External Ear Diseases PDF

Dr. Abdullah R. Alkhalil College of Medicine University of Duhok  i i Anatomy of External Ear — Consists of the auricle and EAM external A doses restes — Skin-lined apparatus — The canal is approximately...

Dr. Abdullah R. Alkhalil College of Medicine University of Duhok  i i Anatomy of External Ear — Consists of the auricle and EAM external A doses restes — Skin-lined apparatus — The canal is approximately 2.5 cm in length — Lateral 1/3 Cartilage — Medial 2/3 Bony — S-shaped — Narrowest portion at bony-cartilage junction — Ends at tympanic membrane Diseases of Auricle Congenital anamolies — Anotiaabsenceofexternalear — Microtia abhgffde.ir underdeveloped — Accessory auricle — Bat ear Prominrnt auricle due to absence of antihilex — Preauricular sinus q These anomalies can be isolated or associated with middle ear or inner ear ' abnormalities " "  normal anotia microtia Accessory auricle Prominrnt ear Preauricular siuns Acquired diseases of the auricle — Traumatic — Auricular laceration — Hematoma auris — Inflammatory — Perichondritis of the auricle Pinna laceration I — Wound cleaning, remove foreign body — Simple suture Only the skin, do not suture the cartilage — Antibiotics if cartilage exposed — Need to rule out other injuries e.g. head injury Hematoma auris — Definition Collection of the blood in the sub perichondrial plane of auricular cartilage 0 — Causes — Direct blunt trauma to the anterior auricle — Common facial injury in wrestlers Can be idiopathic (spontaneous) — Pathophysiology gf II.fm — Tearing of the perichondrial blood vessels and subsequent hematoma formation — Separation of perichondrium from the underlying, tightly adherent cartilage. — This will compromise the viability of the avascular underlying cartilage. — If untreated well this may lead to — cartilage necrosis — Abnormal new cartilage formation — The resulted deformity is — (cauliflower ear or wrestler’s ear) — The goal of treatment is to — completely evacuate the subperichondrial blood — prevent its reaccumulation. — This by — Aspiration in mild cases — incision and drainage of the hematoma under strict aseptic conditions (formal one), — pressure dressing — sometimes may need silastic suturing to prevent reaccumulation — All above steps should be performed under Antibiotic cover Diseases of the external auditory canal Congenital anamolies — Atresia lackof ear cord C— Aural atresia refers to the absence or incomplete formation of an external ear canal. usually both the external and Normal middle ear may be malformed. Canal absent 00 Acquired diseases of the external auditory canal — Traumatic — Direct trauma to the canal (iatrogenic) — Foreign body — Inflammatory L — Otitis externa — Otomycosis — Malignant otitis externa — Ramsay Hunt syndrome (HZO) 11200 — Idiopathic — Wax impaction Foreign bodies — Organic or inorganic — Pain — Discharge — Deafness Treatment is removal by — Syringing — Instruments(probe, hook or forceps) — Removed under GA using the operating microscope To — For living insects: killed with olive oil before removal attempt Hook for round objects which Forceps (angled so that you see it when you are removing a foreign body) can’t be catches by forceps  swimmers ear Otitis Externa Inflamber of canal outer ear — Bacterial infection of external auditory canal — Acute — Localized (Furunculosis) — Diffuse — Chronic Malignant (necrotizing) otitis externa spread to tff f  fun Localized Furunculosis Aub — Acute localized infection — Lateral 1/3 of canal — Obstruction and infection of a pilosebaceous unit — Most common Pathogen: — S. aureus Symptoms — Pruritus — Localized pain — Hearing loss (if lesion occludes canal) Signs — Localized edema of the canal — Localized erythema — If abcess , flactuation — Tenderness — Severe cases — Diffuse edema and eryrhema — Post auricular swelling — Pre and post auricular lymph node enlargement Treatment — Apply hot pad — Analgesia — Local and oral anti-staphylococcal antibiotics a — Incision and drainage reserved for localized abscess — IV antibiotics for soft tissue extension  I Acute Otitis Externa (diffuse) — This is a common generalized inflammation of the 90 skin of the EAM — Causes — Trumatic, — finger