Nipun Malhotra

Maulana Azad Medical College

Relevant Anatomy

Auricle - formed by a

framework of cartilage, except the lobule which mainly has adipose tissue

External Ear Canal (EAC)

- 24 mm in length- Lateral third is

cartilaginous, and has pilosebaceous units

- Medial third is osseous, and is devoid of pilosebaceous units

- Santorini ducts

External ear also includes the lateral part of Tympanic Membrane.

Classification

Infectious Reactive

Bacterial

Furuncle

Diffuse OE

Malignant OE

Fungal

(Otomycosis)

Viral

HZ Oticus Hemorrhagic OE

Exematous OE

Seborrheic OE

Neurodermatitis

Infection of apopilosebaceous unit

Lateral 1/3 of external auditory canal

Pathogen: Staphylococcus sp. Presents as painful well

circumscribed erythematous pustule around the hair

•Symptoms•Pain•Hearing loss

•Signs•Marked tenderness•Tragal sign•Edema, may obliterate post-auricular sulcus•Conductive hearing loss

•Treatment•Hot fomentation and analgesics•Oral antibiotics•Ichthammol glycerine 10% ear-pack

•Abcess – incision and drainage•If recurrent, rule out diabetes

Diffuse involvement of meatal skin Two factors responsible for this condition are Trauma to the meatal skin Invasion by pathogenic organisms

Pseudomonas Staphyloccus sp.

Diffuse otitis externa can be

◦ Acute◦ Chronic

Acute phase Severe pain, aggravated on jaw

movements Discharge – initially serous, later

becomes purulent Marked tenderness on

manipulation of tragus (Tragal Sign) or pinna

Decreased hearing – due to collection of debris in the canal

Otoscopy – diffuse inflammation of meatal skin

- TM - dull

Chronic Phase Itching (indicates chronic phase) Discharge – scanty, may be

absent Otoscopy – inflammed meatus,

debris, sometimes skin hypertrophies to cause occlusion of the meatus (stenotic OE)

Ear toilet – acute phase - remove exudate and debris - dry mopping, suction-clearance or irrigation

with saline - Anterior recess Medicated wicks – antibiotic-steroid combination - reduce edema and increase

absorptionAnalgesics Systemic antibiotics Chronic phase – reduce swelling and itching - icthammol glycerine

- or steroid-antibiotic creamStenosis – surgery

Fungal infection of External Auditory Canal skin

Most common organisms: Aspergillus and Candida

Clinical Features Itching – most prominent symptom Sense of fullness Watery discharge with musty odour On examination Aspergillus niger – black growth (Wet newspaper) Aspergillus fumigatus – pale blue / green growth Candida albicans – ceamy white mass

Ear toileting to remove epithelial debris &discharge

Topical antifungals- Clotrimazole Nystatin (Candida)• Keratolytics – like 2% salicylic acid to

remove infected skin

Aggressive infection of external canal, progressively spreading to soft tissues, bone of skull base and ultimately to intracranial structures

It is rare, occurs in elderly with Diabetes and in immunocompromised, very rare otherwise

It occurs secondary to Otitis externa Pseudomonas – main causative, Staph. Aspergillus – most commmon fungal cause Presents with severe otalgia, otorrhea Characteristic finding – granulation tissue at floor at osseo-cartilaginous junction Canal is occluded

Necrotising OE – spread Destruction of base of skull – spread to dura and to

intracranial structures- produces headache, vomitting

Facial nerve palsy – involved at stylomastoid foramen

Posteriorly to mastoid air cells Medially to middle ear and petrous bone Jugular foramen and temporomandibular joint – rare

Treatment Tobramycin, Ceftazidime – i.v., oral for 6 weeks Surgery- Debridement of non-viable bone and facial

nerve decompression Serial gallium scans, CT scans Hyperbaric oxygen

Viral infection – Varicella zoster, involving VII nerve Early phase – Unilateral burning pain, fever, malaise Late phase – vesicles on meatal skin, choncha, post

auricular groove, otalgia, SNHL Ramsay Hunt Syndrome – VII and VIII nerve

involvement Treatment – Acyclovir 800mg five times a day for 10 days Steroids

Postherpetic neuralgia is very common

    

    

    

    

Viral - Infuenza virus or Mycoplasmal in origin Hemorrhagic bullae on TM and skin of deep meatus Clinical Features Severe pain Serosanguinous discharge Treatment Analgesics – mainstay Role of antibiotics

Eczematous OE Occurs as allergic reaction to topical agents,

commonly neomycin, or hair sprays, shampoos etc. Presents with vesicles on choncha and external

canal with irritation and oozing

Seborrheic OE Part of Seborrheic dermatitis (of scalp) Presents with greasy scales on pinna and external

canal and itching, with similar symptoms of scalp

Neurodermatitis Caused by compulsive scratching due to

psychological factors Treatment – psychotherapy prevention of secondary infection (ear bandage may be used)

It occurs after radiotherapy Often difficult to treat Limited infection treated

like Chronic Otitis Externa Involvement of bone

requires surgical debridement and skin coverage

Complications of OE Perichondritis and cellulitis Cause – Staphylococcus Treatment – oral antibiotics

Canal Stenosis Post chronic OE, due to fibrosis and adhesions Surgery- bone is drilled and meatus is lined by aplit

skin graft

TM perforation

Malignant OE

Infections of pinna

Cellulitis and Perichondritis Post OE or trauma Distinguished by presence of induration in

perichondritis Treatment – oral antibiotics

Erysipelas Cause - β hemolytic Streptococci General infection of face

External Canal Cholesteatoma Very rare Presents as OE with a bony crater filled with

infected keratin debris, in the floor of the external canal

May be associated with OME Erosion may extend into mastoid Treatment – debridement and follow-up Differentiated from Keratosis obturans by presence

of bone erosion

Granulating OE Occurs post surgery or after treatment of OE Treatment – removal of granulations and topical

antibiotics and steroids

Recurrent Polychondritis Autoimmune disease Cartilage of ear, nose and bronchus involved Treatment – oral corticosteroids

Chondrodermatitis nodularis helicis Winkler’s disease Nodule on helix or anti-helix Treatment – excision of skin and cartilage

Lymphadenosis cutis benigna Bäfverstedt’s disease Nodule on lobule Cause – Borrelia

Thank you for the patient hearing.