SUBJECT SEMINAR:

DISEASES OF THE
EXTERNAL EAR
EAR ANATOMY
• EAR IS DIVIDED INTO

• EXTERNAL EAR

• MIDDLE EAR

• INTERNAL EAR
ANATOMY OF THE EXTERNAL EAR
• External ear consists of
1. Pinna
2. External auditory canal
3. Tympanic membrane
Pinna
• Made up of cartilage and covered by skin
and connective tissue
• Cartilage forms helix and antihelix
• They surround the concha
• The concha is shielded anteriorly by the
Tragus
Function of the pinna:
To collect high frequency sounds which are amplified
By the external auditory canal
EXTERNAL AUDITORY CANAL
• 24 mm long tube like structure
• Arises from the first cleft
• Lateral 1/3rd cartilaginous: lined by
Skin hence has hair follicles and
ceruminous glands
Present at birth
• Medial 2/3rd bony : develops later
• S shaped
EXTERNAL AUDITORY CANAL
• The temporo-mandibular joint sometimes creates a bulge in the deep
part of the canal
• At the bony cartilaginous junction, the skin becomes thin and is
devoid of glands
• Hence the bony projection of the temporo-mandibular joint is seen
anteriorly
Disease of external ear
Diseases of external auditory
Diseases of the pinna canal
• Congenital disorders • Congenital disorders
• Trauma to the auricle • Trauma
• Inflammatory disorders • Inflammation
• Tumors • Tumors
• Miscellaneous condition
Trauma to the auricle
• Hematoma of auricle
• Injury leading to collection of blood and serum between the
auricular cartilage and its perichondrium.
• Extravasated blood may clot and then, organize.
• Earlier thought to have auto-immune aetiology but now discarded in
favour of trauma
Clinical features

