Hearing Disorders Week 2 PDF

Created with Coconote - https://coconote.app Understanding External Ear Disorders Good afternoon. My god. So we'll get started. This microphone is not charged. Look. Can you hear me back there? I have the other one off. Can you guys hear me back there? Yes. So so can you hear me? Is this thing n...

Created with Coconote - https://coconote.app Understanding External Ear Disorders Good afternoon. My god. So we'll get started. This microphone is not charged. Look. Can you hear me back there? I have the other one off. Can you guys hear me back there? Yes. So so can you hear me? Is this thing not on? Okay. Can you hear me from can you hear me better? So I did send out a schedule of our class. So there are so there are a couple makeup classes already in your schedule, and you'll notice that there are, I think, 3 more Monday classes where will have to be moved. Just scheduling wise, it just worked out that way. So the midterm will be on Friday, one of the makeup classes. It's in a different room row. Road. It's the business building, I think. But it's pretty roomy, and, it's actually a nice draw have room to write exams, and so it should be okay. But the midterm will be on February 14th, Valentine's Day. K? It will be for an hour. So we have the room starting at 8:35, but we'll start at 9:9 AM. K? And we'll go till 10. It's only an hour. After that, we can leave. We're not gonna try to start lecture number 6. Just go home and enjoy the weekend. As so when we come up to weeks where there won't be a regular regularly scheduled class on Mondays, I'll try to email you guys to remind you just so you don't show up. There may be one lecture I may try to do virtually because I'm not gonna be here physically, but I'll get that sorted out for you. Questions about the schedule? Yes. Are these things paper or with, online? They'll be very likely paper. Any other questions at all? Oh, I'm asking. The same thing. Yeah. And, obviously, I'll tell you what how the setup will be in terms of the exam midterm exam as we get closer. Okay. So I guess I'll have to use this. Can you hear me? Okay. So hopefully the other microphone will get charged during the first little bit here. So today we're gonna talk about disorders of the external year. Okay? And here's the alpine. Pretty clear there. So the external ear is part of your ear. Right? So there's the external, middle, and inner ear, and then the auditory central pathway. So we're gonna sort of start on the outside and then go inwards. So what that means is we're mainly gonna be focused on structural or physical problems, right, which causes conductive ear and loss. And we'll cover both congenital and acquired disorders, and you know what the definitions are of those terms. But congenital ones, we're gonna cover some of the syndromic ones, we'll cover later as well when we actually discuss specific syndromes, so there will be some overhang. But if you haven't heard the term congenital, congenital means that it's present at birth. Right? Something that you're born with. Now you may think, well, congenital does not mean it's genetic. Well, not necessarily. If it's a congenital infection, for instance, you know, it's not a genetic problem. Right? It's an infectious disease problem. But it's something you're born with as a pregnant newborn. Acquired means it's not present at birth, but it's acquired later on in life. Whether it's during childhood or during your older ages, it's not their at birth thing. So remember, when we talk about the external ear, we mean not just the ear you see. Right? So that's part of it. So we call that the penile or the oracle, but we also mean the ear canal as well. Right? The external ear is composed of the penna and the ear canal. K? That's important for us. It's called the outer ear here, but we call it the external. Now when we talk about especially congenital disorders, we do have to know about a bit about embryology. And I'm pretty sure nobody mentioned embryology as their undergraduate degree, but I'm sure some of you have taken some embryology before. Right? So some of this may be familiar with you. But we just wanna know the very basics of embryology. So embryology means what's happening during basically pregnancy, embryogenesis. Right? So how do different parts of your body form? For instance, the external ear, how does it form? And the reason why we have to learn this is because if we know how the ear forms, then we can understand how abnormalities happen. Right? If something disrupts that normal embryogenesis process, then you can sort of understand how some of these disorders may come to you. Okay? So here is an example of an embryo, about 3rd, 4th week of gestation. Okay? So we actually have a pretty long tail that's been cut off in this picture, but this is what human beings look like, homo sapiens. They're not even actually human beings. They're embryos. Right? Now if you take a cross section sort of like this way, okay, And then imagine that if you're looking at it from that cross sectional point of view, this is what you see. Okay? So these these little bumps correspond to these bumps here. So these are called the branchial arches. These little bumps here. Right? So that's the head. That's sort of the spine and the back. That's sort of the bottom trunk, you can say. But in the head and neck area, there's the primordial eye, and then all these sort of little bumps along the head and neck area. Okay? So those structures are called branchial arches, also known as pharyngeal arches. They mean the exact same thing. Now there's a number of different pharyngealarches, right, or pharyngealarches. And they have different names and different numbers to them. That's not important, but just be aware that there are multiple pharyngealarches. So the way these form is they come from this structure called a neural tube, and some of those cells migrate as shown in these arrows here and then form these branchial arches. So the reason why brachial arches are important is because those are the structures that give rise to a lot of the important structures in your hand. So you can see, for example, from branchial arch number 1, which is shown here, that's later on gonna develop and form part of your mandible. Right? And then part of your incus and malleus. Right? So pharyngeal arch 1 gives rise to your incus and malleus. Pharyngeal arch or pharyngeal arch number 2 gives rise to, again, other sort of, skeletal structures in your neck along with stapes and so forth. And again, there are 5 main pharyngeal arch or branchialarches, And they have different names. The thing to note about these pharyngeal arches is that they have so those little mounds of tissue, they'll give rise to a muscle shown there, a skeletal structure, like a bone or cartilage or something, as well as a nerve, major one of the major cranial nerves, and a mercury. So again, just knowing this, imagine what happened happens if you disrupt, let's say, this migratory phase during embryogenesis. Right? You can have abnormalities during incus and the incus and malleus formation. Right? Right? That means you can have conducted paraffox. Right? So that's the way to think about embryology. It's not truly just an esoteric thing that you have to learn for your exam. It's something that you should sort of try to understand so that you can understand how some of these anomalies the donor. So in terms of the pinna, the external part of the external ear, so the pinna comes from the first and second branchialarches. The first arch forms these structures called hillocks of His tissue, numbers 1, 2, and 3. And hillocks of His tissue 4, 5, and 6 comes from the second branchial arch, and the picture is shown there. Okay? So look at this embryo, human embryo at 4th about 4th week of gestation. Okay? So you just got pregnant, and this is what your embryo looks like in 4th weeks. So what do you notice? Well, you see the ear structures are starting to form. You can see that's hillocks of His tissue 1, 2, and 3 coming from branchial arch 1. Branchial arch 2 gives rise to hillocks of His Tissue 4, 5, and 6. Now if you read different textbooks, you may see the numbers a little bit different. It's not perfectly clear that it's as neatly distributed as shown here, but we're gonna go with this. So again, you can see the henna started form here. Right? So what do you notice that's way off about that embryo and the ear. Obviously, not all the intricate structures are there. But what else do you notice? Seems a little too low down. Yeah. Where is your ear right now? It's basically on the side of the head. Right? But in an embryo, it's like here. Okay? So what does that tell you? Well, the ear has to form, but it also has to migrate. It has to form, but it has also has to move postural superiority into the correct position. So again, what happens if something happens during that migratory phase? Right? Then you can get low set years, for instance. Right? And we know we'll learn about lots of syndromes with low set years. Right? And then you can think, well, how did that happen? Well, you know the year migrates, so something disrupted the process. Right? Right? So going further along, this is again about 7th week of gestation. You can see those hillocks of His tissues, these sort of roundish tissues, have sort of fused with each other and and start forming some of the recognizable inner structures. So starting week 8 of gestation, you can start seeing some of the auricular structures, like the helical rim, tragus, and some of those structures. And by 18 week of gestation, your ear looks like an ear. Okay. So how many weeks is a typical pregnancy? 