’s ear”• Preinflammatory stage• Acute inflammatory stage

• Mild• Moderate• Severe


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Factors contributing to AOE• High humidity

• Water exposure

• Maceration of canal skin

• High environmental temperature

• Local trauma

• Perespiration

• Allergy

• Stress

• Removal of normal skin lipids

• Absence of cerumen

• Alkaline pH of canal


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AOE: Preinflammatory Stage

• Oedema of stratum corneum and plugging of apopilosebaceous unit

• Symptoms: pruritus and sense of fullness• Signs: mild edema• Starts the itch/scratch cycle


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AOE: Mild to Moderate Stage

• Progressive infection• Symptoms

• Pain• Increased pruritus

• Signs• Erythema• Increasing edema• Canal debris,

discharge


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AOE: Severe Stage

• Severe pain, worse with ear movement

• Signs• Lumen obliteration• Purulent otorrhoea• Involvement of

periauricular soft tissue


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AOE: Treatment

• Most common pathogens: P. aeruginosa and S. aureus, E.coli and proteus.!

• Four principles• Frequent canal cleaning; swap or suction• With sever EO, palcement of a wick made of sponge or

gauze provides a pathway for drops to be delivered to the EAC wall skin for 48-72 hours!

• Topical antibiotics, and if sever>> Systemic PO,ABT• Pain control• Instructions for prevention


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AT A GLANCE. . .

• Ostalgia• Tenderness on palpation or manipulation

(tragus sign)• Ear fullness• Conductive hearing loss.• Erythaema of meatus and canal• Swelling and obstruction of canal• Crusting and discharge• Odor!


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Furunculosis

• Acute localized infection• Lateral 1/3 of posterosuperior canal• Obstructed apopilosebaceous unit• Pathogen: S. aureus


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Furunculosis: Symptoms

• Localized pain• Pruritus• Hearing loss (if lesion occludes canal)


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Furunculosis: Signs

• Edema• Erythema• Tenderness• Occasional

fluctuance


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Furunculosis: Treatment

• Local heat• Analgesics• Oral anti-staphylococcal antibiotics• Incision and drainage reserved for

localized abscess• IV antibiotics for soft tissue extension

- tri-adcortyle!


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Erysipelas

• Acute superficial cellulitis

• Group A, beta hemolytic streptococci

• Skin: bright red; well-demarcated, advancing margin

• Rapid treatment with oral or IV antibiotics if insufficient response


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Otomycosis

• Mostly in children who are exposed to warm, moist climates or who have a Hx of chronic use of antibiotic ear drops.

• Fungal infection of EAC skin

• Primary or secondary• Most common organisms:

Aspergillus and Candida


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Otomycosis: Signs• Canal erythaema• Mild oedema• White, gray, green,

yellow or black fungal debris

• Often indistinguishable from bacterial OE

• Pruritus deep within the ear• Otorrhoea• Dull pain• Hearing loss (obstructive)• Tinnitus

Otomycosis: Symptoms


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Otomycosis: Treatment

• Thorough cleaning and drying of canal• Topical antifungals (clotrimazole for eg.,

amphotericine B, oxytetracycline-polymyxin, and nystatin are very effective!)

• Acidifying of the EAC with drops like 2% acetic acid, 3% boric acid or sulzberger’s powder are also helpful in the t/t of fungal infections.


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NEO: Signs & Symptoms• Similar to Otitis Externa except

• Severe, unrelenting Ear Pain and Headache• Persistent discharge• Does not respond to topical medications• Commonly associated with Diabetes Mellitus

• Granulation tissue in posterior and inferior canal• Pathognomonic for necrotizing otitis• Occurs at bone-cartilage junction

• Extra-auricular findings• Cervical Lymphadenopathy• Trismus (TMJ involvement)• Facial Nerve Palsy or paralysis (Bell's Palsy)

• Associated with poor prognosis


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NEO: Dx, Prevention and T/T:

• Prognosis; Reportedly mortality 20-53%

• Dx: Hx, PE, Labs and Imaging:- Labs; FBC, Culture of discharge, ESR, Serum glucose, Serum

creatinine.- Radiology; CT, or MRI (ear),Tc 99m medronate methylene bone

scanning, Ga 67 scintography.

• Prevention:- Avoid use of cotton swabs in ear and other canal trauma.- Use caution when irrigating ear of high risk patients.- Treat eczema of ear canal and other pruritic dermatitis


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Necrotizing (malignant) External Otitis(NEO)

● Potentially lethal infection of EAC and surrounding structures

● Pseudomonas aeruginosa is the usual culprit

● Risk Factors:

- Diabetes Mellitus

- Elderly

- Immunocompromised state

- Human Immunodeficiency Virus (HIV)

● Typically seen in diabetics and immunocompromised patients


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NEO: Treatment

• Intravenous antibiotics for at least 4 weeks – with serial gallium scans monthly

• Local canal debridement until healed• Pain control• Use of topical agents controversial• Hyperbaric oxygen experimental• Surgical debridement for refractory cases


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NEO: Diagnosis

• Cohen and Friedman – criteria from review: They were divided into two categories: obligatory and occasional. The obligatory criteria are: pain, edema, exudate, granulations, microabscess (when operated), positive bone scan or failure of local treatment often more than 1 week, and possibly pseudomonas in culture. The occasional criteria are diabetes, cranial nerve involvement, positive radiograph, debilitating condition and old age. All of the obligatory criteria must be present in order to establish the diagnosis. The presence of occasional criteria alone does not establish it. The importance of Tc99 scan in detecting osteomyelitis is stressed. When bone scan is not available, a trial of 1-3 weeks of local treatment is suggested. Failure to respond to such treatment may assist in making the diagnosis of MEO.