• Commonly seen on the anterior surface

• Swollen, bluish and tender auricle
• If left untreated, necrosis of cartilage and scarring of the auricle
• Superadded infection results perichondritis ad abscess
formation.
Treatment
• Aspiration of the hematoma under aseptic condition
and pressure dressing to prevent re-accumulation
• Incision and drainage if aspiration fails.
• All cases should receive antibiotic prophylaxis.
Laceration of auricle
• The auricle may be cut through-and-through or avulsed partially or
totally in RTA, knife injuries, etc.
• Treatment includes repairment as early as possible.
• Broad spectrum antibiotics given for 1 week.
Inflammatory disorders
• Perichondritis
• Is infection of perichondrium of the auricular cartilage
• Results from infection secondary to lacerations, hematoma or
surgical incisions.
• Commonly caused by Pseudomonas aeruginosa
Clinical features
• Pain, swelling and tender to touch
• Patient often has fever
• Necrosis of the cartilage, fibrosis and
scarring if not treated immediately.
Treatment
• Should be prompt and vigorous
• High dose ciprofloxacin should be used.
• Local applicants- magnesium sulfate for
soothing
• Incision and drainage and C/S if abscess
formed.
• Surgical debridement to remove unhealthy
granulations and necrosed cartilage.
 Relapsing perichondritis
• A rare autoimmune disorder involving
cartilage of the ear.
• Any cartilage can be involved.
• Entire auricle except its lobule becomes
inflammed and tender.
• External ear canal becomes stenotic.
• Treatment consists of high dose of systemic
steroids.
Relapsing polychondritis
 Chondrodermatitis nodularis chronica
helicis
• Small painful nodules near the free border of
helix.
• Tender and patient unable to sleep on the
affected side
• Treatment is surgical excision of the nodule
with its skin and cartilage.
Chondrodermatitis nodularis chronica helicis
 Tumor
s
•Benign tumors Malignant tumors
• Hemangioma • Squamous cell
• Sebaceous cyst carcinoma
• Dermoid cyst • Basal cell
• Papilloma carcinoma
• Keratoacanthoma • Melanoma
• Neurofibroma
 Hemangioma
• Benign tumors of blood
vessels
• Congenital tumor commonly
seen in children
• Bleeds frequently
• May get infected
• Treatment: surgical excision
 Dermoid cyst
• Developmental cyst
• Presents as round mass
over the upper part of
mastoid behind the pinna
• Treatment: surgical
excision
 Sebaceous cyst
• Cysts of sebaceous glands
• Contains cheesy materials
• Common site is postauricular
sulcus or below and behind
the ear lobule
• Treatment: total surgical
excision
 Papilloma
• May present as a tufted
growth or flat grey plaque and
is rough to feel
• Viral in origin
• Treatment: surgical excision or
curettage with cauterization of
its base.
 Squamous cell carcinoma
• It can arise anywhere in the external ear, commonly
helix.
• May present as a painless nodule or an ulcer with
raised everted edges and indurated base.
• Grows rapidly, invades the surrounding bone and
spreads through lymphatics
• Treatment:
– Small lesions with no nodal metastasis- local
excision with 1 cm of external auditory
canal
– Lesions with nodal metastasis- total amputation of
the pinna, often with en bloc removal of parotid
gland and cervical lymph nodes.
Squamous cell carcinoma
 Basal cell carcinoma
• Commonly seen over helix and tragus
• More common in men beyond 50 yrs
• Presents as nodule with central crust, removal of which
results in bleeding.
• Ulcer has a raised or beaded edge
• Lesion often extends circumferentially into the skin,
may penetrate deeper to cartilage or bone
• Treatment:
– Superficial lesion not involving cartilage- irradiation
and avoidance of cosmetic deformity
– Lesions involving cartilage- surgical excision as in
SCC
Basal Cell Carcinoma
 Diseases of External Auditary
Canal
• Congenital disorders
• Trauma
• Inflammation
• Tumors
• Miscellaneous conditions
 Trauma to the ear canal
• May range from minor laceration of EAC wall
to fracture of the bony wall
• Foreign body in the EAC may cause trauma to
the wall of ear canal.
• There may be pain together with bleeding due
to laceration.
• May get infected if treatment is delayed
• Treatment:
– Minor injuries require no treatment.
– Oral and local antibiotics in more severe cases
– Ribbon gauze soaked in 10% ichthyol in glycerine
as an ear pack
– Reduction of fracture only necessary if the
fracture produces occlusion of the EAC
 Inflammations of
EAC
May be divided into
1. Infective group
– Bacterial
• Localized otitis externa (furuncle)
• Diffuse otitis externa
• Malignant otitis externa
– Fungal
• otomycosis
– Viral
• Herpes zoster oticus
• Otitis externa hemorrhagica
2. Reactive group
– Eczematous otitis externa
– Seborrhoeic otitis externa
– neurodermatitis
 Furuncle (Localized otitis externa)
• Infection of hair follicle in the outer cartilaginous part
of the EAC
• Commonly caused by Staphylococcus aureus.
• Follows trauma like scratching or cleaning of the EAC
by matchsticks, cotton buds, hair clips, nails, etc.
• Symptoms
– Earache
– Swelling/abscess
– Discharge
– Hearing loss
• Signs
– Inflamed skin and swelling
– Tenderness: tragal tenderness and also with
movement of auricle
– Discharge
– Granulations
– Hearing loss
• Furuncle at posterior meatal wall causes oedema
over the mastoid with obliteration of the
retroauricular groove.
• Preauricular l.n. may be enlarged and tender
• Treatment
– Analgesics and local heat
– Antibiotics (cloxacillin)
– Ear packing with 10% ichthyol in glycerine or other
medicated wick
– Incision and drainage if abscess formed
 Diffuse otitis externa
• Diffuse inflammation of meatal skin which may
spread to involve the pinna and epidermal layer of
TM
• Commonly seen in hot and humid climate and in
swimmers.
• Most common factors are
– Trauma to the meatal skin
– Invasion by pathogenic organisms (S. aureus, P.
pyocyaneus)
• Clinical features very similar to localized otitis
externa.
• Differentiating features from localized form are:
– Entire EAC is uniformly inflamed and swollen and there is
discharge.
– No abscess formation
– No swelling in the areas adjoining the EAC in diffuse otitis
externa
• Treatmen
t
– Ear toilet
– Medicated wicks: aluminium acetate(8%) or silver
nitrate(3%)
– Antibiotics: cloxacillin or flucloxacillin or
ciprofloxacin together with pseudomonas
coverage
– analgesics
 Malignant otitis externa
• Aka necrotizing otitis externa
• It is an inflammatory condition caused by
Pseudomonas infection usually in the elderly diabetics,
or in those on immunosuppressive drugs.
• Early manifestation resemble diffuse otitis externa but
there is excruciating pain and appearance of
granulations in the ear canal.
• Facial paralysis is common
• Infection may spread to the skull base and jugular
foramen causing multiple cranial nerve palsies.
Diagnosis
• Severe otalgia in an diabetic patient with granulation
tissue in the EAC.
• CT scan may show bony destructions
• Gallium -67 scan
• Technetium 99 bone scan
Treatment
• Control of diabetics
• Toilet of ear canal. Remove discharge, debris and
granulations or any dead tissue or bone and send for
culture sensitivity.
• Antibiotic treatment continued for 6-8 weeks
– Gentamicin combined with ticarcillin
– Third generation cephalosporins: ceftriaxone 1-2 g/day iv
or ceftazidime 1-2 g/day iv combined with
aminoglycosides
– Quinolones are also effective: combined with rifampin
 Otomycosis
• Is a fungal infection of the EAC caused either by
Candida albicans or Aspergillus niger.
• Seen in hot and humid climate.
• Occurs commonly after entry of water in the EAC,
after putting oil and after prolonged use of topical
antibiotic eardrops.
• Commonly occurs together with CSOM which is
actively discharging
Clinical features
• Itching
• Aural fullness
• Discomfort and pain
• Discharge
• Tenderness (in severe case)