37 weeks. What's that? 37? Yeah. It's well, 30 well, the correct definition is 36 to 40 weeks, but, yeah, 37 is right there. So so what does this tell you? The ear, the pinna at least, is formed during the first half of your pregnancy, during gestation. K. So what does that mean? Well, if you see a child with a regular abnormalities, then you know the injury or the insult happened during the first semester or first half of the second semester trimester, sorry, that semester. K? It happened earlier on during pregnancy. It didn't happen during their 30th week, for instance. Okay. So going along going further along in terms of external ear embryology, remember the external ear also includes the ear canal, the external auditory canal. So the external auditory canal starts forming at the same time, and but it forms a bit differently. So the key thing here is that there's, like, there's a bit of a plug that forms in the ear canal, the external auditory canal. And then that plug actually disintegrates. And we'll talk more about this later on. But that's how the ear canal falls. K? But we're gonna be mainly focused on, the panel or the oracle today. Again, you know, you ever seen ads for, ultrasounds and get ultrasound images of your baby? There are private ultrasounds that you can get as well, three-dimensional ones. And these are some pictures from there. You can see again when you so most, I would say, pregnant individuals get ultrasounds done privately when they're babies. Little few weeks or few, their babies little few weeks or few, yeah, a week or two before their baby's being born so they can say it was their picture first picture taken. But you can see the ears already well formed. Right? You can see a pretty normal looking ear here. You can see actually even things like these these are called preauricular skin tags, which we'll cover in a bit. But you can find abnormalities in auricular or penne formation on fetal ultrasounds. K. These are ultrasounds done during pregnancy. But this tells you again the year is formed pretty during the first half of pregnancy. Okay. So we have a bit of embryology background. So this is what a normal pinna usually looks like. Okay? Again, like we said 2 weeks ago, there are lots of intricate folds and crevices and different areas that you can look at when you carefully look at your ears. Now the important things are listed there. So this is the helix or the helical rim. But actually, the first thing is first thing to note is your top 2 thirds of your penne is cartilage covered by skin. The bottom 1 third is the lobule, or there is no cartilage, just fat. There's fat and then skin. That's where you get VODs, so you get you guys yummy. It piercings everywhere, but most of the time, you get in another globule. So at the cartilage part, the important parts of the antenna include the helical rim or the helix. And then there's another rim inside here called the antihelical rim or antihelix. Okay? Showing here. Now the antihelix splits into the superior crust and the inferior crust, c r u s. K? So the between the space or the fossa means it's a bit of a concave space. So the space between the superior crust and and the inferior crust is what you call triangular fossa. And it's shaped like a triangle, so that makes sense. The space between the antihelix and the helix is called the scaphoid fossa or scapha. Now this deep area is called the concha or the conchobole. Now the conchobole is separated into the superior part and the inferior part. And then the split is by the root of the helix. Remember, this is all helix here. The outer ridge. So the top part of the conga is called conka simba, c y m b a. The bottom part is called the conka cavum, c a b u n. Now, couple other things to note. This little bump in the cartilage here, sort of covering the external auditory meatus or the opening of the ear canal. It's called a tragus. Right? It's this bump here. Below that is the antitragus, another bump in the cartilage. So you have to have all of those structures basically present for your ear to be considered normal. So again, you can see the importance of norms on normal anatomy. Now remember, there's the the way the ears look, and there's also the positioning of the ear. Right? So the ear is usually a bit of a tilted structure. Don't worry. It's much of a bangle, but it doesn't go straight up and down if you look at the longest axis of the ear. And also remember the positioning, straight line from the lateral eyebrow to the top of the helix. Bottom of the columella, if you draw a straight line parallel to the floor, you should hit your lobule. That's the general positioning. There's the angle of the ear as well. K. You see this angle? Don't worry too much about the number. Just know that there's a big range, but there's a norm considered a normal range of ear or pinna protrusion. So again, the appearance of the ear, the positioning of the ear. That ear is like any structure. It's innervated, so there's a sensation to it. And the sensory innervation is by lots of different cranial nerves. 5, 7, 9, 10, in fact. And also the great auricular nerve, so that's a nerve that's coming from your c spine. So if any of those nerves are damaged, you can feel numbness or tingling in your ear. Now all structures in your body need a blood supply too. Right? Without blood supply, oxygen that part of the body can die. Same thing with the ear. The main supply to the main blood supply to the ear is the superficial temporal artery, which is shown here, going in front of the ear. And and then there's another one called posterior auricular artery going behind the ear. Right? So if you you know, when you get when your blood's pumping, you've just ran, you know, you feel your temple and you feel the pulsation, that's your superficial temporal artery. Right? That's what's providing blood supply to your external. Again, many structures, not all, but many structures in your body also have lymphatics. Lymphatics is part of your circulatory system, but they channel lymph rather than blood. Lymph is sort of infect or, immune system related fluid. So in the area which covers the external ear, the lymphatics will drain into lymph nodes in your parotid gland. That's your big spit salivary gland along along your cheek in front of the ear, as well as they can go down to the neck or those lymph nodes behind the ear as well. So again, sometimes some of the ear related disorders may present with infectious disease ones, for instance. They may present with some enlarged lymph nodes in front of the ear or behind the ear or even along the neck. And this is why. Okay. So now we have some basic understanding of embryology, anatomy, physio or not physiology, but, normal anatomy. K? And bit of physiology in terms of blood supply and drainage. Okay. Now we're gonna talk about actual abnormalities or anomalies. Okay? So these are the things we're gonna cover. Alright. So who is the character on your, left? Come on. You guys you guys are all pretty nerdy smart people. Yes? Like us from the. Yes. What about Spock. Spot. Right? That's the old spot. There's a new spot apparently. New Star Trek movies, which hasn't seen them happen. Now what? Are they so are they human beings? No. So what's what's what's Legolas? Hell. It's enough. Okay. What about Spock? Vulcan. He's a Vulcan. Yeah. So they're not human beings. Right? So what's different about them? They're ears. Right? I mean, these look like human beings. They look identical to us. Well, I mean, funny haircut, really yeah. This thing's an eyebrow button. The only thing that's setting them apart is their ear. Right? Their ears look pointy. Right? But just from I mean, even if I didn't show you this sort of famous characters, we know when we look at them, there's something that doesn't look right. Right? And main thing main difference is their ears. Their ears look pointy. So what am I trying to say? Well, I'm trying to tell you that your ear is part of your face. Right? It's makes it's what makes us who we are. Right? We've done, research studies, and most people, when we talk to each other, we focus on the central triangle of the face, eyes, nose, top of the mouth. But also sometimes our sight will go to the ears because, again, that's part of a normal human being's face. Right? So again, this tells you if there's something that's different about your ears, it's noticeable. Even subtle things like pointy ears. So the first