OTORHINOLARYNGOLOGY

LECTURE: External Ear

LECTURER: Dr. Alejandro P. Opulencia
DATE: January 9, 2017
TRANSCRIBER: Group Number 3 (Lapostre 09271385847), Lechago,
Legaspi, Liban, Lim, P.
EDITOR: Nhor Robles (09178704163)

OUTLINE  Why ears are considered “S” organs? Ears are

I. External Ear sensitive organs.
A.Functions of the Ear  Mongolian and Indian Mythology – Legends of
B.Disease of the External Ear cutting ears of thieves will render them sterile
C.External Auditory Canal  Hippocrates
II. Non-inflammatory Diseases of the External Ear o Father of modern medicine
A.Impacted Cerumen o Thought that the semen passes via a
B.Laceration vein behind the ears and ultimately to
C.Frostbite the genitalia
D.Hematomas
E. Foreign Bodies 2. Increase in life expectancy
III. Infectious and Inflammatory Diseases of the External  Old man with big ears – “big ears extend life
Ear expectancy”
A. Otitis Externa o The ear grows bigger relative to the
B. Furunculosis face. The older you get, the bigger your
C. Diffuse Otits Externa ears become but it doesn’t mean that
D. Otomycosis the bigger the ear, you’ll have a long life
E. Herpes Zoster Oticus
F. Dermatoses (Eczematous Dermatitis) o Truth: The bigger the ear, the better the
G. Necrotizing External Otitis hearing due to increase in sound
H. Relapsing Polychondritis conduction from the pinna to the middle
IV. Cyst and Tumors ear  also the reason why people put
A. Exostoses their hand to their ear to supposedly
B. Osteoma improve hearing
C. Adenoma
D. Cholesteatoma
E. Keratosis Obturans B. Diseases of the External Ear
F. Squamous Cell Carcinoma 1. Congenital Malformations
G. Malignant Melanoma a. Aural Atresia and Stenosis
H. Adenoid Cystic Carcinoma  Occur in 1 in 10 000 live births
I. Basal Cell Carcinoma  Malformation from the first and second branchial
J. Keloid arches and first branchial cleft
 May occur in isolation or in combination with other
OBJECTIVES: craniofacial syndromes
No objectives were given in the lecture.  1/3 of cases are bilateral
 EAC stenosis predispose to canal cholesteatoma
References (APA Bibliography format): o Condition wherein keratinizing squamous
2018A Transcription epithelium is found at an abnormal location
Lecturer’s ppt o Bone is then destroyed through an
inflammatory osteoclastic process
Legend: Italicized – quoted from the lecturer; bold – emphasis, o Frequently associated with auricular anomalies
or from references o Not usually treated surgically
I. EXTERNAL EAR
b. First Branchial Cleft Anomaly
A. Functions of the Ear  Type I
o From ectoderm of first brachial cleft
1. Hearing o Represents a duplication of membranous
2. Balance EAC
3. Pressure Equalization o Posterior, inferior and medial to conchal
4. Decoration cartilage
5. Procreation o May open into EAC itself
6. Increase Life Expectancy  Type II
o Both ectodermal and mesodermal elements
Ancient Functions: from first and second branchial arches
1. Decoration o Anterolateral neck, anterior to the SCM
2. Procreation o Often course over the mandible, through the
 Ears serve as the female organ of generation parotid toward the bony-cartilaginous junction
 This thought originated from the belief that Virgin of the EAC
Mary’s conception was caused by the breath of  Rare, 1% of all branchial cleft anomalies
the Holy Ghost into her ear  Failure of normal obliteration of ventral portion of

TRANSCRIBER: Trans Group 3 (LAPOSTRE 09271385847) EDITOR: Nhor Robles (09178704163) Page 1 of 11
OTORHINOLARYNGOLOGY: 1.01 External Ear (Dr. Opulencia)
the 1st branchial cleft
 Cyst, sinus, or fistula may develop
 Asymptomatic, noticed as a result of an infection,
and may require incision and drainage
 Tx: Complete surgical excision with preservation of
facial nerve
2. Classification of External Ear Anomalies
 Group 1: Minor Malformations
o Commonly seen in craniofacial dysostoses,
which is a defect in bone development,
particularly ossification
o Auricle is usually normal but may exhibit some
variation
o EAC may be normal but occasionally
hypoplastic in its entire length
o Tympanic membrane can be normal with
regular canal
o Handle of malleum often is deformed and in
abnormal position
o The middle and inner ear are intact
o Inner ear is usually normal except in rare
cases
 Group 2: Moderate Malformations (Mild Microtia)
o Encompasses majority of ear deformities
o Auricle are usually abnormal except in rare
cases and is often represented as a small
rudimentary tissue (microtia)
o EAC is either hypoplastic or aplastic
o Tympanic bone may be present or absent
o Ossicles may be anomalous or malpositioned
o Inner ear may be abnormal in most cases
o Tx: Some people will go for a middle ear repair
which provides a 10%-15% success rate; as
long as the other ear is fine, the patient may
have a good prognosis
 Severe Malformations (Microtia and Anotia)
o Associated commonly with severe craniofacial
malformations
o Auricle severely malformed or even absent
o Middle ear and mastoid may be absent and
present as slit-like lumen
o Ossicles are also frequently absent
o Inner ear abnormalities can involve
semicircular canals, cochlea, or vestibule
o Only the vestigial organ may be present
o People who have these malformations will
have some sort of hearing loss: conductive or
neurosensory hearing loss. Some of them may
not have the middle or inner ear
o Treatment: Repair is useless for there is
already nothing to repair – the middle and
inner ear are already absent
C. External Auditory Canal
 2.5 cm to 3.5 cm
 It dictates the pain, signs and symptoms of the ear
a. Cartilaginous portion
o Anatomically and functionally continuous with the
auricle
o If either the auricle or external auditory canal (EAC) is
diseased, the disease may travel to the unaffected
part, and can spread from the auricle to the EAC or the
TRANSCRIBER: Trans Group 3 (LAPOSTRE 09271385847) EDITOR: Nhor Robles (09178704163)
EAC to the auricle 

