external ear diseases

7/25/2019 External Ear Diseases

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NON-INFLAMMATORY DISEASES AND INJURIES OF THE EXTERNAL EAR

Description Etiology/Pathogenesis Signs and Symptoms Treatme

Prominent Ears aka Protruding Ear

Increased angle in protruding ear Normal: 20-

30

Normal congenital variant

No functional consequences

Deep concha

Lack of development of the

antihelix

Surgery: concha is reduced a

constructed done usually at

general anesthesia

Cerumen Impaction Cerumen:

Produced by ceruminous and sebaceous glands

in the skin of the ear canal

Forms a protective film

Protective function of cerumen:

Acts as a vehicle fir the removal of epithelial

debris and contaminants away from t he

tympanic membrane

Provides lubrication and prevents dessication

of the epidermis with its associated fissuring

Fatty acids, lysozyme, and immunoglobulin

components are believed to be inhibitory or

bactericidal

Self cleansing of the ear canal: epithelial

migration from the tympanic membrane

towards the external meatus

The migration of the stratum corneum

contribute to the formation of the cerumen

ThepH of the combined ingredients is around 6 ,

an additional factor that acts to prevent infection

Excessive cerumen secretion

Disturbance of the normal self-cleansing mechanism

Cleaning using Q tips, aging,

decreases sebaceous secretion;

not advised

There is a general tendency for

cerumen to be drier in older

individuals because of physiologic

atrophy of apocrine glandswith

subsequent lessening of the sweat

component of the cerumen

Pressure sensation in the ear

Hearing loss

Vertigo

Tinnitus

Otoscopic findings:

Obstruction of the ear by a

yellowish-brown to black material

Removal with a small inst

currette)or by aural irriga

cannula

Give cerumenolytic (wax s

to soften cerumen prior to

IRRIGATION:

body temperature water is a

postero-superior direction to

pass between the cerumen

posterior wall of the canal. A

several irrigations the patien

blockage, suction is occasion

Do not hit the tympanic m

perforation

Avoid irrigation if a tympaniperforation may exist

Prophylaxis:

Avoid improper cleaning o

The most effective method t

by the patient is not clean it

Foreign Bodies in the Ear Canal Children: small play objects (beads, pellets,

erasers)

Adults: noise-reducing ear plugs, objects used for

manipulations in the ear canal like cotton, insect

Cockroach: most common foreign bodies in the

ear canal in adults

Complications:

Middle and inner ear damage

secondary to tympanic membrane

perforation

Secondary otitis externa

Removal of foreign body

1. Do not remove insect righ

with baby

oil and when it is paralyzed,

forceps.

2. Do not use forceps when

objects because it will only mdeeper. Irrigate instead usin

3. Contraindication for irrig


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membrane perforation, tem

ear surgery

4. Button Batterydo not u

removal

because its electrical charge

the fluid,

causing severe alkali burn

Auricular Hematoma/ Auricular

Seroma

A collection of blood of serous fluid between the

perichondrium and auricular cartilage

This condition is most frequently seen in

wrestlers and boxers

Blunt trauma (e.g. from contact

sport)

Skin and attached perichondrium

separate from the auricular

cartilage

If injury remains close, hematoma

or seroma formation

Signs and symptoms:

Pain

PE findings:Swelling and fluctuation of the skin

over the lateral auricular cartilage

Complications:

Perichondritis secondary to

aspiration which can lead to

infection

Cauliflower ear

Surgical Evacuation; aspira

drainage of collected blood

conditions

Contoured dressing: cotto

with oil so as not to have an

hematoma/seroma

Injuries to the External Auditory Canal Usually there is history of trauma Foreign bodies

Harmful manipulations

Sign and Symptoms:

Tender meatal skin

Bleeding from the ear canal

Otoscopic findings:

Epithelial injury

Bleeding Hemorrhagic bulla

Crusted blood

Complications:

Secondary infection

Cyst formation or stenosis of ear

canal secondary to

scarring

Reapproximation of detac

Packing of the ear with Ge

bleeding

Traumatic Tympanic Membrane

Perforation

Probing of ear canal with a Q-tip

Forceful syringing of the ear for cerumen of

foreign

bodies

Forceful change of air pressure in the ear canal

(e.g. Blast injury, blow to the head)

Sudden pain

Bleeding

Tinnitus

Hearing loss

Cautery of edges with silv

trichloroacetic acid

Paper patch to act as scaf

Myringoplasty: may be n

healing or for larger perfo

Optional: otic drops

Most linear tears heal spont


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INFLAMMATORY DISEASES OF THE EXTERNAL EAR

DESCRIPTION ETIOLOGY/PATHOGENESIS SIGNS AND SYMPTOMS T

ECZEMA AND DERMATITIS OF THE AURICLE An inflammatory condition of the

auricle confined to the

dermis

Differentiation between a primary

dermatosis and

infection may be difficult (for

example: seborrheic dermatitis vs.

Skin reaction to neomycin)

Jewelry items

Soaps and Cosmetics

Listening aids

Thermal injury

Itching

Burning with little pain

Skin is erythematous and may be dry and scaly

or moist and weeping

Contours of the auricle remain unchanged

Complications:

Pyoderma

PerichondritisCellulitis

Eliminate

Antibiotic

superinfec

When a co

the auricle

lesion see

dressing u

Burows m

48 hours, fluorinate

solution a

PERICHONDRITIS OF THE AURICLE An acute inflammation of the skin and

perichondrium that also involves the

auricular cartilage

Develops when trauma or

inflammation causes an

effusion of serum or pus between the

layer of the perichondrium and the

cartilage of the external ear

Changes are localized (do not spread

beyond auricular cartilage)

Caused by a bacterial infection

stemming from a small injury in the

conchal cavity or auricle

Staphylococcus

Pseudomonas

Severe pain of rapid onset

Feeling of tension

Effaced auricular contours, earlobe is spared

Swelling of the concha with marked tenderness

Painful and enlarged regional LNs

Fever

Complication:

Cartilage destruction with permanent auricular

deformity (cauliflower ear)

Systemic a

and Pseud

Incision a

Cleansing

canal

Applicati

antibiotic

ointment

NSAIDs

AURICULAR CELLULITIS An acute streptococcal infection of the

subcutaneous tissue involving the

auricle and its surroundings

Streptococci gain access to the auricle

through small injuries in the concha

or external meatus

Redness, swelling and warmth of the auricle and

its surroundings

Earlobe and adjacent facial skin are involved

Malaise with fever and otalgia

DDx:

Dermatitis - no fever and systemic effects

Perichondritis - surrounding tissues and earlobe

are NOT involved

Zoster oticus - concomitant involvement of CN VII

High-dose

preferabl

NSAIDs

Cleansing

canal


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HERPES ZOSTER OTICUS RAMSAY HUNT SYNDROME

The onset of facial paralysis, when

accompanied by otalgia and a

herpetic eruption involving portions

of the external ear is caused by a

viral infection involving the

geniculate ganglion

Caused by reactivation of the

dormant varicella zoster

virus in ganglion cells

Involves CNs VII &/or VIII

(occasionally IX & X)

Vesicular skin involvement may be

limited to the specific area of the

external ear canal innervated by a

small sensory branch of the CN,

extend to the auricle or have faded

by the time the patient is seen

Ear pain or burning on one side in the absence of

PE findings vesicles erupt hearing loss,

vestibular complaints, facial nerve palsy

Other combinations of symptoms may exist

owing to progressive involvement of vestibular

and acoustic fibers of the eighth cranial nerve

PE findings:

Herpetiform vesicles on the meatus and concha

and occasionally on the pinna

Lymphadenitis

Facial nerve palsy

Complications:

Secondary bacterial infection (Staphylococci or

pseudomonas

Zoster meningoencephalitis

Neuralgia

Systemic t

Corticoste

Local Antis

Treatment

DIFFUSE OTITIS EXTERNA AND ECZEMA OF

THE EAR CANAL

An inflammatory condition of the

external auditory canal

involving the canal skin (eczema,

dermatitis due to mechanical injury,

toxicity, or allergy) acute bacterial

infection of the skin

Also known as swimmers ear

Occurs during hot, humid weather

Gm (-)predominantly Pseudomonas

and less oftenStaphylococcus albus,

E. coli, and Enterobacter aerogenes

Anaerobes

Itching

Pain (severe)

Crusting

Purulent discharge

Conductive hearing loss

Presence of tender regional adenopathy

Tragal tenderness

The stroma overlying the bone of the inner third of

the canalvis very thin, allowing minimal room for

swelling. Thus, thesubjective discomfort the patient

experiences is often out ofproportion to the extent

of the disease visualized

Absence of acute infection:

o Dry, cracked and scaly canal skin

o Thickened skin with sites of desquamation

Presence of acute infection:

o Diffuse swelling of the canal skin with discharge

or crusting

Meticulou

and drying o

Antiseptic

Due to the

wall edema,

to bring med

with most of

Only sever

drugs be con


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CIRCUMSCRIBED OTITIS EXTERNA Confined to the fibrocartilaginous

portion of the external auditory

meatus (furuncle)

Circumscribed lesion caused by an

acute bacterial infection of the

cartilaginous portion of the ear canal

Pathogenesis:

Local mechanical trauma and

contamination of the ear canal

Obstruction of the hair follicles or

glandular ducts

Staphylococcal infection of the

pilosebaceous units (usually

aureus or albus)

Very painful, tender swelling

Mild hearing loss secondary to swelling

Otorrhea

Afebrile

PE findings:

Tragal tenderness

Pronounced swelling of the ear canal with debris

In severe cases, surrounding cellulitis may extend

beyond this area

Eventually, abscess formation occurs and apoint mayform, at which time drainage can be

establishes by needle

Treatmen

furuncle s

reaction

Meticulo

canal

Antibioti

drops

NSAIDs

Systemic

Heat

NECROTIZING OTITIS EXTERNA Malignant otitis externa

Exclusively in older patients with DM

Common in warm climates

A severe infection involving the

temporal bone and soft

tissue of the ear

Patients with otitis externa (OE) for

more than 2 weeks

should be evaluated for NOE

Simple OE

Infection with Pseudomoas

aeruginosa

Ulceration and osteitis on the floor of

the ear canal

Spread to the middle ear, skull base,

retromandibular fossa

and parotid compartment

Insiduous, persistent OE that does not heal

Moderate pain which may become severe

Fetid aural discharge

Local deb

of the ea

High dos

against P

(systemic

of therap

admitted

Close mo

DM

Surgical r

bone in ucases

OTOMYCOSIS Common in tropical countries

Due to cleaning ear with

contaminated implements

Common DM and

immunocompromised patients

May occur in conditions when the

normal flora is affected, such

overuse of certain topical antibiotics

particularly with steroid combination

Aspergillus (niger and flavus)

Candida albicans

Pityrosporum

Severe itching

(with manipulation, can lead to trauma and

eventually secondary bacterial infection)

Ear fullness

Thorough

ear canal

Local antim

Systemic a

immunoco

patients


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TUMORS OF EXTERNAL EAR

Keloids Basal Cell Carcinoma Squamous Cell Carcino

Very common benign tumor

Massive overgrowth of reparative (scar) tissue

Rare complications of earring use

Occur more commonly in African-American

A common skin CA

Caused by chronic exposure to sunlight

Usually occurs in older men on the

superior portion of the pinna

Treatment:

Surgical excision followed by repeated steroid injections

Appraise patient that keloid may grow back

Treatment:

Complete excision with histologic control of margins (of about 1 cm)

Primary goal: remove the tumor

Secondary goal: reconstruction

Treatment:

Complete excision with histologic

margins, may require auricular rese

Primary goal: remove the tumor

Secondary goal: reconstruction

external ear diseases

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