thing is called Darwin's Tuber pole, and if you look at your classmate or your family or even your own ear, some of you will have this, and it's just a little bump in the ear. Okay? Usually on the inner aspect of the whole helical rim. So and some of the less evolved species also tend to have little bumps as well, so that may you have a little bump, they tell you about your evolutionary stage, but, you know, obviously, that's not true. This is just a sort of a normal finding, right, that lots of people will have. Obviously, it doesn't cause any problems. You don't have to worry about it. Just for interest sake. Now, this can cause some problems. Okay? So remember, we talked about the angle of the ears. Right? So when that angle is really wide, your ears pop out. Right? So we call that prominent ears. You may hear other terms like promenotia, outstanding ears, bad ears, some people call it, but we will use we will use the term prominent ears. So any idea what problem this can cause? Yeah. Maybe hearing noise from behind you? Yeah. So organization. Yeah. Though that's so we've actually Steve Ape and I did a research project on that. But so, yeah, you would think if you have ears that's cupped out, it may filter background noise out if it's coming from above. So, you know, when you guys are if you guys are at a bar or a party, you know, how many times have you gone have you done this to try to, get listen to the conversation more when there's lots of background noise? So there may be a bit of that, but it's pretty minimal or negligible, because the human ear will adapt. Now bats have ears that look kinda funny. Right? And the reason why their ears look like that is to get vertical, sound localization better. Human beings, the effect is pretty negligible. So in terms of sound, resonance, as well as filtering out background noise. Any other problem you can foresee? Yeah. Are you bullying? Yeah. Right? So kids are mean these days. Well, right, especially on social media and stuff. So some kids with prominent years or some individuals, even adults or adolescents, with prominent ears, they may get bullied or teased. So I see lots of kids with prominent ears, and they get made fun by fun of by their friends called biggie mouse ears, dumbo ears, stuff like that. So if that happens and if the parents want to get that corrected, then we can do surgery to pin back the uterus. That's called otoplasty. Right? Otoplasty means where we're changing this, alternative shape. Now, obviously, not every kid or every individual with promenadeers need otoplasty. Right? It's only if it's causing pretty significant psychosocial distress. And if you look at president Obama, he has problems with yours. But does he need that fixed? No. He's a very successful person who I'm sure people don't mention his ears a lot. So again, it is a cosmetic surgery, but it's well, it's probably the only cosmetic surgery I would do, but because it's covered by the province and it has some psychosocial outcomes related. It. Now the next condition is called cryptosia. Anybody know the term crypt, what that means? It's from Latin. Yeah. Yeah. Sort of hid. It's under basement or tails of the crypt. Right? Crypt means it's hidden, basically. K? So cryptosia is when your superior part of the auricular cartilage is hidden. So it's buried under the skin. Okay? So the cartilage is there, the auricular or helical rim cartilage, but it's buried under the skin. So what problems can this have? Can you imagine any? Yeah? I feel like you might just get more things in your ear. Not really. I mean, that's a reasonable thought, but not really. Yes? More. Actually, you had your hand up first. Go ahead. Hard time, like, localizing stuff? Not really because, again, your sound transmission is pretty similar. But, yeah, I mean, you would think, well, maybe you're missing some of the folds, some of the resonance may be affected, but not significantly. Not enough that it would actually cause, sound localization, ability changes. Were you gonna say the same thing? No. I'm not here. K. You're you guys are thinking way too deep about this. We're very superficial in this class. Right? Yes. superficial in this class. Right? Yes. I'm just thinking about, like, if the child needs glasses or something. Yeah. That's right. Hands touching. Right? Look. Where we where are we gonna put that? There's no supraoral sulcus this area is called. Right? So glasses. What else do you put? Alexander, say bullying again, maybe? Yeah. It's pretty subtle, to be honest. If you see somebody with this, you probably don't even notice it. Now you'll know because you've learned that. Right? Now you're gonna be looking at your friends and go, oh, there's something wrong with your background. It wouldn't cause it on its own, but if there's a occluding to and it's for hearing loss, then you wouldn't be able to get, like, an over ear. That's right. Hearing aid. Right? Some of the behind ear hearing aids have that little supra aural sulcus component where you have that. So again, pretty rare. Probletant ears are very common if you look at people in the general public. Lots of people have ears that stick out a bit. Right? And is that a big deal? Usually, no. Cryptosha is pretty rare. K? But if you look for it, you'll probably see it. So what we do is again, remember I told you the cartilage is there just the way the skin is formed, it's hiding it underneath. So we can actually do things like molding, which I'll show you pictures of later when babies are young to reform the skin around the cartilage. And again, you can see that here looks normal now. While here, the cartilage is buried under the skin. K? Now for older kids, sometimes you have to do surgery to make and we do some advancement flap procedures, it's called, to bring out the cartilage and then suture the skin. Again, not super common, but if a child needs glasses or hearing aids, we may need to address that. Kapilopyr or kaprolopyr, the form of the is shown in the pictures there. The best way to describe it is your top of the ear is sort of folded on itself, and you can clearly see that ring. Obviously, differing degrees, the bottom pictures are more severe than the top pictures, but that's what it means. So some happened during cartilage formation. That means a fold out. Well, you can imagine if, if the baby's ear was folded during embryogenesis and, you know, cured lymph nodes, for instance. Okay. The next one is called Stalier deformity. Again, pretty rare, but if you look for it, you may you probably see it sometime during your lifetime. Okay? So Stall year is when you have this extra tissue here. So remember the normal year has superior crust, inferior crust, which join to form the antihelix. However, when you have stell ear, you have this 3rd crust, extra tissue, cartilage. Okay. More subtle ear. So when you see these ears, the ears look really pointy. They look like in, those fictional characters we discussed earlier. Now prominent ear or a stall ear, even prominent ears or cryptosha, if you find them in a brand newborn baby, you can do molding. There are these custom molds, and you can actually reshape the ear, because baby's ear cartilage is still malleable. So if you catch them early, then you can actually reshape just by putting in these molds for a few weeks. If we get them later, then we have to use surgery to correct some of these anomalies. So the final or the next auricular anomaly is called Nicotia, and we're gonna cover this in more detail when we cover syndromes. Because Micromatia can occur by itself, but it tends to occur with or it can occur with a lot of different syndromes. So microtia is when you have underdeveloped external ear. So what do you notice here? Well, obviously, the ear looks really abnormal. There's no really identifiable ear structure. There's just a little nubbin of tissue. This baby has some cartilage, little globule there. Basically, no recognizable structures. Right? What else do you notice? Yeah? Well, I just had a question. Is it typical, like, if it happens on one side, would it happen on the other or it could just be No. It's typically unilateral. But, again, we'll cover that, in mind. But these kids obviously won't have any ear canals. Right? So they can't hear. Right? So we need to discuss that later as well. So that's it. Yeah. Is it that they don't have the canal or just an opening for the canal? Could be different things. They may not have an opening. They may not have a near canal. They may not have lost calls. Either ear is usually normal, but any part of the ear can be affected. Megan will cover that when we talk about syndromes and microtia. I was gonna ask a second question. What's the what's the difference between microtia and, like, a more severe case of cup look ear deformity? Well, they're kind of on the spectrum. Cup ear deformity usually has a normal ear canal. Okay. But you can think of it as on a bit of a spectrum, but micros are usually they don't have an ear pair. Okay. So the next condition, again, super common if you look at your