EXTERNAL

EAR DISEASE

Types Features Tx
CONGENITAL Atresia of external canal -failure of development in ear due to shallow -hearing assessment done (TPA, OAE)
blind pit or complete absence of canal -bony anchored hearing aids
-a/w microtia -titanium implants to mount prosthesis
-failure of canalisation of the core that fills the
first branchial cleft
-external meatus maybe blocked with bone or
fibrous tissue
-tympanic membrane normal

Colloaural fistula --abnormality of first branchial cleft
-two end connection
-one opening at neck behind angle of mandible
with the other end in external ear

TRAUMA Laceration






WAX
- Wax is composed of secretion of sebaceous glands, ceruminous glands, hair, desquamated epithelial debris, keratin (shed from TM and bony
meatus) and dirt.
- Sebaceous and ceruminous (modified sweat glands) open into the space of the hair follicle
- Sebaceous gland : fluid rich in fatty acids
- Ceruminous gland : rich in lipids and pigment granules
- Fx : protection, lubricates ear canal and entraps any foreign material that enter the canal.
- Normally, only a small amount of wax is secreted, which dries up and is later expelled from the meatus by movements of the jaw
- Retention of wax (dry and form hard plug) : sweating may cause excessive wax to be secreted and deposited as a plug in the meatus
: narrow and tortuous ear canal
: stiff hair or obstructive lesion of the canal, e.g. exostosis


INFLAMMATION

Types Features Sign and symptoms Tx

Symptoms Early
Bacterial Localised OE (furuncle) -severe pain disproportionate to -systemic antibiotics, analgesia
-staphylococcal infection size of furuncle -ear packed with 10% ichtammol
of hair follicle only in -movement of pinna painful glycerine provide splintage and
outer cartilaginous part of -jaw movement cause ear pain reduce pain ; glycerin edema
external canal -furuncle in post meatal wall
cause edema of mastoid with Abscess
obliteration of retroauricular -I & D
groove
-preauricular LN enlarged and Recurrent furuncle
tender -TRO diabetes, staph carrier with
nasal swab

 Aetiology Acute phase Early tx
Diffuse OE -trauma to meatal skin -hot burning ear pain worsened Aural toilet
-diffuse inflammation of -invasion by pathogenic by jaw movement -removal of debris and exudate from
meatal skin that may organism -thin serous discharge that later external canal
spread to pinna and -secondary to OM, allergy to become thick and purulent -dry mopping w absorbent cotton
epidermal layer of TM topical meds -meatal lining swollen, buds
-break in continuity of skin edematous -suction clearance under microscope
lining lead to introduction RF -conductive deafness : collection -irrigation with warm saline
of foreign bodies -excessive sweating changes of discharge and debris in -anteriorinferior meatal recess must
the acidic ear canal to alkali meatus be cleaned properly
(prone to pathogen growth) -itchiness
Complication -trauma from scratching ear -regional LN enlarged Medicated wicks
-cellulitis canal with pin, unskilled -later, discharge dries up and -gauze wick soaked in antibiotic
-perichondritis instrumentation to remove FB become crust steroid preparation n inserted into
-medial canal fibrosis -skin disease like eczema, ear canal
psoriasis Chronic phase -antibiotics ear drops must be done
-irritation and strong desire to BD/TD to keep the gauze moist
Pathogen itch. -gauze changed everyday for 3/7
-staph aureus -responsible for acute -local steroid relieve pain and edema
-pseudomonas pyocyanea exacerbations and reinfection -aluminium acetate/silver nitrate in
-e.coli -discharge is scanty and may dry wick form to dry up oozing discharge
-proteus vulgaris up to form crusts
-meatal skin which is thick and Systemic antibiotics
swollen may also show scaling -in acute lymphadenitis/ cellulitis
and fissuring
-rarely, the skin becomes
hypertrophic leading to meatal Late Tx in chronic phase
stenosis (chronic stenotic otitis -10% icthammol glycerine wick to
externa). reduce swelling

 - chronic stenotic otitis externa
surgically excised ; bony meatus is
widened with a drill and lined by
split-skin graft