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NEO: Mortality

• Death rate essentially unchanged despite newer antibiotics (37% to 23%)

• Higher with multiple cranial neuropathies (60%)

• Recurrence not uncommon (9% to 27%)• May recur up to 12 months after treatment


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Perichondritis/Chondritis

• Infection of perichondrium/cartilage• Result of trauma to auricle• May be spontaneous

(overt diabetes)• Usual pathogens include

pseudomonas species and mixed flora


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Perichondritis: Symptoms• Pain over auricle and deep in canal• fever• Pruritus

Perichondritis: Signs• Tender auricle• Induration• Oedema• erythaema• Advanced cases

• Crusting & weeping• Involvement of soft

tissues04/19/23 Under Graduate ENT Lectures by

Dr. M.Tuwaijry46

Perichondritis: Treatment

• Aspiration of the pus• Use antibiotics of gram-negative coverage, specifically

anitpseudomonals.• If frank chondritis develops, incisions should be made in

the cartilage in order to provide adequate drainage.• Mild: debridement, topical & oral antibiotic• Advanced: hospitalization, IV antibiotics• Chronic: surgical intervention with excision of necrotic

tissue and skin coverage


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Relapsing Polychondritis

• Uncommon progressive inflammatory disorder that may affect children, but more commonly in adults.

• Episodic and progressive inflammation of cartilages• Autoimmune etiology?• External ear, larynx, trachea, bronchi, and nose may

be involved• Involvement of larynx and trachea causes

increasing respiratory obstruction


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Relapsing Polychondritis

• Fever, pain• Swelling, erythaema• Arthralgia!• Tenderness of the nasal

septum may progress to complete destruction of the septum


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Dx and T/t

• Weak +ve RF• ANA +ve• High ESR,• Anaemia• And difinitve Dx is made

by a biopsy from the affected cartilage

-Systemic steroids such as prednisolone-In resistant cases; dapsone, cyclophosphamide or azithioprine may be used


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Herpes Zoster Oticus(Ramsay Hunt Syndrome)

• J. Ramsay Hunt described in 1907• Viral infection caused by varicella zoster• Infection along one or more cranial

nerve dermatomes (shingles).- herpes zoster of the pinna with otalgia.

- facial paralysis

- sensorineural hearing loss

- Bullus myringitis

- A vesicular eruption of the concha of the pinna and the EAC.


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Symptoms

• Early: burning pain in one ear, headache, malaise and fever

• Late (3 to 7 days): vesicles, facial paralysis

Treatment• Corneal protection• Oral steroid taper (10 to 14 days)• Antivirals (eg. Valacyclovir)• Facial nerve decompression

(controversial)!


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Bullous Myringitis

• Viral infection • Confined to tympanic membrane• Primarily involves younger children


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Bullous Myringitis: Symptoms• Sudden onset of severe pain• No fever• No hearing impairment• Bloody otorrhoea (significant) if rupture

Bullous Myringitis: Signs• Inflammation limited to TM & nearby canal• Multiple reddened, inflamed blebs.• Hemorrhagic vesicles


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Bullous Myringitis: Treatment• Self-limiting• Analgesics• Topical antibiotics to prevent secondary

infection• Incision of blebs is unnecessary


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Chronic Otitis Externa

• Acute otitis externa occurs in 4 of every 1000 people per year

• Otitis externa is defined as chronic when the duration of the infection exceeds 4 weeks or when more than 4 episodes occur in 1 year

• Bacterial, fungal, dermatological aetiologies

COE: Symptoms• Unrelenting pruritus• Mild discomfort• Dryness, Crusting, and flaking of canal skin


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COE: Signs

• Asteatosis• Dry, flaky skin• Hypertrophied skin• Mucopurulent otorrhoea

(occasional)


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COE: Treatment

• Similar to that of AOE• Topical antibiotics, frequent cleanings• Topical Steroids• Surgical intervention

• Failure of medical treatment• Goal is to enlarge and resurface the EAC


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Radiation-Induced Otitis Externa

• OE occurring after radiotherapy

• Often difficult to treat• Limited infection treated

like COE• Involvement of bone

requires surgical debridement and skin coverage


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Granular Myringitis (GM)

• Deepithelization of the TM• Localized chronic inflammation of pars

tensa with granulation tissue• Sequela of primary acute myringitis,

previous OE, perforation of TM• Common organisms: Pseudomonas,

Proteus


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GM: Symptoms• Foul smelling discharge from one ear• Often asymptomatic• Slight irritation or fullness• No hearing loss or significant pain

GM: Signs• TM obscured by pus • “peeping” granulations• No TM perforations


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Eczema

• External clue to OE (atopic, contact and sebrrheoic) dermatitis

• Usual symptom is itching.• P/E; erythaema, oedema, flaking and crusting.• T/t:

- Local cleansing.- Usage of corticosteroid and drying agents.• Metal sensitivity is the most common form of chronic

dermatitis involving the ear.!• Nickel is the most common offending metal.• Women are affected more than men.

- Ear peircing is an important cause of primary sensitization to nickel.


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Auricular haematoma

• Comonly seen due to blunt trauma• Collection of blood between

auricular cartilage and its perichondrium

• Urgent aspiration with application of pressure bandage / Incision and drainage with application of dental rolls.

• Antibiotics• If untreated can lead to Cauliflower

deformity


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Keloid of Auricle

• It may follow trauma or ear piercing

• Usual sites, lobule or helix• Surgical excision usually

results in recurrance.• Recurrance can be prevented

by pre and post operative radiation (600-800rads)

• Intra leasional inj.of long acting steroids AFTER EXCISION.


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Conclusions

• Careful History• Thorough physical exam• Understanding of anatomy and various disease

processes common to this area• Vigilant treatment and patience


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Questions/Comments?


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