classmates' ears, some of them may have this it's called a preauricular tip. It's literally a little dimple in your skin in that location where the helical remisor lift is taking off there. So it's a preauricular pit. So pre means before before the year, little pit. Now you can imagine remember going back to embryology, you can imagine how this can form. Right? Remember the hillocks of his tissue are fusing, moving around, fusing with each other. Maybe that fusion was not completed, so it formed it leaves a little gap. So that's how some of these pits may form. The problem with these pits is even though it looks like a little skinned or maybe actually a puddle of skin, it may be deeper than the thing. And if that's the case, then sometimes there can be trapping of some dead skin debris because they track this line by skin, and that can become infected. That's if that's the case, then we have to to sort of return with it. But most of the time, when you see someone with preauricular PIP, it doesn't cause any problems. Some people don't even know that they have that. Just a little dimple. Now related anomaly is called a preauricular skin tag, and that's when you actually have not a pip, but actually more skin tag. It's like a little tag of skin. Here. K? And again, it's usually doesn't cause any problems other than that other than the fact that it's a cosmetic issue. You know, kids get can get made fun of or other kids start pulling on it even daycare. So we usually take these out, if the parents want it. Now the thing with preauricular hits and tags is most of the time, they occur by themselves, and it's not a big deal. However, sometimes, they can indicate that there's something else going on. So for instance, if you have someone with a preauricular skin tag, and you test their hearing if they have sensory neuroendocrine loss, or they failed their newborn hearing screen, so you know they have hearing loss. They may have this thing called brachial overreminal screen. We'll cover what that is later. So a lot of the auricular abnormalities we discussed, they may not actually be causing any problems. Let's say a child with mild problem years. Who cares? However, sometimes, some of these anomalies, like prerequisites tags or cryptosha and some of the other stuff can be a harbinger of something else like syndrome. And again, we'll talk about some of these anomalies later on in game with syndromes. Okay. Questions about that part? Alright. So next, we're gonna move on to traumatic injuries of the external ear infection and little bit about skin cancer. So we'll start with a regular hematoma. Now before we do that, we have to learn very crystal, very basic dermatology. Right? Just the layers of the skin. So the top layer of the skin is called epidermis. Right? Below that is the dermis. Right? Epidermis is pretty thin. The dermis gets pretty thicker. And then under that is what we call subcutaneous tissue, like fat or muscles, cartilage, bone, lip. But generally speaking, that's what our structures what, covers our skin. And the other thing to note is some of the other structures, like the hair follicles, the nerves, the sensory nerves, and the sweat glands, and other stuff. Now the ear is a bit different because, remember, the top 2 thirds of the pinna is covered by skin. Right? There's dermis, epidermis, and dermis, but there's no fat or other stuff. Right? There are actually small intrinsic muscles of the ear, but you don't have to go about them. But there's skin, and then there's cartilage, tightly adherent to each other. Right? Now the lobule, again, there is more of this structure here. There's the fat. So just remember that sort of picture when we talk about some of these disorders. So the first thing is called an irregular hematoma. Hematoma means it's a collection of blood. Anything with he means blood. Oma means it's a mass or some type of a growth. So it's literally a collection of blood as shown in these two pictures in the ear. So how do you think most people get these? Yeah. Like, trauma can be cured. Yep. Can you be a bit more specific? Like, friction or a cane? Can you be a bit more specific? What activities? Contact sports, ma'am. Can you be a bit more specific? What Can you be a bit more specific? What contract sports? I'm gonna say wrestling. Yeah. Yeah. I'm sure you can say. Wrestling? What else? What else is a very common I'm sure some of you. Okay. You had your hand Singing. Boxing. Yes. Yeah. Yep. Rugby. Rugby. That's another common one. Do you have another one? I was gonna say, could piercings cause? Yeah. It can, but usually causes something else. We'll cover another bed. But that would be unless you get your piercings at Claire's by a 12 year old, which you shouldn't do. You're not gonna get this from piercing. That'd be pretty rare. Okay. So wrestling. Not I mean, when I say wrestling, I don't mean the the WWE and Roman Greco wrestling with, in the Olympics and rugby. Right? And you you guys play rugby? Some of you. No. It's usually but when you see wrestlers or rugby players, you know how they wear those funny hats with the the ear flaps? And that's to prevent vernacular hematoma formation because that will later turn into something else. But, yeah, it's traumatic injury. Right? And it's not just usually a direct hit. It could be sort of like a rock, but usually fairly severe, trauma to the ear. So then what happens is there's collection of blood that separates the skin from the cartilage. Okay? So it lifts up the layer or the plug gets in between the layer between the skin and the underlying cartilage. Now, if the injury is bad enough, you can get ear and or blood in the middle of your space, that's called hemotipinum, and that can cause some head up to hearing loss. You can also have ear canal swelling. These would be pretty severe injuries, so they usually don't happen. Maybe this is more consistent with the motor vehicle accident. Now the important thing to note are the last two lines, sir. So if you see a hematoma in a very young child, they usually don't get them, so we have to suspect abuse. Child abuse. Again, very rare, but if you see a child, the caregivers wondering about here in Boston, they get they have hematoma, and you have to think about that at the back of your mind. Again, very unlikely you'll see it, but we do we see it sometimes. Now these do need relatively urgent incision and drainage, meaning the blood has to be drained up. And sorry if you're grossed up by some of these pictures, but we usually make a pretty wide incision to drain up the blood. And then we actually put some splint there. Because if you fill a little hole in me, fill that up. K. The reason why we have to do this is because we wanna avoid cauliflower here. Right? Which is Right? Remember if you or we talk about wrestling. Remember some famous wrestlers, if you look at their ears, they look like this. Right? They look like there's a whole bunch of weird looking sort of excessive curvature, so that's called cauliflower here, the farming. And the reason why that happens is when the blood separates the overlying skin from the underlying cartilage, the blood supply to the cartilage itself gets disrupted. And what happens to the cartilage when you disrupt blood supply is it forms this sort of new weird neal cartilage, which is what can lead to the solid flower you're referring. Right? So obviously, it's not it's pretty unsightly, so you wanna avoid this, especially if you're younger or just playing rock beating, you have the hematoma. Right? You need this term. Yes. Pardee? I've seen this with folks that have, like, self injurious behaviors, like, with intellectual disabilities. What would you recommend in that case? Like, would you give them something usually to, like, stop it or, like, put something on their head to prevent it? Or would you continuously drain it every, like, x amount of time? Yeah. I mean, you've heard of scenarios like that. I mean, those are difficult cases. They do self injurious harms. I mean, probably the most prudent thing to do is to cover the ears, protect the ears. You're not gonna sedate these people just because of the virus. In itself is has some risks. So, yeah, I mean, we've had some kids with, you know, really severe autism, for instance, that bang their ears a lot or they pick up their ears constantly. And, yeah, we usually try to cover their ears. Sometimes I have to train them once in a while. But, usually, that's more handled by, like, you guys or the EIBI team, for instance. Right? That's more of a behavioral thing. Right? So do they need intensive therapy to change that behavior? That's sort of the way you need to look at those individuals, unfortunately. Okay. Next thing is called cellulitis. So when you hear the term cell in medicine, it means skin. Right? So cellulitis means you get infection or inflammation of the skin. And you can get that anywhere, obviously, right, including the ear. So you can see this ear, it looks a bit red. So when you have cellulitis, just generally speaking, you get the classic