o Lateral (outer) 1/3 of EAC
o It is angled downward and forward relative to medial
1/3.
o In otoscopy, the mobile cartilaginous part is pulled
posterolaterally to straighten the canal.
o The direction of the canal is upwards-backwards-
downwards-forwards
o In infants, the cartilaginous portion is shorter than the
bony portion
b. Bony portion
o Inner 2/3 of EAC
o Formed by tympanic part of temporal bone
o The ONLY place in the body where there is skin
directly overlying the bone with no subcutaneous
tissue.
o Has very thin skin that directly overlies the periosteum,
which accounts for the temperature and pain
sensitivity felt by the patient
c. Earwax (Cerumen)
o Antibacterial and antifungal properties
o Moistens the canal and coats the hair
o Trap dust, small insects, and foreign bodies from
entering the ear
o Mildly acidic
o From sebaceous glands in ear canal’s skin
o Fatty acid, lysozymes and creation of an acid milieu
effectively protects the skin of the ear canal
o Self-cleansing of the ear canal occurs when there is
epithelial migration from the tympanic membrane to
the external meatus
o Without the earwax, one is more prone to infection.
 Itchy ear is due to scaling and scabbing
o Putting soap and water into ear when taking a
bath makes the ear neutral or alkaline. Thus
increasing the susceptibility for fungal infection.
Remember: Do not put anything inside your ear that is smaller
than your elbow. All the manipulations may lead to impacted
cerumen, infection, laceration and perforation of the tympanic
membrane.
II. NON-INFLAMMATORY DISEASES OF THE EXT. EAR
A. Impacted Cerumen
 Results from disturbance of the normal self-cleansing
mechanism or excess cerumen secretion
 Imprudent cleaning interferes with self-cleansing
mechanism and displaces the cerumen toward the tympanic
membrane
 May cause obstruction of the ear canal after contact with
water
 Hard cerumen may be retained in a narrowed canal when
aging, drying of the meatal skin, and changes in secretions
occur
Symptoms:
 Pressure sensation in the ear with concomitant hearing loss
 Vertigo and tinnitus
Diagnosis:
 Otoscopy may show obstruction of the ear canal by a
yellowish brown to black material.
 The consistency of the cerumen is variable.
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OTORHINOLARYNGOLOGY: 1.01 External Ear (Dr. Opulencia)

temporomandibular joint, and skull base should be

Differential Diagnosis:
 An epithelial plug or crust from a cholesteatoma
 Thin skin flap or cuticle obstruction
 Tumors, foreign bodies, crusted blood
Treatment:
 Mechanical extraction under direct vision
 Aural irrigation
o Soften hard cerumen with hydrogen peroxide, glycerine-
containing agent or other fetergents for days
o Irrigate ear with pure water at 37oC using an ear syringe
with a blunt cannula
o Jet water posterosuperiorly not directly at tympanic
membrane
 Follow-up with otoscopy and tuning fork test
 Contraindications (referral to specialist)
1. Positive otologic history
2. Single hearing ear affected
3. Restless, uncooperative patient
4. Foreign body
Instrumental Removal of Impacted Cerumen:
 Softened using eardrops, oil or hydrogen peroxide, followed
by mechanical removal under direct visualization or
irrigation.
 Do NOT irrigate canal if the tympanic membrane is
perforated
 Migrating ink Dot – ink is placed in the center
of the eardrum; migration occurs and ink can be found at
the periphery of tympanic membrane
Prophylaxis
 Avoid improper cleaning of the ear canal especially regular
use of cotton-tipped swabs
 Never put small objects, you should only clean the crevices
 Never use organics if you insist on cleaning, it can cause
fungal growth
 Cotton buds should not be inserted inside the ear.
excluded
Complications:
 Secondary infection
 Cyst formation or stenosis of the ear canal due to scarring
during healing process
Treatment:
 Approximate detached epithelium if possible
 Pack the ear canal with Gelfoam or synthetic sponge if
bleeding
Prognosis:
 Isolated injuries to the ear canal are usually uncomplicated
and show a good healing tendency
Figure 2: Auricular Laceration
C. Frostbite
 Soft tissue and cartilage are frozen
 Injury secondary to direct cellular damagre and
microvascular insult leading to local ischemia
 Initial management includes rapid warming and antibiotics
 Surgical debridement delayed
 The first part of the ear that gets frozen is the pinna. During
cold weather, occasionally feel for your pinna to check if it
has not fallen off. Frostbite is very painful.
o The pinna has no subcutaneous fat.
o It is very susceptible to damage due to cold weather.
ALWAYS COVER EARS IN FREEZING WEATHER!!!

