Disease Of External EAR DR ISSAM AMINE ASSISTANT

Disease Of External EAR DR ISSAM AMINE ASSISTANT PROFESSOR ENT DEPARTEMENT DAMASCUS UNIVERSITY

The “Ear” is housed within the TEMPORAL BONE

: The Outer Ear Consists of The Pinna cartilaginous, highly variable in appearance, some. landmarks n External Auditory Canal (or external auditory meatus). 2. 5 cm tube n

Pinna Landmarks Helix Antihelix Concha Tragus Intertragal Notch Antitragus n n n

External Auditory Canal n n n lateral portion-cartilage medial portion-osseous lined with epidermal (skin) tissue hairs in lateral part cerumen (ear wax) secreted in lateral part.

Outer Ear Functions Amplification / Filtering n Protection n Localization n

EXTERNAL EAR -The external ear consists of auricle or pinna and external auditory canal 1) Auricle or Pinna consist of framework of a single piece of elastic cartilage covered with skin , the lateral surface is adherent to perichondrium while it is slightly loose on the medial surface there is no cartilage between the tragus and crus of helix ( incisura terminalis ) this is the place of endaural approach used in ear surgery

External auditory canal -24 mm long -divided into 2 parts : *outer 1/3 cartilaginous 8 mm * inner 2/3 bony : 16 mm -EAC is not straight its outer 1/3 is directed upwards backwards and medially while its inner part directed downwards forwards and medially

Diseases of external ear canal 1 -diseases of pinna 2 -diseases of external auditory canal (EAC) 3 -diseases of Tympanic membrane (TM)

1 -Diseases of pinna *congenital disorder: A-BAT ear (Lop ear) B-preauricular pits or sinus C-anotia D-Macrotia E-Microtia

Disease of pinna n Trauma of the auricle 1 -haematoma : -collection of blood between cartilage + perichondrium - caused by blunt trauma (boxers , rugby players) - if not treated → ear deformity called cauliflower ear - if heamatoma infected → perichondritis

Trauma of the auricle - treatment : 1 -repeated aspiration + pressure dressing 2 - if failed : incision + drainage (I/D) + pressure applied by dental rolls tied with through and through suture 3 - prophylactic ATB

Trauma of the auricle 2 - lacerations -repaired as early as possible -ATB for 1 WK 3 - avulsion of pinna - early reattachment is required 4 - frost bite - clinical picture variable : oedema , erythema , bulla formation , necrosis with loss of affected part -treatment rewarming analgesics , ATB , surgical debridement should wait several months

Trauma of the auricle 5 - keloid of auricle: - followed trauma or piercing of the ear -surgical excision → recurrence -injection of local steroid ↓ recurrence - some use PRE and postop radiation

Disease of pinna n Inflammatory disorders : 1 - perichondritis : -result from infection secondary to laceration , heamatoma , ear surgery -pseudomonas and mixed flora are common pathogens -symptoms: red , hot , painful pinna, later abscess → necrosis -treatment : ATB , if abscess I/D +C/S

Inflammatory disorders 2 - chondrodermatitis nodularis - small painful nodules near the free border of helix - ♂>50 y - nodules are tender and pt is unable to sleep - treatment : excision

Diseases of EAC Congenital disorder n Trauma n Inflammation n Tumors n Miscellaneous condition n

1 -Trauma of EAC n § Minor laceration : - scratching the ear with hair pins, needles or match stick. - usually healed without sequel Major laceration : - result from : * gun shot * automobile accident *fights - require careful treatment - stenosis is common coplecation

2 -Inflammation of the (external canal (EAC A- Infective group : Localisted otitis externa (furuncle). Bacterial Diffuse otitis externa. Maligant otitis externa. Fungal Viral Otomycosis Herpes zoster oticus. Otitis externa haemorrhagica.

Inflammation of the (external canal (EAC B- reactive group : - Eczematous otitis externa - Seborrhoric otitis externa - Nerudermatitis

Furuncle (localised acute ( EXT otitis n n n Furuncle is a staphylococcal infection of the hair follicle Single or multiple Situated in cartilaginous part of meatus Pt C/O sever pain and tenderness Movement of the pinna are painful Post furuncle cause odema over mastoid

1 -Furuncle (localised ( acute EXT otitis n n n Periauricular LN enlarged and tender In case of recurrent furunclosis diabetes should be excluded Treatment - systemic ATB -analgesic -ear pack of 10% ichthammol glycerine ↓ pain - if abscess formed I/D

2 -DIFFUSE OTITIS EXTERNA -BACTERIOLOGY: 1 -STAPH AUEREUS 2 -PSEUDO pyocyaneus 3 -proteus 4 -Esch. coli