nail or cotton bud — “swimmer’s ear” because of continuous shedding of protective ear wax — common pathogens are P. aeruginosa and S. aureus Pathophysiology — Allergic eczematous response to soapy water entering the canal — Starts the itch/scratch cycle — Scratching the ear canal with finger nail or cotton bud causing local trauma and allows a portal of entry of infection — Superadded bacterial infection Clinical features — Mild to Moderate — Symptoms — Pain — Intense pruritus — Ear discharge — Signs — Erythema — Canal edema Canal debris I — — Otorrhea (serous not mucous) — Severe — Severe intense pain — Deafness — Signs — Edematous swollen canal — Total or partial occlusion — Purulent otorrhea — Tenderness on moving the auricle or tragal pressing — Tragal sign — Involvement of peri auricular soft tissue — Postauricular — Cheek — Peri auricular lymphadenopathy Treatment — The aim of therapy is to — Remove any irritant factor( avoid the use of cotton bud , and water precaution) — Treat the infection — These achieved by: — Meticulous aural toilet (dry mopping or suction clearance) is the mainstay of treatment — Local medication — antibiotics +/- steroids drops — aural wick of antibiotic/ steroids — L Systemic antibiotics for gross cellulitis — Instructions for prevention( dry ear precaution) — Analgesia Chronic Otitis Externa 2 months — Chronic inflammation of the ext. auditory canal — Persistent symptoms (> 2 months) — Aetiology — General skin condition , e.g. eczema , psoriasis — Generalized skin infection, e.g. erysipelas — Neurodermatitis — Trauma , frequent use of cotton buds — Middle ear discharge, as in CSOM Symptoms — Unremiting pruritus — Mild to moderate discomfort — Dryness of canal skin — Discharge is infrequent but may occur from time to time. Signs — Dry, fissured canal — Sometimes canal stenosis — Mucopurulent otorrhea (in case of chronic middle ear infection) Treatment — Topical antibiotic / steroids — Surgical intervention — Failure of medical treatment — Goal is to enlarge and resurface the EAC in case of canal stenosis  0tomn Otomycosis — Fungal infection of EAC skin — Most occurs in humid environment. Summer, pooling — Most common organisms: — Aspergillus — Candida — Mixed of both 090 Symptoms — Often indistinguishable from bacterial OE — Pruritus and itching deep within the ear — Dull pain — Hearing loss (debris obstructing the canal) — Tinnitus in some cases Signs — Canal erythema — Mild edema — White or gray debris (candida) — Black spores with fungal hyphea (aspergillus) Treatment L — Thorough cleaning ( aural toilet) — Dry water precaution — Topical antifungals — Nystatin ( anti candida) — Clotrimazole (wide spectrum) azole dn Malignant External Otitis — Potentially lethal infection of EAC and surrounding structures — Best considered as infection of skull base — (skull base osteomylitis) — Typically seen in poorly controlled diabetics and immune compromised patients — Pseudomonas aeruginosa is the usual causative micro organism which spread to the bone causing — Periosteitis, osteitis and osteomylitis of skull base Symptoms — Poorly controlled diabetic — Deep-seated otalgia — Chronic otorrhea unresponsive to usual treatment — Aural fullness Signs — Inflammation and granulation tissue in the canal floor — Purulent secretions — Occluded canal — Cranial nerve palsies — Facial nerve (VII) as the infection involve the facial canal — Nerves exiting from jugular foramen (IX, X, XI) can be involved as the infection spreads across the skull base Imaging — Computerized tomography — Bone scan — Technetium-99 – reveals bone infection — Gallium scan – useful for monitoring the treatment — Magnetic Resonance Imaging Treatment — Strict glycemic control — Intravenous antibiotics for at least 8 weeks – with serial gallium scans monthly Antipseudomonas (e.g quinolones) — Local canal debridement until healed — Pain control — Surgical debridement for refractory cases  H2 syndrome Heffer oticus Ramsay Hunt Ramsay Hunt syndrome — (termed Herpes Zoster Oticus) — is a herpes zoster virus infection of the geniculate D ganglion of the facial nerve. Infect of facial — It is caused by reactivation of herpes zoster virus that has previously caused