4.2 External and Middle Ear_M Merven_2024.pdf

Disorders of the external and middle ear Dr Marc Merven ENT department Overview 1st lecture Otalgia and otorrhoea External and middle ear disorders causing those 2 symptoms 2nd lecture Hearing loss, tinnitus and vertigo External, middle and inner ear disorders cau...

Disorders of the external and middle ear Dr Marc Merven ENT department Overview 1st lecture Otalgia and otorrhoea External and middle ear disorders causing those 2 symptoms 2nd lecture Hearing loss, tinnitus and vertigo External, middle and inner ear disorders causing those symptoms Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Otalgia Ear pain Primary Originating from the ear Secondary or referred Distant pathology causing otalgia Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Otalgia - Secondary or referred otalgia Originates from outside the ear Most commonly – TMJ/ teeth Cranial nerve (CN) - V Other CN - VII, IX, X, C2/C3 Pharynx and larynx Nose and sinuses Cervical spine Intracranial Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Otalgia – Primary otalgia Originates from the ear External ear Pinna EAC Ear drum Middle ear Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Pinna – trauma – auricular haematoma Extravasation of blood between the cartilage and perichondrium Cartilage relies on perichondrium for nutrition If haematoma not drained early, the cartilage will resorb and be Auricular haematoma replaced by fibrous tissue Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Otitis externa Inflammation of the ear canal Herpes Zoster Oticus Viral Mringitis Bullosa Cellulitis/Perichondritis Infective Bacterial AOE Diffuse Localised (Furunculosis) ACUTE Granular Myringitis Fungal Acute Fungal OE Non-Infective Viral Infective Bacterial Necrotising / ‘Malignant’ OE CHRONIC Fungal Non-Infective Eczema Seborrhoeic dermatitis AOE – Acute otitis externa; OE – Otitis Externa Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Pinna - Perichondritis Inflammation of perichondrium Cause trauma E.g. Piercings Sport (blunt trauma) Infection Pseudomonas aeruginosa Autoimmune May cause severe damage to the ear cartilage framework Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Pinna - Perichondritis Symptoms and signs Pain Induration Erythema Oedema Fluctuant = abscess Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Complication of Perichondritis and auricular haematoma Complication: ‘Cauliflower ear’ Distortion due to cartilage (framework) being replaced with fibrous tissue Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Ramsey hunt syndrome/ Herpes Zoster oticus Shingles of the ear Varicella zoster virus dormant in the nerve or ganglion Becomes re-activated Vesicles in the pinna bowl/ EAC Associations Facial nerve palsy (CN VII) Vesicles on palate/tongue Other CN Palsy V, VIII Hearing loss Vertigo Higher risk in immuno-compromised patients Elderly, HIV, Diabetes Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe AOE - diffuse / ‘Swimmers Ear’ Pathophysiology: Trapped moisture Swimmers Humid climates Trauma to EAC Cotton buds Paper clips Pencils Match sticks Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe EAC - Acute otitis externa - diffuse ‘Swimmers Ear’ Pain on manipulation of auricle Peri-auricular lymphadenitis Otoscopy: Inflamed EAC Swollen, maybe even closed EAC TM difficult to visualize Scanty pasty discharge if any Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Acute otitis externa – localised Furunculosis Lateral EAC (hair-bearing) Pustule → furuncle Staph aureus infection Localised symptoms Severe otalgia Periauricular lymph nodes Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Acute otitis externa – fungal Otomycosis Fungal infection Aspergillus Candida species Can be a primary pathogen Or a superimposed infection Symptoms as for diffuse acute otitis externa Otalgia, Scanty otorrhoea Pruritus Fungal spores seen in EAC Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Necrotising / “Malignant” otitis externa A misnomer (It is not a malignancy) A severe infection of the EAC and lateral skull base The infection spreads through the bony-cartilaginous junction into the temporal bone Pseudomonas aeruginosa the most common pathogen Immunocompromised host Diabetes mellitus the most common HIV Renal failure etc… Presentation: Persistent/resistant OE Deep boring pain Granuloma in EAC may be seen Can progress to skull base osteomyelitis with cranial nerve neuropathies Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe EAC - Tumours More common for tumours of the skin of the pinna to enter the EAC E.g. Basal cell carcinoma, squamous cell Ca Rarely arises from the skin of the EAC Usually squamous cell carcinoma Deep boring pain Blood stained discharge Exophitic lesion filling EAC May be associated lymph node/ CN palsies Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Otalgia arising from the tympanic membrane (TM) and the middle ear Tympanic membrane (TM) Bullous myringitis Granular myringitis Middle ear Acute otitis media (AOM) Acute Mastoiditis Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe TM - Bullous myringitis Acute severe pain Mostly unilateral Bloody discharge Pain improves after discharge Clinical diagnosis Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe TM - Granular myringitis Granulations on the lateral aspect of TM Presents with Itching Otalgia (mild) Aural fullness Otorrhoea Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Acute Otitis Media (AOM): Definition: Acute onset of infection/ inflammmation in the middle ear with an intact tympanic membrane (eardrum) Causes: URTI => Eustachian tube (ET) => AOM Bacteria: Strep. Pneumonia Haemophilus Influenzae Moraxella Catarrhalis Staph. Aureus Viral Predisposing factors: Genetics, young age and non breast-feeding Exposure to ‘day care’ and passive smoking Adenoid hypertrophy and craniofacial abnormalities (ET dysfx) Allergies and reflux Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Otalgia - Acute otitis media (AOM) Clinical picture: History: Otalgia and pyrexia (Discharge & relief) (Hearing loss) Examination: 4 phases: 1. T.M. inflammation 2. Exudate(pus in ME) 3. T.M. rupture & discharge 4. Resolution Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Acute otitis media... 4 phases 1. Tympanic membrane (TM) inflammation 2. Exudate (mucopus) 3. +- TM rupture & discharge 4. Resolution Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Acute otitis media... 4 Phases: 1. TM inflammation 2. Exudate 3. TM rupture & discharge 4. Resolution Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Acute otitis media... 4 Phases: 1. TM inflammation 2. Exudate 3. TM rupture & discharge 4. Resolution Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Acute otitis media... 4 Phases: 1. TM inflammation 2. Exudate 3. TM rupture & discharge 4. Resolution Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Otalgia - Acute Mastoiditis Definition – Osteitis of the mastoid air cell system Cause - preceding AOM or sometimes cholesteatoma Clinically Symptoms and signs of infection Pain, fever Erythema and swelling over mastoid antrum (postero-superior to pinna) Pinna displaced (infero-laterally) +- Fluctuation Loss of post-auricular skin crease May present with complications Meningitis, intracranial abscesses Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Otorrhoea Pus From EAC – scanty From middle ear - profuse Blood Trauma Mixed with pus Mixed with CSF (Halo sign) CSF/Perilymph Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Non-infective OE Chronic eczematous otitis externa Can be any skin lesion Eczema Seborrhoeic dermatitis Contact dermatitis Psoriasis Lupus Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Non-infective OE Itchiness May be scanty discharge Recent change in shampoo, make-up, etc.. Canal is red, scaly, dry Lichenification (thickened skin with hyperpigmentation) if chronic Can develop secondary bacterial infection Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Otorrhoea – Purulent Chronic suppurative otitis media (CSOM) Definition: Defect/ perforation of the TM Chronic/ recurrent purulent otorrhoea No pain Classification: Without Cholesteatoma Active / Inactive With Cholesteatoma With Mycobacterium Tuberculosis (TB) Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe CSOM - The nature of the types Without Cholesteatoma: TM perforation Intermittent infection With Cholesteatoma: Skin in the middle ear (ME) Desquamates into ME Defect in TM where skin goes in TB: TB infecting TM and ME soft tissues Bone Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe CSOM – without cholesteatoma Recurrent/ intermittent otorrhoea Presence of a chronic TM perforation A fistula between skin of the drum and mucosa of the middle ear Therefore unlikely to heal spontaneously Organisms involved when active Pseudomonas aeruginosa Staph aureus Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe CSOM – with cholesteatoma Presence of skin (stratified keratinized squamous epithelium) in the ME (normally lined by non-keratinized squamous and ciliated columnar epithelium) Pathophysiology: Poor aeration of ME (poor ET function) Creates a negative ME pressure Causes a retraction pocket in the TM Pulls the skin (EAC layer of TM) into the ME cavity Desquamated keratin collects in ME cavity and cannot migrate out of ear Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Cholesteatoma: Skin/debris where it does not belong - deep to TM! Site of TM defect Pars flaccida Postero-superior marginal “Sentinel” or inflammatory polyp Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe TB ear Otorrhoea non-responsive to Rx Exposed bone and ossicles Multiple perforations CN VII (facial nerve) palsy In 50% of cases patients will have disseminated TB or pulmonary TB (PTB) “In South Africa, a person with a runny ear and a facial nerve palsy has TB until proved otherwise” Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Bloody otorrhoea - Traumatic perforation of the TM Causes: Penetrating injury Pressure(diving or flying)/explosion Skull base fracture Clinically: Bloody otorrhoea May be hearing loss May be balance fallout Blood in EAC TM Perforation Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe CSF otorrhoea – skull base fracture Battle sign (mastoid bruise) Racoon eyes (periorbital bruising) CSF Otorrhea/Rhinorrhea (Halo sign) Hemotympanum Hearing loss CHL: TM Rupture/Ossicular chain disruption SNHL: Cochlear injury Nystagmus / Vertigo – if vestibular apparatus affected Facial nerve palsy – if # line though FN canal Halo sign Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Barotrauma Difference in pressure between environment & ME => barotrauma Causes: Descent – Atmospheric pressure +; relative vacuum in M.E. Ascent=>air escapes passively Reversed when diving (outside pressure increases on descent) Valsalva/equalization allows pressure to equalize between the ME and the surrounding pressure through the ET Factors: E.T. Inherent URTI etc Active opening Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Ear diseases that may never present Otitis media with effusion Otosclerosis Tympanosclerosis Exostoses Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Otitis media with effusion / middle ear effusion / “glue ear” Definition: Condition where fluid accumulate middle ear, behind intact TM. Causes: Inadequate ventilation by ET Adenoid hypertrophy Following episode of AOM Incidence: Very common in children Due to anatomy of ET Eustachian tube problems Cleft palate, nasopharynx tumours Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe  Middle ear effusions/ glue ear/ otitis media with effusion (OME): OME causes impairment of the ear drum movement Present with mild / moderate conductive hearing loss Occurs mainly in children May present with speech impairment Otoscopy – Intact TM Dull TM, air-fluid level Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Middle ear effusions/ glue ear/ OME Unusual in adults: May be as a result of preceding AOM If unilateral and persistent in an adult Nasopharyngeal carcinoma is a possible cause of ET dysfunction Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Otosclerosis Abnormal bone fixes stapes footplate Familial/spontaneous Conductive hearing loss Usually bilateral, with no cause No trauma No previous ear infections Normal, mobile eardrum Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Tympanosclerosis Scar tissue in tympanic membrane Middle layer of the drum Usually has normal drum mobility Normal hearing Occasionally involves the ossicles Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Exostoses of EAC “Surfer’s ear” External auditory canal partially/near completely obstructed by bony overgrowth As a result of prolonged exposure to cold water and wind Seen in surfers and swimmers Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe Thank you! Medicine and Health Sciences · EyeNzululwazi ngezoNyango neMpilo · Geneeskunde en Gesondheidswetenskappe