clinical features, which include warmth, pain on touch, right, redness or erythema, swelling or we call it edema, sometimes it's a bit itchy feeling or pruritus, and sometimes there can be some discharge. Okay? So what can cause this? Well, piercing, like you said, can cause especially when you, again, don't have good hygiene practice when you're on the yeah. You can during piercing, you can spread bacteria into the into the cartilage or the other structures in here. What about frostbite? Like, if you got some mild Frostbite. Yeah. In a in a couple slides later. A few slides. Yeah. But, yeah, that can lead to cellulitis. Now if you go deeper so cellulitis in the breast, it's a skin infection. If you go deeper in the ear, what do you get? You get cartilage. Right? Cartilage is also always surrounded by this layer of tissue called perichondrium. So chondrium means cartilage. Perichondrium means it's the thin layer that's adhering to the cartilage. K? So if you if the infection goes deeper, let's say, again, from a piercing, then you can get paracond drivers or conchondriners. Now it's very similar in terms of presentation to cellulitis, but there's a key difference. Right? The key difference is the fact that in the lobule, there is no curvature. Right? So you can't get pericondritis or chondritis in the lobule. Right? So if you have purely pericondritis and chondritis, then your lobule is spared. Right? Top 2 third 2 top 2 thirds of the year will look red, pain on palpation or touching, but not the lung. But they usually go hand in hand. Chondritis, perichondrinous, and cellulitis, they tend to occur together. Right? That makes sense because you usually get a skin infection which goes deeper. So, again, causes of cellulitis, perichondritis, chondritis usually include some type of trauma or piercings. It could be something iatrogenic. So iatrogenic means it's caused by some type of procedure, some type of health care provider. That's what it means. K. So if you, you take the wrong medicine and you get a side effect, that's iatrogenic injury. But sometimes when you do ear surgery, you know, you get a wound infection there, for instance, and that would be an iatrogenic cause of perichondritis, for instance. A lot of these individuals will have underlying conditions such as diabetes or other immunosuppressive conditions, which makes them more, which makes them more prone to some of these conditions. And again, usually they do need antibiotics because if you don't treat it, there's sometimes an abscess formation. Abscess is when you get pus buildup, and you can get cauliflower or deformity from these as well. Do these affect hearing? Not really. I mean, if you get lots of swelling in with cellulitis, for instance, that go into the ear canal, not because of conducting ear loss, but that would be great in brain. The final one in this group is called the split globule. How do you think you get this? Yeah. Your pure skin works. So usually happens to moms or caregivers with babies. Moms are wearing blue burns, for instance. Right? K. What's the cause I mean, it hurts, obviously, but, usually, something pretty easy for us to fix. Alright. So we'll take a break. We'll talk about some weather weather related injuries afterwards. So it's 3:32. I've got 3:42. Okay. Can you guys hear me? Okay. So cover the next 2 here. Alright. So first, we're gonna cover frostbite, and sunburn after that. So these injuries realistically, I'm not gonna see them. You're not gonna see them, but you may see some chronic changes related to them. So, unfortunately, with people who don't have homes and stuff too, it's becoming a bit more common. They tend so people who get these weather related problems tend to have risk factors or susceptibility factors. So, obviously, things like being homeless is one of them. But related to that, it can be mal they can have malnutrition and prolonged exposures. Pretty self explanatory. And there may not just be in good health, generally speaking. So when we talk about frostbite and sunburn, you wanna think about the depth of involvement of your skin. Right? Meaning, you go from superficial to deep. Right? The deeper you go, obviously, the worse it is. Right? And the different things that can happen are shown they're listed here. So this would be superficial, but deeper you get, the more lines you can sort of cross off. So if you have if you get a lot of cold exposure, you can get some redness on your skin. I mean, everyone's had that. K? If you walk outside for a long time with your cheeks exposed, that's what happens. But obviously, if you go deeper in terms of, the, cold exposure, you can start getting some numbness, tingling, other things, like, you can get blisters. And then finally, if it gets deep enough and prolonged enough in terms of exposure, you can get something like this. Right? You can actually have tissue death where you're actually part of your body or your tissue dies off. So that's called necrosis. So, obviously, thing to do is to get in the get in a warm space and warm it up as fast as you can. So fingertips, very common. Toes, common. Ears, common. Right? People sort of, tend to have exposed ears a lot in the cold. So those are some of the common places where you can get frostbite. Now sunburn, pretty common, especially during the winter, summer transition when our we tend to have, like, sort of sort of fair skin, haven't had a lot of sun exposure. Right? Other risk factors include, you know, if you have really light skin, red reddish hair, freckles, that gives you more propensity to develop sunburn and other sun related skin damages. Again, exposed skin areas, like we mentioned for phosphites, that's similar. So lots of people put they put sunscreen on their face or nose, but they may forget their ears. People who wear hats, baseball hats, 30 years are exposed right now. Well, you can get sunburned during winter time as well when there's lots of snow. Right? Because the light snow reflects light. So if you're at a ski hill, for instance, all day, you can easily get a sunburn, so you should be aware of that. The component of the sunlight is the ultraviolet rays, UVA and B. Initially, we thought it was UVB only, but both ultraviolet rays can contribute to causing sunburn and sun or, skin cancer. K? So the concern about sunburn is if you get them a lot or if you get bad ones, it can lead to skin cancer. Similar to frost bites, first degree means it's pretty superficial. We've all had this properly. Right? Sometime during our life where we get sun exposure, we didn't put enough sunscreen on it. You can get some redness. You can get some discomfort on it. But deeper you go, the worse it is. Right? Obviously, when you get to the 3rd degree level, that's very concerned. Right? That's when you need actually medical treatment and, possibly other measures, interventions for you to recover from that sunburn. And the key there is you feel no pain. Right? When you've had some exposure and sort of mild or first degree burns, you know, it's really red, it's painful, we've all had that. We've all had that. Right? But if it goes really deep, it starts the sunburn actually starts killing off the nerves, the sensory nerves. Right? Remember that picture of the skin cross section? The nerve is on the deeper part below the dermis. So the damage is becoming low, deeper and damaging actually sensory nerves. So you don't feel any pain. Right? So it's a bit paradoxical because it feels better. It feels better than a first and the second degree of urine, but it's worse. Right? And then again, if you go down to 43, then you're really in trouble. You may need skin graft and other surgical procedures. Now, again, you know, it's just nice to be aware of these because you do deal with the face that had a knife and the ear. Where your part comes in is if you do sort of see signs or if you're suspicious of chronic sun exposure or other stuff, then you may need to counsel them. Because, again, it can lead to things like skin cancer development. It's one of those things where you can actually prevent these things from happening because you can cover up the ear or use sunscreen or some type of protection from the weather or exposure. Can these injuries affect hearing? Well, I mean, extremely rarely they would. Right? If the sunburn is so bad that it's going into the ear canal or ear canal where it swells up, or if there's other things like secondary infection or other stuff going on. But, typically, if you get a sunburn of the ear, it's not gonna cause your hearing to go down. There's a couple dermatological conditions you should be aware of. Again, it can happen anywhere on the skin, but these are two conditions that very commonly occur in the ear, and they're called the tendin keratosis and staphylocapothermottanius. So tendin keratosis is shown here. These are little sort of they look like little scaly patches, right, All along the ear, mainly, going down onto the neck. Now these are important to know because these are premalignant skin lesions, k, caused by usually