Diseases of external ear,dr.s.gopalakrishnan, 13.06.17

 Darwin’s tubercle : an inherited cond. Presence
as a small elevation in post-sup part of helix.
 Wildermuth’s ear : Prominence of antihelix and
under-development of helix & assoc. with CHL
& SNHL.
 Mozart’s Ear : an dominant inheritance
presencs as fusion of helix and antihelix.

 Congenital Abnormalities of Auricle :
 Anotia
 Microtia
 Synotia
 Melotia
 Bat ears : Abnormal protrusion of auricle ,
disappered spontanously in first year of life.
 Lop Ear : Crux anhihelics is poorly formed
 Cup Ear : Antihelix is undeveloped

 Pre – Auricular Sinus :
 Faulty fusion of 1st & 2nd arch
 Opening :
1) Anterior border of ascending limb of helix
2) Line extending b/w tragal notch & angle of mouth
3) Pinna (or) Lobule
 Extend upto the level of tympanic ring.
 C/F : Asymptomatic , If infected – chr.discharge ,
recc.abscess & calculus
 Treatment : Excision ( careful for facial nerve)

 Collaural Fistula
 Tract : Line joining the angle of mandible &
Sterno-clavicular joint
Outer opening : Ant border of SCM
Inner opening : Bony Cartilagenous junction of EAC
C/F : Discharge fistula , Abscess , Ear discharge ,
Gran.tissue in EAC
Treatment : Excision of fistula

 Cicatrical Stenosis & Acquired Atresia of EAC
 Aetiology : Following external trauma , mastoid surgery ,
blunting following a lateral graft technique , keloid , COE,
burns , radiation , neoplasms
 Treatment : Surgical Removal of fibrous tissue &
Reconstruction of canal

 Cystic swelling in upper half of the anterior aspect of the
auricle.
 Formed within degenerate cartilage as a cystic space that has
no lining but contains straw coloured fluid.
 Oral Prednisolone ( 4 week period ) – fluid was absorbed and
the intra-cartilaginous fibrosis and granulation was
prevented.
 Insertion of drainage tube into the pseudocyst thro a guide
needle which was left in place for 5 days with pressure
dressing.

 Caused by an extravasation of blood b/w the cartilage
and the perichondrium producing a soft doughy
swelling of the pinna
 If untreated , blood clot becomes organised and the ear
remains permanently thickened – Cauliflower Ear
 Aspiration with wide bore needle
 Incision (along the margin of helix) & Evacuation of clot

 Infection of superficial layer of skin by staphylococci.
 Involve the whole auricle doesnot extend the EAC
 Reddish – purple vesicles filled with serum – later
bursts to exude - dries to form semi-adherent amber
crusts.
 Bathing with warm sterile saline.
 Topical Antibiotic Ointment

 Due to streptococcal infection of the skin producing a
raised red oedematous eruption with a
characterically well – defined edge.
 Auricle – red & swollen
 Assoc with fever and rapid pulse
 Antibiotic theraphy

 Infection or inflammation of perichondrium /
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 )

 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.
 May be spontaneous (overt diabetes)
 Org : Pseudomonas Aeruginosa , Staph. Aureus

SIGNS & SYMPTOMS
 Pain over auricle and deep in
canal
 Pruritus
 Induration
 Edema
 Advanced cases
 Crusting & weeping
 Involvement of soft tissues

 TREATMENT :
 Topical & oral antibiotics
 Discharge (or) Abscess – Drainage
 Sub-perichondrial Abscess – I & D & Irrigating with 1.5 % acetic acid &
garamycin
 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 neg. bacteria.
 Removal of eschars and crusts.