Etiology:
 Frequently occurs on the auricle because it is exposed and
inadequately protected from cold
 Confined auricle burns are rare
Diagnosis:
Figure 1: Impacted Cerumen (L); Migrating Ink Dot (R)  Frostbites may appear initially as white skin discoloration
B. Laceration  May go unnoticed until frostbitten area is rewarmed
 Commonly due to manipulation  Check for involvement of the ear canal and tympanic
membrane
 If minor  no intervention necessary
Differential Diagnosis:
 For several lacerations, exploration is done.
 Prophylactic antibiotics are given if there is contamination  Caustic chemical injuries
of wound or cartilage exposure.  Electrical injuries
 Lacerations from trauma (e.g. ear pinching, human bites) Complications:
 Etiology: foreign bodies or harmful manipulations  May cause cartilage necrosis and permanent deformity if
thermal injury is deep
Diagnosis:  Chilblains may develop on the helical rim with ulcerations
 History or ear trauma and itching
 Meatal skin is tender, bleeding from the ear canal  Perichondritis
 Otoscopy reveals epithelial injury, bleeding, hemorrhagic
bulla, or crusted blood. Treatment:
 Associated injuries to the tympanic membrane, middle ear,  General principles in surgical wound care for burns and

TRANSCRIBER: Trans Group 3 (LAPOSTRE 09271385847) EDITOR: Nhor Robles (09178704163) Page 3 of 11
OTORHINOLARYNGOLOGY: 1.01 External Ear (Dr. Opulencia)

frostbites from the auricular cartilage → a hematoma forms between

 Local treatments (dressings) should not exert pressure on these layers if injury remains closed
the auricle to avoid further compromise of the auricular  There is little tendency for fluid collection to be reabsorbed
blood supply Symptoms:
 Gently warming the area (e.g. with a heat lamp)
 The trauma itself is painful, but typically there is no pain
 Dry treatment and await demarcation of frostbite if with
bulla formation or necrosis afterward
 Circulatory stimulants such as dextran or pentoxifylline can Diagnosis:
be used  Inspection and palpation
 Skin over the lateral auricular cartilage shows swelling and
Reconstructive Surgery: fluctuation.
 Deferred until the site has completely healed which usually  Exclude associated injuries to the temporal bone, ear
takes about six months (both frostbite and burns) canal, middle ear, and temporomandibular joint (TMJ), and
secondary infection of the hematoma
Prognosis:
Differential diagnosis:
 Permanent auricular deformity in severe burns and
frostbites  Recurrent polychondritis can give rise to spontaneous
seroma
D. Burns Complications:
 Occur in 90% of patient with facial burns  Perichondritis from a secondary infection during needle
 25% develop suppurative chondritis aspiration of the hematoma
 1st degree burns treated conservatively  "Cauliflower ear" develops from deformed cartilaginous
 2nd degree burns treated with silver sulfadiazine with framework caused by poor fluid reabsorption
mesh dressings
 3rd degree burns are extensively debrided, closed, and
Treatment:
grafts may be used later
 Burns confined to the auricle are rare  Aspiration of hematoma
 Surgical evacuation and reattachment of perichondrium to
Treatment the cartilage
 Based on general principles of burn care  A contoured dressing (e.g. oil-impregnated cotton) is then
 Superficial burns in particular should be cooled applied
immediately and treated with other local anti-inflammatory
measures
Prophylaxis:
 Surgical debridement for more severe burns
 Wear ear protection during contact sports

Thermal injuries (for both frostbite and burns) to the

auricle are graded as follows:
 Damage confined to the skin:
o Grade I: Localized Erythema
o Grade II: Blistering of the Skin
 Damage involves the entire skin-cartilage unit:
o Grade III: Deep Tissue Necrosis

Figure 3: Fresh Hematoma. It is adherent to the skin and the ear folds
E. Hematomas will disappear producing a cauliflower ear

 An auricular hematoma or seroma is a collection of blood

or serous fluid between the perichondrium and auricular
cartilage
 Commonly seen in wrestlers and boxers
 If untreated, may lead to “Cauliflower ears”
 Aspiration or evacuation of hematomas and placement of
pressure dressings done as treatment
 Anti-staphylococcal antibiotics are given
 One of the most difficult to treat. IV and oral antibiotics will
not penetrate the perichondrium or the cartilage.
 Sometimes, removal of the ear is necessary to get rid of
the infection, and just replace it with just an artificial ear. Figure 4. “Cauliflower Ear”
Pathogenesis:
 Blunt trauma causes skin and perichondrium to separate