a lots of sun exposure. So very common in elderly farmers, for instance, where they were out in the field a lot, and they were not using sun protection. And, again, they look like thick, crusty patches of sort of, on top of the ear. K? Now if you recognize this, and you can see some chronic sun damage in the ear. Right? And if you refer them early, it's a very good thing for you to do because these things can turn actually into skin cancer later on. Right? But if you if you refer them early, they can have these removed by a dermatologist or other sometimes hanging doctors by things like liquid nitrogen or other measures, and you won't get cancer. So, again, it's something you probably won't see a lot, but something to have in the back of your mind. Next one is called cephalocompothermatitis, and these are usually hearing aid related. Like, hearing aid I mean, behind the ear, you know, it can get sweaty, and you don't sometimes forget to clean that area super well. So sometimes there's poor hygiene related to hearing aid wear and fainting on that area. And bacteria, specifically staphylococcal aureus bacteria bacteria, can build up. K? And cause some skin infection or irritation. So that's called staphylococcal dermatitis. You can see how sort of reddish and swollen it is from here. That may need antibiotics, but usually better hygiene, better cleaning, better looking after your hearing aid, mold, should do the trick. Okay. So the next topic is skin cancer. So the risks of skin cancer are first, 2 are pretty obvious. Right? Obviously, skin sun exposure, the ultraviolet rays that you're exposed to. Skin type, we already mentioned. Right? Now other things like immunosuppression and genetic predisposition, can also affect your skin cancer, development propensity. We'll learn this later on as well, but a lot of cancer development has to do with your immune system status. If your immune system can bite off certain types of things, you may not develop certain types of cancer, for instance. There is a couple genetic conditions. One of them is called xeroderma pigmentosa. These are rare genetic conditions that predisposes you to get certain types of skin skin cancer. So there are some risk factors. Now there are 3 major types of skin cancer. There are sort of other super rare ones, but the top three skin cancers are basal cell carcinoma, overwhelming majority. Squamous cell carcinoma is the next most common. In squamous cell carcinoma, USLPs will see for sure because that's the type of cancer you get in your larynx, tongue, your upper aerodigestive tract. Melanoma is the 3rd most common type, and I'm sure you've heard of melanoma before. So basal cell carcinoma is super common. There's a very, very good chance that many of us in this room will have it. Sometime during our night, But it's one of those very, benign slow growing slow growing cancer, so you may die with it. Right? You may have a small basal cell in your back that you didn't even know there's cancer. It's one of those things. Now so it is the most common malignant disease in human beings. K? And other numbers are listed there. So it's a very common type of cancer that for human lives. Now most basal cell carcinomas occur in the head and neck. Right? Why would that be? Yeah. More exposure. Yeah. Some exposure. Right? So look at us. I'm covered basically neck to my feet. Right? So we always have our head and neck area exposed. So that makes sense. Now you can get them on your back and other some exposed areas, but head and neck area is the most common. So basal cell carcinomas, they typically look like this. Now you should be aware there are different types of basal cell carcinomas. There's things like morpheiform and other other rare types, which can be very, progressive. K? But the typical basal cell carcinoma looks like that. K? A little bit raised a little bit raised, a little bit red. Sometimes there's a little scab in the middle that's called sort of ulceration or telangiectasia. Telangiectasia is when you have little broken blood vessels Again, this is a pretty benign, or, I don't wanna say benign, but it's a pretty slow growing, nonaggressive cancer. So if you notice this, you notice it getting maybe a bit bigger a few months later. People see your doctor. They do a they may get you to see a dermatologist. They do a biopsy or remove it. That's it. Right? Most of the time. Now there are some severe forms, like I said. So this is a different type of more more aggressive type of basal cell carcinoma in a patient that's affecting the ear. Right? So lots of sun exposure. You can see sort of sunspots there, and this is again spreading over time. It's actually going into the underlying bone there as well. So you actually have to remove basically the entire ear. You reconstruct the ear later on, but, obviously, you have to remove cancer first. So, yeah, nasal cell carcinoma, very common. Very rarely this aggressive. Squamous cell carcinoma is worse. It's more aggressive than basal cell carcinoma. And it has higher incidence of metastasis. Right? So metastasis means it's spreading. Right? And it's spreading either through your lymphatic channels or your blood, your circulatory system. So you know how you can have cancer, like, in your breast, which can spread to your brain or your kidneys. That's metastasis. Right? It's different than local spread, growing locally and invading adjacent structures. But, again, it's has to do with sun exposure again, and that can occur from that benign condition called the pericaroptosis, right, which we cover. So squamous cell carcinomas can look like the picture there. This looks like a scab. Right? Looks like a scab that everyone's had on on their skin. But it's a scab that's not gonna heal. Right? If you have a little cut, it scabs over, scab falls off, and the underlying skin has healed. But this is a scap that's gonna continue to sort of be there, grow, lead. That's what squamous cell carcinomas look like. Now melanomas malignant melanomas are bad. K? This is not what you wanna have. It can be deadly, very common. Thankfully, it's not super rare, especially in the younger population, but certainly seen people in their twenties thirties with malignant melanoma, that spread and they can end up, again, palliative or even dying from it. So it is the most aggressive type of skin cancer, and it's the most common skin cancer that will actually cause mortality or death. Now, about 10 years ago 10, 15 years ago, it was increasing in incidence, but this may be changing a lot because, I don't know if you guys are familiar with tanning beds and stuff like that. Right? It used to be a lot more popular. There was a tanning tenning bed place, very close to your large jeans, a Chinese restaurant at in that Lazard, for instance, about 10 years ago. So certainly, there's more awareness of skin cancers, so people are starting to use more sun protection, but still, I mean, it still unfortunately happens relatively commonly. So melanomas tend to come from these cells called melanocytes. So we all have melanocytes. They're part of your skin cell system, and they tend to produce melanocytes. So they tend to produce the color we have. But some for some reason, with sun exposure and DNA damage, these cells turn into cancerous cells. They grow. They spread rapidly. So usually when you have melanoma, you need multimodal treatment, meaning not just surgery, not just radiation, but probably a combination of chemotherapy, immunotherapy, and others. Because again, it's a very aggressive disease to have. A malignant melanomas can just appear like a little mole on the ear. Right? This is a looks like a little mole on the helical ring. Right? So, you know, in Lao, like, I have that on my back. But these are, again, aggressive tumors, so they tend to grow. Moles are they stay the same. So there are these features of melanoma, and the acronym is a, b, c, d, Right? So, you know, this is sort of the way to differentiate between a malignant melanoma versus, like, a mole that everyone has on their skin. Right? So melanomas tend to be asymmetric. They have weird shapes. Their borders, if you look closely, even with, like a magnifying glass, they tend to have irregular borders. So your moles usually have smooth orders. Right? Their color may be more variegated, meaning that it's small if you look at it. It's just usually one color, dark brownish. Right? But if you melanoma, if you look at the lesion, it's got different sort of patches of color inside. Some areas more darker than the others. So that's called bariguity. And DNE, it's growing. Right? Cancer's growing. Right? Especially, aggressive ones like molybdenumeloma. So both tend to stay the way they are. This thing is spreading. It's getting bigger over time. And there's a big tendency for these cancers to metastasize. Okay. Alright. So we're gonna finish off with external auditory canal, some disorders. Now again, some of the external auditory canal stuff we're gonna cover during syndromes along with microtia because remember the picture of