 Acute localized infection of single hair follicle.
 Lateral 1/3 of posterosuperior canal
 Obstructed apopilosebaceous unit
 Pathogen: S. aureus

SYMPTOMS :
 Localized pain
 Ear blockage
 Exudates a scanty sero-sanguinous discharge
 Pinna & tragus – tender on palpation
 Pruritus
 Hearing loss (if lesion occludes canal)

SIGNS :
 Edema
 Erythema
 Tenderness
 Occasional fluctuance
DD : Ac.mastoiditis

TREATMENT :
 Local heat
 Analgesics
 Oral & systemic anti-staphylococcal antibiotics
 Topical ( antibiotics, Hygroscopic Dehydrating
agents)
 Incision and drainage reserved for localized
abscess
 IV antibiotics for soft tissue extension
 For recurrent : Eradication theraphy with nasal
mupirocin , oral flucloxacillin (14 days)

 Fungal infection of EAC skin
 Common in hot , humid
climates & is often secondary
to prolonged use of topical
Antibiotics.
 Most common organisms:
Aspergillus and Candida
 Occur bcoz the protective
lipid/acid balance of the ear is
lost.

SYMPTOMS :
 Often indistinguishable from bacterial OE
 Pruritus deep within the ear
 Dull pain
 Hearing loss (obstructive)
 Tinnitus

 Canal erythema
 Mild edema
 White, grey ,green , yellow or black fungal debris
( wet newspaper)

TREATMENT
 Thorough aural toilet & removal of debris
 Topical antifungals
 Resistant otomycosis – Exclude fungal inf. anywhere
including Athelete’s foot .

 Gen. cond of skin of the EAC that is charac. by
General edema & Erythema assoc. with itchy
discomfort and usually a ear discharge.
 Predisposing factors :
 Anatomical ( narrow / obstructed ear canal) ,
Dermatological ( Eczema , Sebhorrhoeic dermatitis )
Allergic ( Atopy , Non–atopy , Exposure to top.med)
Physiological ( Humid environment , Imm.comp)
Traumatic ( Skin maceration , ear probing , rad.theraphy )
Microbiological ( P.aeruginosa , Active COM , Fungi )

 Edema of stratum corneum and plugging of
apopilosebaceous unit
 Symptoms: pruritus and sense of fullness
 Signs: mild edema
 Starts the itch/scratch cycle

 Progressive infection
 Symptoms
 Pain
 Increased pruritus
 Signs
 Erythema
 Increasing edema
 Canal debris, discharge

 Severe pain, worse with
ear movement
 Signs
 Lumen obliteration
 Purulent otorrhea
 Involvement of
periauricular soft tissue

 Most common pathogens: P. aeruginosa and S. aureus
 Frequent canal cleaning ( Microscopic Toilet )
 Topical Medications ( IG pack )
 Pain control ( NSAIDS )
 Instructions for prevention ( avoidance of water pentration
into ear – cotton wool with petroleum jelly , custom made
ear moulds , nonprene head bandage)
 Aqua-Ear (or) Ear Calm , Blow driers - will remove the
water

 Unrelenting pruritus
 Mild discomfort
 Dryness of canal skin
 Hypertrophied skin
 Mucopurulent otorrhea
(occasional)

 Similar to that of AOE
 Topical antibiotics, frequent cleanings
 Topical Steroids
 Surgical intervention
 Failure of medical treatment
 To enlarge and resurface the EAC

 Localized chronic inflammation of pars tensa with
granulation tissue with possible involvement of EAC
 Toynbee described in 1860
 Causes : High temp , swimming , lack of hygeine , local
irritants , foreign body , bacterial & fungal infections
 Sequela of primary acute myringitis, previous OE, perforation
of TM
 Common organisms: Pseudomonas, Proteus, Staph.aureus &
Candida albicans

 Myringitis Externa Granulosa :
 Has granulation on lateral surface of drum & medial
part of the ear canal skin
 Granular Myringitis :
 Involves only the ear drum

 PATHOLOGY :
 Odematous granulation tissue with capillaries and diffuse
infiltration of chronic inflammatory cells

SIGNS & SYMPTOMS :
 Foul smelling discharge from one
ear
 Often asymptomatic
 Slight irritation or fullness
 No hearing loss or significant pain
 TM obscured by pus
 Posterio-superior granulations
 No TM perforations

 Careful and frequent debridement
 Specific Anti-microbial drops or powder with or without
steroids for 2 weeks
 Removal of granulation by physical methods
 Appln of caustic agents – Chromic acid , 0.5 % formalin ,
silver nitrate
 Laser evaporation of granulation