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OTORHINOLARYNGOLOGY: 1.01 External Ear (Dr. Opulencia)
Figure 5. Perichondritis of the the Auricle. Inflammation of
the perichondrium, a layer of connective tissue surrounding the cartilage;
involves infection of the pinna due to infection of traumatic or surgical
wound or the spread of inflammation into depth
F. Foreign Bodies
 Any object that can fit into the opening of
the external auditory canal
 Visualization is mandatory for removal
 Sedation or general anesthesia may be required if
patient is uncooperative
 After removal, additional injuries must be assessed
 Living foreign bodies: cockroach, ant, “garapata,”
worm, maggots, spider
o Prior to removal of live foreign bodies, its suffocation
must be done to prevent further movement deeper into
the ear canal. Oil is one of the primary suffocating agent
used.
 Non-living foreign bodies: matchstick, pearl, stone
Causes:
 Small children inserting small toy pieces in their ear canal
 Adults placing noise reducing ear plugs or ear canal
manipulation objects
 Insects
Diagnosis:
 History and otoscopy
 Difficulties from secondary injuries, swelling, or
inflammation
 Signs of associated injury to middle or inner ear structures
(e.g. tympanic membrane perforation), otitis media, facial
nerve lesions, vertigo, nystagmus, or sensorineural hearing
loss
Differential diagnosis:
 Cerumen impaction
 Dried blood
 Tumors of the ear canal
 Cholesteatoma
 Otitis externa
Complications:
 Middle- and inner-ear damage if object is deep enough
 Secondary otitis externa with fetid discharge results if
prolonged retention of foreign body
Treatment:
TRANSCRIBER: Trans Group 3 (LAPOSTRE 09271385847) EDITOR: Nhor Robles (09178704163)
 Foreign body should be carefully removed with a small
extraction hook
 Be cautious, don't push the foreign body deeper into the
ear canal or through the tympanic membrane
 Aural irrigation should not be used on foreign bodies in the
ear canal
 In children, extraction of foreign body is preferably done
under general anesthesia
 Insects can be killed with a 10% lidocaine solution
 Very rarely, a surgical incision may be needed to remove
foreign bodies lodged tightly in the ear canal
III. INFECTIOUS AND INFLAMMATORY DISEASE OF THE
EXTERNAL EAR
 An inflammatory condition of the auricle or external auditory
canal diagnosed clinically; additional tests are rarely
needed.
 The pathogenesis of different inflammatory conditions of the
external ear is interrelated; thus, it is not always easy to
distinguish them.
 Otitis externa (inflammation of the external auditory canal)
can spread to the auricle causing auricular inflammation and
vice versa.
 Inflammations of the external ear may manifest acutely,
subacutely, or present with chronic complaints.
 A profuse, mucopurulent aural discharge often originates in
the middle ear, and not in the external ear canal
Pathogenesis:
 Inflammations of the external ear are often caused by
factors that interfere with the normal defenses against
infection.
 Normal defenses: cerumen (acid pH, antibacterial fatty acid
content) and physiologic migration of the epithelium lining
the ear canal
 Exogenous factors: maceration of the skin by water, pH
changes caused by soaps and shampoos, insertion of
cotton swabs, earphones or earplugs, the creation of a
warm moist chamber
 Endogenous factors: eczema, allergies, and metabolic
disorders such as diabetes mellitus
 Local changes: exostoses, stenosis, anatomical variants
 Inflammation may involve:
o External auditory canal (EAC)
o Diffuse otitis externa and eczema, circumscribed otitis
externa, necrotizing otitis externa, bullous otitis externa,
otomycosis
o Auricle
o Eczema and dermatitis, perichondritis, auricular cellulitis,
herpes zoster auticus
Acute vs Chronic inflammations:
 Acute inflammations are often caused by bacterial
infection.
 Chronic inflammations more closely resemble eczema.
Table 1: Acute VS Chronic Inflammatory Changes
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OTORHINOLARYNGOLOGY: 1.01 External Ear (Dr. Opulencia)