microtia, they don't have an ear canal. Right? Congenital issues. K. But here's the outline for rest of today. So if you look at the ear canal, there's some things to note. So you can see that the ear canal is outer bit is lined by skin. Right? But also underneath the skin or over like the skin is cartilage. Right? If you stick your thumb in and then move around, you go to that ear canal. Right? Because it's made of cartilage. However, the inside part, skin is the ear kinda is bone knee. K? So inside part is bone and skin. Height b adherent to each other. There's nothing else. No fat, subcutaneous tissue, muscle, cartilage. Outside cartilage, that's what these white features are doing. There are other things, right, like hair follicles, sebaceous glands, where hair follicles are, which produces wax. So it all happens sort of on the distal ear canal. So the jump jump between the bony cartilaginous area of the ear canal is called the isthmus. And that's the narrowest part of the ear canal. That's when things like foreign bodies, when kids stick Lego pieces in their ear, that's where they get stuck. So wax is normal. Right? Cerumen is the medical term for wax. But if you have something like this, you're not gonna be able to see the eardrum. You're gonna have to get try to clean that out somehow or ask the person to use some, oil drops or other drops to soften the wax so it will eventually come out. But if there's some wax, you gotta learn to try to look around them. Because everyone has I'm just trying to wax as a normal thing. Now some people do irrigation flushing and stuff. Usually, family doctors do that or some providers in the emergency department. Sometimes it works, sometimes it doesn't. Usually not tolerated in kids, and you should try to make sure that the eardrum or the tympanic membrane is intact. There's no perforation there, but you can't really see the eardrum. Right? So sometimes it's hard to do. Do. But the best thing to do is to recommend some type of oil, whether it's olive oil, baby oil, whatever they have. You can buy little droppers out of the pharmacy. Use few drops a couple of times a week, and then come back in a few weeks. If you make the wax off, they should eventually sort of migrate outwards. There are other products like cerulinics. If you go to pharmacy and look look at the part of the gear where they have, gear stuff. You'll see some products that actually help with wax removal. Unclear how well they work, to be honest, but it may be helpful. So in terms of the ear canal, you can have this thing called oral atresia or oral stenosis or external auditory canal atresia or external auditory canal stenosis. So atresia means there's no ear canal. Right? There's no connection from the outside world to the eardrum and the middle ear space. So there's no ear canal at all. Now stenosis means that there is an ear canal, but it's narrow. So when you have atresia or stenosis, it's usually congenital. Usually, it could occur with syndromes, but you're you're born thin. Something happened during embryo genesis. And we'll talk more about that when we cover microchia and syndromes. Now next thing to note in the ear canal is called otopomycosis. So otopo is the ear. Mycosis means it's some type of a fungal infection. So it's actually describing fungal infection of the external auditory canal of the ear canal. And when you look, you see something like this. Very characteristic. Right? You don't see this kind of picture anywhere else. These are sort of fungal hyphae, and these are fungal elements. Sort of like black black tissue with these sort of lines and these little egg like things. These are fungal elements. Right? This looks like a bit of discharge at the back here, but you can see almost like looks like a tissue paper. Right? These are all fungal elements. Right? You're not gonna see this anywhere else. So if you know what you're looking for, you can diagnose allobacosis pretty easily. K? Now commonly, it's caused by the aspergillus species of fungus, but Candida can also affect your ear canal as well. Right? Candida is candidiasis. Very common. Babies can get it from breastfeeding and stuff. Basically, it's similar to an yeast infection. So when you have otomycosis, the person will tell you they have itchiness in the ear. They feel like their ears feel wet. Makes sense, right, with all that stuff stuck in the ear canal. Sometimes they have some discomfort, pain. Obviously, conductive hearing loss. Right? The sound does not sound energy is not hitting the eardrum, making it vibrate normally. And it may present similar to a kiteoshextron, which we'll cover. Now treatment is sometimes fungal infections are difficult to manage. You guys watch that show, Last of Us? Mhmm. Right? That's about fungus. Yeah. It's about fungus. Chordosets. I think. Chordosets. It's fungus. Right? Yeah. You don't have to get it. Smart one. Chordosets. Whatever it is. Humble infections, they can be, pretty scary actually. Right? Because they can be very invasive. Right? So sometimes it's difficult to manage. It's not like you can just get fungal medications or antifungals. Sometimes we have to see them as specialists. We have to clean out all that debris and then apply antifungal medication, get them to get them systemic antifungals as well. Especially for those who are immunosuppressed, this otomycosis can be a pretty serious infection to have. The next one is more common. Fungal infection of the ear canal is not super common unless, again, you're immunosuppressed or you're on chemotherapy. Well, tightness externa is very common. K? So tightness externa means there's infection or inflammation of the ear canal. K? That's bacteria, not fungus. So it is the most common condition that affect the ear. So there are acute acute chronic types. So the way otitis externa happens or the pathophysiology of it is shown on this slide here. So most of the time what happens is you have some type of a physical injury in the ear canal. So let's say that you're using q tips, and you abrade the ear canal skin, especially the part that's attached to bone. Right? So here's bone, here's skin, there's no give. It's stuck down to each other. So if you scrape it, then you cause bit of a cut open wound in there. And it's a bit of a deep space. Right? So it's a bit warm. Sometimes water can get stuck in there a little bit after you shower. And what happens is it becomes an environment where bacteria can actually flourish. K? When you go for hikes and stuff, you know how you see, like, mushrooms and fungus growing along wet areas? Similar to inside the ear. Right? Is swimmer's ear a type of otitis externa, or is that Yeah. So swimmer's ear so, yeah, it's a bit of a misnomer because swimmer's ear well, you can see the water exposure part. Right? But there's usually preceding injury, not just water exposure. So how many people swim? Right? Lots of people swim. Not all of them will get what type of sex term. But if they use q tips aggressively and they swim a lot, they make it swimmers here. Not the biggest fan of that term. I know that's what lay people use and that's what, you know, everyone hears. But, because you don't have to swim to get swimmers here, and sometimes it it has nothing to do with swimming. And there's a big confusion because people think, why went swimming, got water stuck in the ear, and it's painful. I have swimmers here. No. Just water being stuck in your ear. I mean, you have some sensitivity. Right? I used to get, like like, I used to swim as a kid, and then I would get ear infections a lot. Do you think it's maybe, like, water stuck in your ear, and then you're, like, trying to get it out? So that's very common. Parents come in and say, oh, my kids swims and they have ear infections. No. It's like It's not possible. Yeah. And you'll know why when we cover otitis media. Because that's an ear infection in kids. Right? So that's the problem with terms like swimmer's ear and then you go Google it and then yeah. But when you hear swimmer's ear, most people mean otitis externa, not otitis media, which is what kids get, which we'll cover, yeah, this month. So remember that I said there's acute and chronic types. So acute otitis externa is caused by this bacteria called Pseudomonas Pseudomonas aeruginosa. Called Pseudomonas aeruginosa. And this clinical features include severe autalgia. So that's the most important thing. So if you go try to examine their ears, if you sort of even gently manipulate the oracle, they're in a lot of pain. Okay? So it's a pretty severe severe pain they have. They have otorrhea. You can see discharge coming out of the ear on this patient's picture there. They can also have pruritus, and then they feel itchiness their ear swelling. Sometimes they'll have conductive ear loss because your canal was swollen and there's discharge in there. Treatment is pretty simple. You can take analgesics. So analgesics are things like alamol, Ibuprofen, anything to control pain. Antibiotic, anti inflammatory ear drops like CiproDEX, that's the most commonly prescribed