 Myringitis Bullosa Hemorrhagica – finding of
vesicles in the superficial layer of TM
 Viral infection ( Influenza ) , Mycoplasma
pnuemoniae
 Confined b/w outer epithelium & lamina
propria of tympanic membrane
 Primarily involves younger children

 Inflammation limited to
TM & nearby canal
 Multiple reddened,
inflamed blebs
 Hemorrhagic vesicles

 Sudden , unilateral throbbiong pain
 Blood stained discahrge
 Hearing loss
 Otoscopy : Serous (or) sero-sanginous discharge
blisters in TM & med. part of Ear canal

 Self-limiting
 Analgesics
 Topical antibiotics to prevent secondary
infection

 Benign NOE : is the clinical cond. of idiopathic necrosis of a
localised area of the bone of the tympanic ring , with
secondary inflammation of the overlying soft tissue and skin.
 Causative organism : Staph.aureus ,
 TM is suspectible to osteonecrosis because of its relatively
poor vascular supply
 Repeated local trauma – ear bud abuse , pricking of ear , use
of hearing aids.

 Poorly controlled diabetic with h/o OE
 Deep-seated aural pain
 Chronic otorrhea
 Aural fullness
 Pruritis
 Hearing loss

 Small area of deficient skin and soft tissue in
EAC revealing a segment of necrotic bone.
 Purulent secretions
 Occluded canal and obscured TM
 Cranial nerve involvement

 Pus swab
 CT Scan – extent of bone necrosis
 Brush cytology & Biopsy – to exclude neoplasm
 Audiometry
 Chronic granulomatous cond like Syphillis & TB should
be excluded.

 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 – necrosis beyond tymp.plate
 Surgical debridement

 Localised necrosis – involves only tympanic plate and leads to
spontaneous sequestration of bone
 Diffuse necrosis – more adjacent neuro-vascular structures
assoc. with more morbidity & lethal seq.
 Limited to tympanic ring - small area of bare bone may
appear on meatal floor , assoc. with pain & irritation , scanty
discharge.
 Conservative management
 Removal of remaining dead bone of the tympanic ring and
reconstitute the soft tissue of the meatus with a graft.

 A very severe dangerous cellulitis and
inflammation of the external auditory canal and
skull base ( temporal bone )
 Caused by psuedomonas organism.
 Majority of these patients are elderly diabetics
 Males
 Spread of this disease occurs through the fissures
of Santorini and osteo cartilagenous junction.

PATHOLOGY
 Immunity is reduced in patients with :
1. Diabetis mellitus
2. Blood cancer
3. HIV infections
4. Patients on anticancer drugs

CLINICAL FEATURES :
 history of trivial trauma to the ear often by ear
buds
 pain and swelling involving the EAC often
severe, throbbing and worse during nights.
 scanty and foul smelling discahrge (When the
discharge is foul smelling it indicates the onset
of osteomyelitis )

C / F :
 Granulation tissue at the bony cartilagenous junction.
 Ear drum is normal.
 EAC skin is soggy and edematous.
 Cranial nerve palsies are common when the disease
affects the skull base.
 The facial nerve is the most common nerve affected.
 Intracranial complications like meningitis and brain
abscess.

 TREATMENT
 MEDICAL:
 Carbenicillin, Pipercillin, Ticarcillin can be used.
 Third and forth generation cephalosporins can be used.
 Ciprofloxacillin in doses of 1.5 g - 2.5 g /day in divided doses can
be administered for a period of 2 weeks.
 Gentamycin can also be administered parenterally in doses of 80
mg iv two times a day in adults.
 Local antibiotic ear drops
 CONTROL OF DIABETES

SURGERY :
 Extensive surgical procedures have failed miserably
to cure this condition.
 Drainage of subperiosteal abscess, removal of
necrotic tissue and sequestrated bone
 Wound debridement in advanced cases.

 Herpes zoster oticus (HZ oticus) is a viral
infection of the inner, middle, and external ear.
 HZ oticus 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

 Pathophysiology
Reactivation of the varicella-zoster virus (VZV) along
the distribution of the sensory nerves innervating the
ear, which usually includes the geniculate ganglion,
is responsible for HZ oticus.