Differential Diagnosis Of toward the middle because it is a round object. It will not go beyond
Differential Diagnosis Of the bone. When the infection crosses the canal, the tendency is the
Chronic Inflammatory
Acute Inflammatory Change more you want to clean the ear, in effect, the more you clean and
Change
manipulate the ear  the ear canal closes due to swelling until it is
completely closed.
 Typically manifest clinically  The dominant symptom of
with severe pain and chronic otitis externa is Symptoms:
tenderness on movement usually itching, not pain.
 Itching (main initial symptom)
of the auricle or tragus.  Inspection will generally
 Pain (during acute infection)
 Obstruction of the ear canal reveal redness and
 Crusting and a purulent discharge
by drainage or swelling can crusting about the meatal
lead to conductive hearing orifice.  Obstruction of the ear canal can lead to hearing loss
loss.  The skin of the ear canal
Diagnosis:
 Herpes zoster oticus shows typical changes
manifests with small bullae such as eczema,  Eczema of ear canal without infection
on the auricle and in the ear ulceration, or  Dry, cracked, and scaly canal skin on otoscopy
canal. granulations.  Infection manifested by diffuse swelling of the canal skin
 Otitis externa presenting  Conductive hearing loss with associated discharge of crusting
with mucopurulent is present in chronic otitis
discharge can be hard to media. Differential diagnoses:
differentiate from  Establish that the middle  Acute otitis media or chronic suppurative otitis media can
suppurative otitis media ear and tympanic lead to an accompanying otitis externa and should be
with a perforated tympanic membrane are intact by excluded by otoscopy
membrane. ensuring that the tympanic
 A valsalva maneuver can membrane is mobile and Complications:
be helpful in diagnosing the conductive hearing loss is  Perichondritis, cellulitis, or abscess formation due to
latter case as this may absent. cracked skin
cause bubbles to appear in  Drainage may hamper  Necrotizing otitis externa may develop in predisposed
the discharge. accurate evaluation and patients
 Bullous otitis externa can must be carefully removed.
be established simply by Treatment:
otoscopic detection of  Principles of Therapy
hemorrhagic bullae on the o Relief of pain
bony canal wall. o Eliminate predisposing factors
o Thorough cleaning
A. Otitis Externa  Meticulous, repeated cleansing, and drying of the ear
canal followed by instillation of antiseptic, antibiotic drops
 One of the most common diseases of the ear that will reduce the swelling
 May be infectious or non-infectious  Steroid and antibiotic ear drops are CONTRAINDICATED
 Certain predisposing factors: in patients with a fungal infection of the ear canal, antibiotic
o Change in pH hypersensitivity, or a perforated tympanic membrane
o Environmental changes
o Mild trauma (e.g. cleaning) B. Furunculosis
 When the pinna is pulled in a patient with otitis externa, it is
very painful. If there’s no pain, it is otitis media.  Outer 3rd of the EAC 
 Inflammation of EAC involving canal skin, acute bacterial  Staphylococcus aureus or S. albus
infection of the skin with a mixed flora that includes Gram-  Affectation of pilosebaceous follicles
negative organisms and anaerobes.  I and D (Incision and Drainage) is the best option for Tx
 Primary or secondary fungal infections of the ear canal  Systemic antibiotics and analgesics
may also develop. Myringitis is also a finding. A warm,
moist climate promotes its development (Swimmer’s
otitis) C. Diffuse otitis externa
 Also known as “swimmer’s ear”
 Predominantly caused by Pseudomonas group
 Diagnostic features:
o Tragal tenderness
o Severe pain
o Canal wall swelling involving most of the canal
o Scanty discharge
o Normal or slightly diminished hearing
o Absence of obvious fungal particles
o Possible presence of tender regional adenopathy
Figure 6: Otitis Externa. There is a painful, swollen, and tender
canal with narrowing. The skin and the periosteum are adherent to
each other at the ear canal. With ear infection, the swelling expands D. Otomycosis (Fungal Infection)

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OTORHINOLARYNGOLOGY: 1.01 External Ear (Dr. Opulencia)
F. Dermatoses ( Eczematous Dermatitis)
Figure 7. (L) Aspergillus niger; (R) Aspergillus albus
 G. Necrotizing External Otitis
 Acquired if the ears are not in natural acidic pH
 Aspergillus niger (more common) or Aspergillus
albus infection
 Velvety grayish membranes on medial 2/3 of EAC
 Aural toilette with hydrogen peroxide as treatment
 2% acetic acid may also be used
 Otic antifungal preparations for two weeks for refractory
cases
 70% of people with itchy ear have fungus. The more
you manipulate the ear, the more the fungus will be
buried inside the ear.
 Fungi grow and multiply depending on pH of ear
 Fungi can infect the skin of the medial ear canal if the
milieu has been altered (e.g. steroid and antibiotic
eardrops use or other factors)
 A warm, moist climate is conducive for fungal growth.
 Symptoms:
o Severe itching and a feeling of illness in the
affected ear, and pain
 Diagnosis:
o White, yellow, or black membrane lining the
swollen, erythematous skin of the ear canal
o Mycelia can be identified in direct samples
 Differential Diagnosis:
o Other forms of otitis externa, especially diffuse,
otitis externa
 Course:
o Typically refractory course and it recurs
 Complications:
o Tympanic membrane perforation and subsequent
otitis media
 Treatment:
o Thorough cleaning and drying of ear canal. There
is no otic anti-fungal preparation.
o Administration of local antimycotics
o Soften the uppermost epithelial layer with
salicylate-containing solutions in order to
enhance antifungal action of medications
H. Relapsing Polychondritis
E. Herpes Zoster Oticus ( Ramsay Hunt Disease)
 Caused by viral infection involving the geniculate
ganglion
 Facial paralysis accompanied by otalgia and herpetic
TRANSCRIBER: Trans Group 3 (LAPOSTRE 09271385847) EDITOR: Nhor Robles (09178704163)
eruptions involving the portions of the external ear
 Other symptoms may be related to progressive
involvement of vestibular and acoustic fibers of the 8 th
cranial nerve
 Symptomatic treatment is usually employed
 Involves the external canal and adjacent portions of the
meatus and concha
 Characterized by swelling, redness, itching and
stage of watery exudation followed by crusting
 Wet dressings, fluorinated steroid ointment and
solution for 24 to 48
 Also known as “malignant otitis externa”
 Debilitating and fatal disease if untreated
 Pseudomonas aeruginosa
 Seen in immunocompromised and diabetic patients
 Very painful and non-responsive to medication
 In severe cases, the ear has to be taken out.
 Management:
o CT Scan to determine extent of disease
o Systemic Antibiotics preferably parenteral
o Extended Mastoidectomy for severe cases
o
 Symptoms:
o Initial history of insidious, persistent otitis externa
that does not heal
o Moderate pain which may become severe as the
condition takes a chronic course
 Diagnosis:
o Reveals signs of infection in surrounding tissues
(inspection), shows ulcer on canal floor with
exposed brownish bone and a fetid discharge
o Smear: positive P. aeruginosa
o Radionuclide bone scan and computed
tomography to define the extent of infection and
cone destruction
 Differential Diagnosis:
o Simple otitis externa
o Cholesteatoma of the ear canal
o Tumor suspected
 Complications:
o Otitis media, mastoiditis, pertositis, and soft tissue
abscess
o Cranial nerve deficits and sepsis in late stages
 Treatment:
o Ear canal is locally debrided and cleaned at regular
intervals
o With minimal bone involvement, high doses of
antibiotic against P. aeruginosa can be
administered for six weeks
o Diabetes mellitus should be closely monitored and
controlled
 Prognosis:
o Dependent on prompt, appropriate treatment
o 50% chance of survival in facial nerve palsy
development or venous sinus thrombosis
 Resemble an acute infectious perichondritis or an
inflamed cauliflower ear
 Loss of cartilage may lead to floppy ears and saddle
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OTORHINOLARYNGOLOGY: 1.01 External Ear (Dr. Opulencia)