2 -DIFFUSE OTITIS EXTERNA -Diffuse inflammation of meatal skin which may spread to pinna+epidermal layer of TM -Aeotiology: * trauma: scratching , removing of foreign body

2 -DIFFUSE OTITIS EXTERNA Clinical features: -pain : aggravated by the movement of the jaw -serous discharge then mucopurulent -EAC : inflamed & swollen -Collection of (debris+ discharge )cause CHL -Enlargement +tenderness of regional LN in sever cases

2 -DIFFUSE OTITIS EXTERNA -Chronic phase: *irritation & sever itching *responsible of acute exacerbations &reinfection -treatment: *ear toilet *medicated wicks : soaked gauze with AT & steroid *ATB *analgesics

3 -otomycosis *fungal infection of the ear canal *Causes: -Aspergillus. fumigatus -A. niger -Candida albicans *seen in hot & humid climate *long using of topical ATB may cause secondary fungal growth

3 -otomycosis • Clinical features - itching ++++ -discomfort or pain -ear discharge -fungal mass appear white or brown or black

3 -otomycosis • Treatment : - ear toilet by ear wash or suction - local antifungal drops : 1 - Nystatin 2 - Clotrimazol 3 - Povidon iodine 2% - local ATB + steroids drops

4 - otitis externa hemorrhagica • • Formation of hemorrhagic bullae on the TM + deep meatus Viral origin ++++ Sever pain + blood stained discharge Treatment : - analgesics - systemic ATB for secondary infection

Herpes zoster oticus n Formation of vesicles on the TM , meatal skin , concha , post auricular groove. n The facial nerve + 8 th nerve maybe involved

Malignant (necrotizing )otitis externa n n n Cause: pseudomonas Usually elderly diabetic or immuno suppressive PT sever ear ache++++ Appearance of granulations in the meatus Facial paralysis++++ Infection may spread to: post: mastoid ant : temporomandibular fossa medially: ME, petrous bone

Malignant (necrotizing) otitis externa n n n CT ++++ for extent of disease radio iostope scanning (technetium 99& gallium ++++ Treatment: - IV anti pseudomonas ( ciprofloxacin, third generation cephalosporin) for 6 -8 wk - DM must be controlled - surgical debridment

Eczematous otitis externa n Ear irritation , vesicles formation , oozing , watery discharge n Treatment: - application of steroid cream

Seborrhoeic O. E n n Associated with seborrhoeic dermatitis of scalp Itching ++++ Greasy yellow scales in EAC , lobule, postauricular sulcus Treatment: - ear toilet -application of salicylic acid and sulphur cream

Tumors of external auditory canal A- Benign tumor: 1 -Oesteoma: *single smooth bony hard pedunculated tumor arising from post wall of the osseous meatus * treatment : surgery

Tumors of external auditory canal 2 - exostoses *multiple bilateral bony swelling * often seen in divers + swimmers * ♂>♀ 3/1 * treatment : - small & asymptomatic →no treatment - big & cause ↓ hearing → surgery

Tumors of external auditory canal 3 -Rare tumor : - ceruminoma - sebaceous adenoma - papilloma

Tumors of external auditory canal B- malignant tumors : 1 - squamous cell CA - primary : arise from meatus - secondary extension from middle ear CA * symptoms : - bloody , mucopurulent discharge - sever earache * examination : - ulcerated area in the meatus - bleeding polypoid mass - granulation - facial paralysis +++ -LN enlarged * treatment wide surgical excision + Rx therapy

Tumors of external auditory canal 2 -Basal cell CA : - same picture as squamous cell CA - treatment surgery & Rx therapy 3 - rare tumors : - adenocarcinoma - malignant melanoma - ceruminoma

Miscellaneous conditions 1 - impacted wax or cerumen - wax is composed of secretion of sebaceous gland , ceruminous gland , hair , debris, keratin, dirt -wax has a protective & lubricant function -normally expelled from the meatus by movement of jaw -wax retention → hearing &tinnitus & giddiness -treatment: *ear wash if no TM perforation *suction *If hard wax → soda glycerin ear drops 4 -5 days before wash

Diseases of tympanic membrane 1 -myringitis bullosa - viral cause +++ - painful - hemorrhagic blebs on the TM + deep meatus 2 - herpes zoster oticus - viral cause - vesicles on the TM , deep meatus - 7 th & 8 th cranial nerves may be involved

Diseases of tympanic membrane 3 - traumatic rupture - TM ruptured by : a-truama due to match stick, hair pins b- sudden change in air pressure (slaps, kiss, blast) c- fluid pressure: diving, forceful syringing d- fracture of temporal bone - treatment : * spontaneous healing in majority of cases * if no → myringoplasty

Diseases of tympanic membrane 4 - Tympanosclerosis -hyalinization & later calcification in the fibrous layer of TM - appear as chalky white plaque - asymptomatic - no treatment