 Severe otalgia ( burning blisters in and around the
ear, on the face, in the mouth, and/or on the
tongue)
 Vertigo, nausea, vomiting
 Hearing loss, hyperacusis, tinnitus
 Eye pain, lacrimation
 In patients with Ramsay Hunt syndrome, vesicles
may appear before, during, or after facial palsy

 Vesicular exanthem - External auditory canal,
concha, and pinna , post-auricular skin .
 Associated findings
 Dysgeusia (alteration in taste)
 Inability to fully close the ipsilateral eye

 Corneal protection
 Oral steroid taper (10 to 14 days)
 Antivirals

 Keratotic mass of desquamating squamous epithelium in
bony portion of EAC
 Aetiology :
 Faulty migration of squamous epithelial cells from surface of TM
and the adjacent canal – accumulation of squ.epithelial cells and
debris end mixed with cerumen
 Pearlly white & glistening
 Pain – erosion of osseus meatus
 CHL & Otorrohea

 Tm – intact
 Gram (-)ve infection – treated topically
 Irritation of efferent vagal nerve endings in the
bronchi produces a reflex secretion of wax
 Assoc with Yellow Nail Syndrome ( yellow nails ,
lymphodema & plueral effusion )
 Treatment :
 Removal of Kerototic mass
 Refractory cases – canaloplasty

 Mixture of two glands – Ceruminous & Pilo-sabeceous
together with squ.epithelium , dust , forign debris
 Outer 2/3 rd of EAC lined by cuboidal and columnar
epithelium
 Secretion – Exocrine & apocrine Functions
 Stimulation of adrenergic receptors – myoepithelial cells
contract – expel liquid content into EAC

 Wet phenotype
 Caucasians & Negroes
 Moist , honey coloured
 Dry phenotype
 Mangaloid races
 Grey , granular & brittle
 C/F
 Deafness , tinnitus , Reflex cough , Ear ache ,
Fullness & Vertigo

 Treatment
 Ceruminolytics (paradichlorobenzene)
 Syringing
 Suction (or) Hooking
 Syringing – Not in Perf. TM , Middle Ear
Diseases , Previous ear surgeries.

 Insects – first killed by instilling oil in EAC and
then by syringing
 Small Objects – Syringing with water
 Vegetable Objects – Syringing with alchohol
(or) removal by small forceps.
 Large Objects - Using Microscopic control , by
small forceps or blunt hook
 Spherical objects – Cyanoacrylate adhesive
(superglue) applied to blind end of cotton swab

 Buttton batteries – may spontaneously leak
alkaline electrolyte solution on exposure to
moisture – liquefication necrosis – removed in
urgency
 Otolaryngeal Complication :
 LMN Palsy
 Nasal Septal Perforation
 Large FB – Expose the meatus thro’ post-
auricular incision , drilling the bone from the
canal wall

 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

 Adenoma
 Sebaceous Adenoma
 Arise from sabeceous gland of meatus.
 Smooth , painless skin covered swelling in outer EAC
 Local Excision
 Ceruminoma ( Hidradenoma)
 Arise from modified apocrine sweat gland
 Smooth innervated polypoidal swelling in outer EAC
 Blocking sensation
 Wide Excision

 Indurated ulcer with everted margins
 Biopsy under L.A
 Regional L.N involvement
 Small leisions - Local Excision
 Large leisions – Excision with external beam radiation
 Advanced Cases – Radical ressection of ear including
Parotidectomy , neck dissection & mastoidectomy

 Results from prolifertion of basal epithelium
 Seen in tragus , border of helix , meatal entrance
 Later cases – whole auricle is involved , with underlying
bone and parotid gland involvement.
 First a flat painless slightly raised leision followed by the
development of rolled edge with penetrating ulcer –
bleeds readily
 Treatment – Wide Excision
 Advanced Stages – Wide Excision & radiotheraphy

 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
 Prognosis is poor

Diseases of external ear,dr.s.gopalakrishnan, 13.06.17

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Diseases of external ear,dr.s.gopalakrishnan, 13.06.17