nose deformities. of desquamated keratin (radiopaedia.org)

 Tinnitus, vertigo and hearing loss may occur due to
collapse of external auditory meatus
 Salicylates or corticosteroids may be used for acute
attacks
NOTE: Necrotizing External Otitis and Relapsing
Polychondritis are considered chronic infections. The rest
are acute
F. Squamous Cell Carcinoma
 Occurs in 20% of tumors in EAC
 Comprise 80% of all malignant tumor of auricle and
EAC
 Metastasis is uncommon
 Treatment for small tumor excision and radical en bloc
resection if with lymphoid involvement

From 2017B:
Two things are considered in ear infections that do
not respond to medication: NECROTIZING OTITIS
EXTERNA OR MALIGNANCY

CYST AND TUMORS

A. Exostoses
 Benign bony outgrowth and often asymptomatic Figure 9: Squamous Cell Carcinoma
 Treatment of choice: EXCISION (if symptomatic)
G. Malignant Melanoma
o Extremely rare
o Dark pigmented nevus with sudden elevation and bleeding

Figure 10: Malignant Melanoma

Figure 8: Exostoses. Bony outgrowth within the ear canal H. Adenoid Cystic Carcinoma
B. Osteoma  Highly variable course and by perivascular and
perineural infiltration
 Benign bone tumors that are isolated masses
 Relatively benign and slow growing
(especially in ethmoid cells and frontal sinus) or forms
 Lymph node metastases are common
extensive masses that grow along the skull base
 Some become fulminant with rapid recurrence and
 Diagnosis:
hematogenous spread
o Skull X-ray
 Symptoms: Pain or nerve deficit due to local
o Symptoms arising from obstruction of drainage
tracts (e.g. headaches, recurrent sinusitis) infiltration
 Treatment: CT tomography (treatment of choice for  Treatment: Surgery
localization)  Prognosis:
o 5 year survival rate is 75%
C. Adenoma o 10 year survival rate is 30%
 Benign mucosal tumor
I. Basal Cell Carcinoma
D. Cholesteatoma
 Proliferation of basal cell
 Middle ear disease  DOES NOT metastasize
 Two characteristics:  Wide surgical excision
o Keratinizing squamous epithelium found in bony
spaces at an abnormal location
o Bone is destroyed through an inflammatory
osteoplastic process
E. Keratosis Obturans
 a rare external auditory canal disease characterised by
abnormal accumulation and consequently occlusion
and expansion of the bony portion of the EAC by a plug

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OTORHINOLARYNGOLOGY: 1.01 External Ear (Dr. Opulencia)

 Every non-healing, ulcerated, or granulating lesion of

the ear canal should be biopsied under the operating
microscope
 Differential Diagnoses:
o Chronic Otitis Externa, especially Necrotizing
Otitis Externa, Chronis Otitis Media with
mucosal polyps, middle ear tumor, penetrating
parotid tumor
 Treatment: Surgery with or without post-operative
irradiation
 Prognosis: depends on extent of disease
Figure 11: Basal Cell Carcinoma
REVIEW QUESTIONS
J. Keloid FROM 2017B. Some were not discussed/not yet discussed.
 an abnormal proliferation of scar tissue that forms at the
site of cutaneous injury (eg, on the site of a surgical 1. The auricle and ear canal amplifies sound entering the
incision or trauma); it does not regress and grows range of:
a. 2-4 kHz
beyond the original margins of the scar.
b. 5-7kHz
c. 8-10 kHz
d. 11-14 kHz