medication for otitis externa. So Cipro is the an antibiotic component. It's the ciprofloxacin, which kills Pseudomonas, species. Dex is the dexamethasone, the steroid part. It's so it reduces swelling and inflammation. Now sometimes, alternative sex are not they need to see us because we need to clean out the air, suction out the drainage, and stuff. But most of the time, if you do use this, that's all you need. So most of the time, they see their family physician or they'll go to a walking clinic or even, pharmacists can now prescribe this. That's all you need. Now counseling is important for you guys. Right? If you know your client has a lot of problems with the entire sensor, what are you gonna tell them? Yeah. To, like, stop using q tips if you're doing them? Stop using q tips. Yeah. If you get water in there, you know, try to get it out. Right? So if you yeah. You've seen box of q tips. Right? What does every box of q tips say? It says do not use in the year. Right? If you look carefully at every box of q tips, it says not to be used in the years. Chronic otitis externa is similar but different in terms of the pain level. K? So the pain is not as acute and severe. So it's more of, like, a dull, low grade discomfort and pain, but the other features are similar. So discharge, orophobia, arthritis, sometimes some dryness in the ear. It's more you can sort of think of it as sort of eczema of the ear canal. Right? More of a chronic condition. Again, your ear canal may look like this. A bit red, a bit swollen, some discharge, can't see the eardrum super clearly because of the discharge. But the treatment is the same. Again, you use those simple decks eardrops. Sometimes you may need this cleaned out once in a while by specialists. Very rarely, if the otitis externa is chronic and unrelenting or it doesn't get better, then we can remove the skin and put in a skin graft, let it heal, that's called canaloplasty, but that would be extremely rare. Yes? Could this be caused by the same way as the Q form? Or Yeah. I mean, it's more of a chronic problem, but it can start up the same way. So you get a cumulative sex and it might it just never heals properly, or you may get, you know, other sort of microorganisms in there, or you may have underlying skin condition, dermatological condition. K. It's almost an almost to the end here. The next infection of the ear canal is called necrotizing externotilis. Another name is malignant externotilis. Now the name is bad because it's not malignant. It's not like it's a cancer. K? But sometimes you use these terms. There's more historic things like malignant hyperthermia, condition where you may react to anesthetics, but it's not like you have a malignancy. But, basically, this so this is when the infection from the ear canal goes into the bone. K? When you have infection of the bone, that's called osteomyelitis. That's a general term for infection of the bone. So it's affecting your temporal bone, which is where the urticulum your structures are housed. So usually, this isn't very rare. It's a very severe rare condition. Usually, it's in the elderly with some type of immunosuppression. Some such as diabetes. And it can happen with ear canal trauma or otitis de externa, which spreads deeper. Now some of these clinical features are similar to otitis externa, such as ear pain, severe otalgia, or ARIA, that's the same. However, when you look at the ear, you have this sort of fleshy looking tissue that's called a granulation tissue, k, in the ear canal. If you touch it, it's very fragile. It will start bleeding. And then they also have cranial nerve weakness, such as facial nerve weakness. Right? So it's gone in so deep that it's starting to affect your structures within the temporal bone, which we learned about 2 weeks ago, right, including the facial nerve root. It can also spread upwards and cause intracranial complications, and then, actually, you can even die from this, but thankfully, it is very rare. So, obviously, they need to be admitted to the hospital. They get intravenous antibiotics. Sometimes we have to go on and clean out all the infection. Beforan bodies are very common, especially in children. Children love sticking things in their noses, ears. Right? That's just what they like to do. Last one I had was a 2 year old who had a piece of a gummy bear in their ear canal. I asked what happened, and she said the gummy bear walked into my ear canal. So what can you say to that other than take it out? Beads are very common, as you can see there. Bugs are very common as well. Obviously, this can happen in adults or kids. Last bug I removed was a tick. I thought it was dead, but it was still moving. But they tend to like sort of tunnels and surfaces. Right? Yeah. I mean, fortunately, you have to see us to get where they move. They tend to get stuck at the isthmus, at the bony cartilaginous junction, right, where it's narrow. Exostosis is the next thing that can occur in the ear canal. So there are 2 sort of bony abnormalities that can happen in the ear canal. We're called exostosis and osteomas. They're similar but different. K? And they're both benign. So exostosis is when you have multiple bony sort of growths in the ear canal. This one is obviously more severe. Right? You can see a bony bump there, bony one here, little one there. You can just see little bit of the eardrum there. So this person would have conductive earring loss. This person's probably not. Lots of room in the ear canal, little bony outcropping there, bony prominence there. So if you touch this, it's rock hard bone with skin on top. So that's called exostosis. Usually, bilateral usually occurs near the eardrum or the annulus. K? And it's usually associated with prolonged whole bar exposure. So this is very common in surfers. Right? This is where I can be a magician. I see a patient and I see them, or you can be a magician. You see somebody and you look in their ears and you see exostosis and you go, I I bet you surf. And almost always, they'll say yes. Right? Surfers get cold ocean water exposure. Right? Here, I can see. So it's pretty common in surfers. Again, if it's bad enough like here, you can get conductive hearing loss. And if that's the case, case, we can drill out the bone, make more room so they can hear. Now, osteomas are, again, similar, but they're a different entity. This is more of a bony growth that's intrinsic to the ear canal bone. So it's usually one solitary. Remember, access to the system is multiple, and it's it was bilateral, because you get water explosion on both sides, while this is just on the right or the left side. And they may look like something like this. A little bit further away from the ear canal as well. So again, if you touch this with anything, it's oh, Typically, it doesn't cause any problems, but if you see it, you know, you should make a note of it. Okay. So the final thing is you can get a malignancy or basically some type of cancer pretty much anywhere in your body, unfortunately. Right? Anywhere you have cells, those cells can turn cancerous. K? And that includes the ear canal. Right? So malignant lesions of the ear canal, common ones include basal cell carcinoma. Right? So if you have sound exposure or sometimes the if you have basal cell at the ORCA, that may spread into the ear canal. Same thing with squamous cell carcinoma. Sometimes, again, what other cells do you have at the ear canal? Well, you have those glandular cells, right, where it produces plaques, those sebaceous glands. So those cells can turn cancerous. So that can get what we call a glandular carcinoma. So the key thing is when you have cancer or malignancy, what they do is they tend to eat away at the bone. You can see some gray eating away at the mastoid bone here, where it's supposed to be all white. White is bone, and you can see gray is eating too. Benign things tend to sort of it can spread, but it tends to push things away. But cancerous things, malignant things tends to eat away or sort of, is more invasive, eat away adjacent structures, like even. Alright. So, today, we covered external ear anomalies, or regular anomalies, congenital ones, and some of the ones are super common, like, congenital or prominent ears, but, you know, a lot of them don't really need treatment. But there are some ones that you should sort of be more concerned about, like, preauricular PIPs and PIPs because along with hearing loss, they may indicate other underlying syndromes. Again, when you see these ear findings, you have to decide who needs referral. Right? And not a lot of them will need a referral. But, again, you have to be aware of them so you can refer those ones who need referral. Right? Some of those infectious disease, skin cancer stuff. Obviously, if you recognize that they need referral. Now a lot of the stuff we covered today don't cause significant hearing issues, but we will cover atresia and ear canal stenosis, some disorders, where we start having act more common earphones. So we will see you next week, next Monday, or lecture 3.