Fungal Otomycosis Pathogen Symptoms Ear toilet
- Aspergillus niger -intense itching -remove all discharge/epithelial
-fungal infection of -A. fumigatus -discomfort/ ear pain debris syringing, suction or dry
external ear canal -Candida albicans. -watery discharge with a musty mopping.
-secondary in pt using odour
topical antibiotics for RF -ear blockage Antifungal x 1/52
treatment of OE/ASOM -hot humid climate -meatal skin inflamed, red and -Nystatin (100,000 units/ml of
(tropical) oedematous. propylene glycol) against Candida
-fungal mass may appear white, -broad spectrum antifungal agents
brown or black and has been clotrimazole and povidone iodine
likened to a wet piece of filter -2% salicylic acid in alcohol
paper. (keratolytic agent which removes
superficial layers of epidermis, and
Types of org along with that, the fungal mycelia
-A. niger ; black-headed growing into them
filamentous growth
-A. fumigatus ; pale blue/ green -ear kept dry
-Candida ; white/creamy deposit -bacterial infections are often a/w
otomycosis, and treatment with
antibiotic/steroid preparation
reduce inflammation and oedema
;permitting better penetration of
antifungal agents.
Otitis externa haemorrhagica -formation of haemorrhagic -severe otalgia -Analgesic
bullae on the tympanic -blood-stained discharge when -Antibiotics for secondary infection
membrane and deep meatus the bullae rupture of the ear canal, or middle ear (bulla
-viral in origin and may be seen has ruptured into the middle ear)
in influenza epidemics.

Malignant (necrotising) OE -inflammatory condition -severe otalgia/otorrhea Ix
caused by pseudomonas, -presence of granulation tissue -ESR
-lateral skull base osteomyelitis rapidly progressive and spread in meatus -technitium bone scan
-usually in the elderly diabetics/ on to skull base and intracranial -facial paralysis, intracranial
immunosuppressive drugs structures infection : headache, neck stiff Tx
-infection at junction between -fail to respond to the usual -high doses of iv antibiotics for 6-8
cartilaginous and bony part of EAM antibiotics treatment Infection may spread wks against pseudomonas
-early manifestations resemble : inferiorly to the skull base (ciprofloxacin, ticarcillin or third
diffuse otitis externa but there osteomyelitis and jugular generation cephalosporins)
is excruciating pain and foramen causing multiple CN -hyperbaric oxygen therapy
appearance of granulations in palsies -diabetes control
the meatus. : anteriorly to -surgical debridement of devitalised
temporomandibular fossa tissue and bone should be done
: posteriorly to the mastoid
: medially to the middle ear and Monitor
petrous temporal bone -ESR
-galium bone scan

Eczematous otitis externa -hypersensitivity to infective -intense irritation -withdrawal of topical antibiotic
organisms or topical ear drops -vesicle formation causing sensitivity
such as chloromycetin or -oozing and crusting in the canal -steroid cream
neomycin
 Seborrhoeic otitis externa -seborrhoeic dermatitis of the -itching -ear toilet
scalp -greasy yellow scales seen in -application of a cream containing
external canal (over lobule and salicylic acid and sulphur,
postauricular sulcus) -scalp treatment for seborrhoea

MISCELLANEOUS

Features Symptoms Treatment

Impacted wax/cerumen Excessive wax secreted and -impairment of hearing -removal of wax by ear syringing or
deposited as a plug in the meatus -sense of blocked ear instrumental manipulation
-tinnitus and giddiness (impaction of wax -hard impacted mass may sometimes
Factors a/w against TM) require prior softening with wax
-sweating -reflex cough due to stimulation of solvents (olive oil, drops of 5% sodium
-narrow and tortuous ear canal auricular branch of vagus may sometimes bicarbonate, hydrogen peroxide)
-stiff hair or obstructive lesion of occur. -instrumental manipulation by
the canal (exostosis) cerumen hook/probe
-onset of symptoms may be sudden when
water enters the ear canal during bathing
or swimming and the wax swells up
-long standing impacted wax may ulcerate
the meatal skin and result in granuloma
formation (wax granuloma).

Foreign bodies Non-living -foreign bodies swell up with time (i) Forceps removal
-paper or sponge -tightly impacted in the ear (ii) Syringing
-grain seeds (rice, wheat, maize) canal/suppurate (iii) Suction
-metallic ball bearings
 (iv) Microscopic removal with special
Living -intense irritation and pain instruments
-Flying or crawling insects like -insect should be killed by instilling oil (a (v) Postaural approach
mosquitoes, beatles or an ant household remedy), spirit or chloroform
enter the ear canal water


Maggots in the ear -once killed, insect removed by -instilling chloroform water to kill the
-foul-smelling ear discharge maggots; later removed by forceps
-severe pain with swelling round the ear -syringing may not be advisable
-blood-stained watery discharge
-maggots seen filling the ear canal
-discharging ears with perforation of the
tympanic membrane
Acquired atresia and It can result from: -meatoplasty
stenosis of external -Infections ; chronic otitis externa -using a postaural incision, scar tissue
meatus -Trauma ; lacerations, fracture of and thickened meatal skin are excised,
tympanic plate, surgery on ear bony meatus is enlarged and the raw
canal or mastoid meatal bone is covered with pedicled
-Burns ; thermal or chemical flaps from meatus or split skin grafts.