2. A patient complains of a very painful nodule with an

umbilicated center which is located on the free border of the
helix or anti-helix. What is your diagnosis?
a. Winkler disease
b. Bafversted disease
c. Sebaceous keratosis
d. Gouty tophi

Figure 12. Earlobe Keloid. Usually from ear piercings. The
more you cut it, the more it grows.
The following section was from 2017B and not discussed by
the lecturer.
1. Tumors of the auricle
 Common site of epithelial skin tumors due to its
exposed location
 Most common in men over 60 years old
 90% auricular tumors
 Diagnosis: Histology after excision
 Treatment:
o Reconstruction (will depend on location
and extent of tumor)
o Excision of suspected malignant tumor with
margins assessed by frozen tissue histology
o Complete auricular resection (excessive
tumors)
 Differential diagnoses: cysts, keloids, otophymas,
and nevoid lesions
 Prophylaxis: Protection from sun exposure
2. Tumors of the EAC
 Isolated tumors to the EAC are rare
 Involvement of the ear canal by auricular tumors
cancels simple excision as treatment
 Carcinoma of the canal skin (most common malignant
tumor of the ear canal)
 Less common: Adenoid cystic carcinomas,
adenocarcinomas, basal cell carcinoma
 Painful, ulcerated, non-healing, bleeding
3. A 60 year old diabetic came into your clinic because of
severe itching and fullness of the affected ear. Otoscopy
showed white, yellow and black membrane lining the
swollen erythematous skin. What is most likely your
impression?
a. Otitis external
b. Otomycosis
c. Bullous otitis externa
d. Herpes zoster oticus
4. Which of the following ear canal condition predisposes
one to an Acute External Otitis?
a. Change of ear pH to alkaline
b. Presence of cerumen
c. Non-cleaning of ear canal
d. Presence of upper respiratory tract infection
5. Which of the following is true regarding the proper
technique of aural irrigation?
a. Indicated on restless, uncooperative patients
b. Water jet is directed on the umbo
c. Ear is irrigated with cold water
d. The ear should be slightly tilted inferiorly
6. What is the most likely etiologic microorganism
responsible for a 50 year old diabetic male with left trial
tenderness, obstructed external auditory canal and
yellowish purulent discharge?
a. Pseudomonas aeruginosa
b. Staphylococcus aureus
c. Streptococcus pneumonia
d. Streptococcus pyogenes
7. it is generally unnecessary to clean the external ear since

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OTORHINOLARYNGOLOGY: 1.01 External Ear (Dr. Opulencia)

the cerumen will extrude from the canal in:
a. 1 to 2 weeks
b. 3 to 4 weeks
c. 6 to 8 weeks
d. 10 to 12 weeks
8. 17 y.o. male patient complains of chronic intermittent
drainage of purulent material anterior to the pinna. The
patient most likely has:
a. Infected 3rd brachial cleft cyst
b. Eczema
c. Preauricular sinus cyst
d. Acute otitis externa
9. The main goal of surgery in the treatment of chronic otitis
media with cholestoma is to:
a. Improve hearing
b. Eradicate infection
c. Relieve negative pressure
d. Improve the quality of life
10. 3 year old male with ear pain which has awakened the
patient. On Otoscopy, there was an insect lodged at the ear
canal. What would be your initial management?
a. Admit the patient and schedule for extraction of foreign body
under general anesthesia
b. Imemdiately suction out the foreign body and send the patient
home with pain medications and oral antibiotics
c. Lay the patient in a lateral decubitus position and pour
mineral oil at the affected ear before extraction.
d. Prescribe antibiotic ear drops and advise to follow up the next
day for extraction of foreign body.
11. A round foreign body obstructing the ear canal should
be extracted using:
a. Tweezer or forceps
b. A blunt hook
c. Suction
d. Pour mineral oil
12. A 39/M boxer was brought to your clinic after his match
in Las Vegas due to swelling and hematoma formation on
the auricle. The skin over the lateral auricular cartilage
shows swelling and fluctuation. How should this patient be
managed?
a. Oral antibiotics, pin medications and hemostatic drugs
b. Surgical evacuation and ear contoured dressing
c. Application of a small pennrose drain
d. Pressure dressing only and oral antibiotics
13. The most common pathogen causing necrotizing otitis
externa:
a. Pseudomonas aeroginosa
b. Staphylococcus aureus
c. Group A Streptococcus
d. Aspergillus flavus
14. Otomycosis is best treated with:
a. Mechanical cleaning and debridement
b. Application of antifungal otic preparation
c. Application of 2% Acetic acid to make pH of ear canal acidic
d. All of the above
15. An infection of the external ear with tenderness,
induration and edema over soft tissue surrounding thee
auricular cartilage is known as:
a. Diffuse otitis media
b. Herpes zoster oticus
c. Polychondritis
d. Perichondritis
16. A 32/F consulted at the emergency room due to facial
palsy on the right. On history, patient noted a burning
sensation on the right ear, which started a few days prior to
onset of facial palsy. And physical examination revealed
vesicles and crusts on the affected ear. Patient also noted
decrease in hearing and a mild vertigo. What is your
impression?
a. Bullous otitis externa
b. Herpes Zoster oticus
c. Circumscribed otitis externa
d. Necrotizing otitis externa
16. Which of the following statements is NOT true of
otomycosis:
a. Aspergillus, Candida albicans, Mucor and dermatophytes are
the common pathogens of otomycosis
b. With proper cleaning and debridement, systemic
antimycotic therapy is not necessary even in
immunocompromised patients
c. Fungal infection aggressively infect the canal if the milieu has
been altered by the use of steroid and antibiotic containing ear
drops
d. a warm moist climate is conducive to fungal infections, which
are most common during the summer months
17. Which of the following tuning forks is used to carry out
Weber and Rinne tests?
a. 256 Hz
b. 512 Hz
c. 1024 Hz
d. 2048 Hz
18. What is the Weber test result in a child with an impacted
cerumen on his right ear?
a. Sound will be heard in both ears
b. Sound will be heard in the right ear
c. Sound will be heard in the left ear
d. Sound will be heard by either ear
19. What is the Rinne test result in an elderly patient with
bilateral sensorineural hearing?
a. Rinne (+) AD, Rinne (+) AS
b. Rinne (-) AD, Rinne (+) AS
c. Rinne (+) AD, Rinne (-) AS
d. Rinne (-) AD, Rinne (-) AS
20. What is the correct position of a child during an ENT
examination?
a. Child is embraced by a parent with both lying down on the
examination bed
b. Child is seated at the parent’s lap, with the parent’s arm
across the child’s chest and the parent’s legs crossed to
hold the child’s legs
c. Child stands on the parent’s lap and restrains the child by
holding an arm across the child’s chest and legs
d. Child is cradles in the arms of the mother while the father is
holding the legs of the child