chickenpox in the patient. — Ramsay Hunt syndrome is typically associated with — Vesicular rash and blisters in or around the ear and eardrum and sometimes on the roof of the mouth or tongue. — paralysis of the facial muscles on the same side of the face as the infection. — Symptoms — The classic symptoms — Red painful rash associated with blisters in the ears or mouth — Unilateral facial paralysis. — Other symptoms — Ear pain — Hearing loss — Dizziness or vertigo — Dry eye Can’t close the eye — Changes in taste sensation — Diagnosis — Is most often made by — Signs and symptoms — Also, a PCR test (polymerase chain reaction) can be performed on the fluid from the blisters to demonstrate the viral genetic material. — Treatment — Treatment consists of STERN — antiviral agents (for example, acyclovir or famciclovir) for about one week, — steroids (prednisone) for 10-14 days in tapered doses. — pain medications. — Early treatment within 3 days from the appearance of the rash usually results in a better prognosis HZO: 60% complete resolution, 40% partial resolution Bell’s palsy: 95% complete resolution. Wax impaction — Ear wax is naturally produced in the outer 1/3 of ear canal formed by a mixure of — Cerumen produced from cerumenous gland 8 — Sebum from the sebaceous gland — Desquamated epithelial cells — Wax is not a disease but if the wax excessively accumulate inside the canal , wax impaction occurs !! This results in a conductive hearing loss. Removal indicated if symptomatic or if it obstructs the view of tympanic membrane — Treatment — Softening the wax by sodium bicarbonate ear drops — Removal either — syringing the ear — suction clearance Ear wax (Cerumen) : ‫الصمالخ‬ It is a mixture of secretions of the ceruminous (wax) gland and sebaceous glands.Which situated in the cartilaginous portion of external auditory canal with desquamated skin cells of external canal The quantity of wax produced varies from individual to another. *majority of wax dried and separated as small flakes ,and expelled out side the ear canal by epithelial migration and movement of the jaw. The ear have self- cleaning of the wax. Functions of the ear wax:- 1. Lubrication of the skin of the external canal. 2. Contains fungicidal and bactericidal enzymes.(acidic pH) 3. prevent dust and sand to enter the ear as they stick to it and carried out wards. Causes of wax accumulation: 1. Attempt of the patient to clean his ear with cotton buds (Q tips) leads to pushing the wax deeper into the canal. Hearing aids ,ear plug. 2.Increased wax production. 3.Retension by narrow external canal,stiff hair. Clinical feature of wax accumulation ; 1.Hearing loss (CHL) when completely occlusion of the canal. 2.Pain or discomfort because pressure on nerve ending, 3.Tinnitus,disturbance of balance because of pressure of the wax on the TM. 4.Reflex cough –stimulation of auricular br.of vagus. Otoscopic exam.wax is yellow to brown color ,gray or black when mixed with desquamated epith. and dried. Methods of wax removal: 1.Ear syringing (irrigation) for soft wax. when it was hard give wax softner, like sod.succinate(dewax ear drop),5% sod.bicarbonate in glycerin. 2. Probing (instrumentation) :Use of ring prob,cerumin hook.crocodil forceps ,for hard dry wax under direct vision. 3.Micro-suction.It is safest when perforation of TM. Technique of ear wash (syringing). 1. Use syringe of ear wash by warm water at body temperature (37º C). 2. Pull the auricle upwards and backwards to straighten the meatus. 3. Direct the nozzle of the syringe of ear wash upward and backward in the external auditory canal and be gentle and careful during wash. Contraindications.for Ear wash (syringing) : 1. Otitis externa. 2.Otitis media. 3.perforated tympanic membrane. 4.Previous ear surgery. 5.young children less than 2 years. Complications of ear wash ( syringing) : 1.Trauma: *Rupture tympanic membrane. *Laceration of external auditory canal. *Osscular damage. *Damage to inner ear = perilymp fistula (rare). 2.Infection : *Otitis externa, (diffuse OE, Otomycosis.). *Otitis media. 3.Vertigo and nystigmus : due to caloric effect (hot or cold water). 4.Reflex cough or syncope due to stimulation of vagus nerve. =================