Examined with otoscope, A. niger appears as black

headed filamentous growth and C. albicans appear as
yellowish deposit.
Treatment:
• Thorough cleaning
• Broad spectrum topical antifungals (clotrimazole
for 10 days)
• If there is discharging COM, treat COM as well.
 Herpes zoster oticus
• Aka Ramsay Hunt Syndrome
• An infection caused by Varicella Zoster virus.
• Usually disease of adults
• Characterized by formation of vesicles on the
tympanic membrane, meatal skin, concha and
postauricular groove.
• Patient is ill, complains of severe earache and may
have fever.
• May involve CN VII and VIII
• Triad of SNHL, vertigo and facial palsy
Treatment
• Oral acyclovir along with high dose steroids.
• Labrynthine sedatives for vertigo
 Otitis externa hemorrhagica
• Viral in origin and may be seen in influenzae
epidemics.
• Characterized by formation of hemorrhagic bullae on
the tympanic membrane and deep meatus.
• Severe pain and bloody discharge when bullae
rupture
Treatment
• Analgesics for pain relief
• Antibiotics for secondary infection of the middle ear
if the bulla has ruptured.
 Eczematous otitis externa
• Result of hypersensitivity to infective organisms or
topical ear drops such as chloromycetin or neomycin.
• Characterized by intense irritation, vesicle formation,
oozing and crusting in the canal.
• Treatment is withdrawal of causative agent and
application of steroids.
 Miscellaneous conditions
Wax
• Secreted by sebaceous gland.
• Two types: hard and soft.
• Seen when self-cleansing mechanism of the
ear is disturbed.
• So, cleaning with cotton buds, hair clips,
matchsticks should be avoided.
Clinical
features
• Discomfort/itching
• Feeling of blocked ear
• Hearing loss
• Tinnitus
• Cough
• vertigo
Treatment
• Wax without pain

Suctioning Syringing

Removal by jobson horne probe

• Wax with pain (a/w otitis externa)
– Antibiotic ear drops followed by wax softners.
– Oil based antibiotic eardrop such as
chloramphenicol is preferred to other antibiotic
because it also softens the wax to some extent.
– Then removed as described above.
 Foreign body
• Common in children than adults.
• Common foreign bodies in the EAC
Children
 Inanimate FB- pieces of paper, eraser, sponge, lead of
pencil, etc
 Vegetable matter- beans, seeds, etc
 Insects- flea, tick, housefly, maggots, etc
Adults
 Inanimate FB- cotton wool
 Insects- flea, tick, housefly, maggots, etc
Clinical features
• Children often do not tell their parents that they
have put a FB in the ear due to fear; incidental
finding
• Small inanimate FB- no symptoms
• Mild hearing loss
• Intense pain – live insects
• Examination reveals FB in the EAC
Treatment
Live insects should be first killed by putting oil or water
and then only be removed
• Methods of removal
1. Removal under microscope
2. Removal by ear
syringing
3. Use of head mirror and ear instruments
 Keratosis obturans

• A condition characterized by excess accumulation of hard whitish-

yellow debris consisting of desquamated epithelium in the bony part
of EAC.
• Eventually cause pressure on the bony walls of the EAC and cause
resorption of the bone
• Clinical features
– Blocked ear
– Pain and discharge if a/w otitis externa
– Cholesteatoma like mass (pearly white hard debris covered by
wax)
– Automastoidectomy
 Treatment

• Removal as done for wax

• General anesthesia may be required because of the pain
• Recurrent collection of desquamated epithelium, so regular follow up
required.