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OTORHINOLARYNGOLOGY: 1.01 External Ear (Dr. Opulencia)

21. Which of the following is not a basic ENT instrument? the eardrum on a patient complaining of decrease hearing
a. Headlight and pain. What is your impression?
b. Light source a. Sensorineural hearing loss
c. Tongue depressor b. Impacted cerumen
d. Suction machine c. External ear cholesteoma
d. Otitis media
22. To view the eardrum in an adult, the pinna is pulled:
a. Upward, backward and outward 30. What would be the appropriate treatment on a patient
b. Downward, backward and outward with an insect lodged inside the external auditory canal?
c. Upward forward and outward a. Drown the insect with mineral oil
d. Downward, forward and outward b. Use forceps for extraction
c. Crush the insect with a cotton swab
23. What is the average length of the external auditory canal d. Prescribing pain medications and then observe
in an adult?
a. 1.5 31. A patient complains of a very painful nodule with an
b. 2 umbilicated center which is located on the free border of the
c. 2.5 helix or anti-helix. What is your diagnosis?
d. 3 a. Winkler disease
b. Bafversted disease
24. Which is the narrowest portion of the ear canal where c. Sebaceous keratosis
inflammatory stenosis usually develops? d. Gouty tophi
a. Area right before the location of the tympanic membrane
b. Entrance to the ear canal 32. A 60 year old diabetic came into your clinic because of
c. Outer 1/3 of the external ear severe itching and fullness of the affected ear. Otoscopy
d. Middle half of the external ear showed white, yellow and black membrane lining the
swollen erythematous skin. What is most likely your
25. Which of the following is the roof of the tympanic impression?
cavity? a. Otitis external
a. Promontory b. Otomycosis
b. Tympanic membrane c. Bullous otitis externa
c. Tegmen tympani d. Herpes zoster oticus
d. Tympanic sulcus
33. Which of the following ear canal condition predisposes
26. Which if the following is true regarding the external one to an Acute External Otitis?
auditory canal: a. Change of ear pH to alkaline
a. Bony portion is formed by the tympanic part of the temporal b. Presence of cerumen
bone c. Non-cleaning of ear canal
b. Average length is 3.5cm d. Presence of upper respiratory tract infection
c. 2/3 bony and 1/3 cartilaginous
d. Inner 1/3 is ceruminous 34. Which of the following is true regarding the proper
technique of aural irrigation?
27. The virus responsible for vesicular eruptions after the a. Indicated on restless, uncooperative patients
onset of ear pain associated with hearing loss and vertigo b. Water jet is directed on the umbo
is: c. Ear is irrigated with cold water
a. Human papilloma virus d. The ear should be slightly tilted inferiorly
b. Cytomegalovirus
c. Varicella zoster virus
d. Epstein-Barr virus

28. What would be the appropriate treatment for a patient

with fever, otalgia, right facial palsy and red painful rash
associated with blisters in the ears and mouth
a. IV antibiotics
b. Systemic antivirals and corticosteroids
c. Send home and observe
d. NSAIDS

29. Otoscopy revealed a dry yellowish brown to black

material on the external auditory canal which totally blocks

END OF TRANS

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