Diseases of external ear and its management

Know about various conditions of external ear

1. Diseases of E xternal Ear and its Management Presented by D r . Binod Chaudhary Department of ENT C h i t w a n M e d i c a l C o l l e g e

2. Anatomy

3. Anatomy

4. Disease of external ear Divided into Disease of the pinna Congenital disorders Trauma to the auricle Inflammatory disorders Tumors

5. 2. Disease of external auditory canal Congenital disorders Trauma Inflammation Tumors Miscellaneous condition

6. Congenital disorders of pinna Due to developmental abnormalities May be minor variations or major abnormalities Minor anomalies Accessory auricular tag Bat ear Lop ear Preauricular sinus

7. Major anomalies Anotia Microtia

8. Anotia Complete absence of pinna and lobule Usually forms the part of first arch syndrome

9. Microtia A major developmental anomaly Frequently associated with anomalies of EAC, middle ear and inner ear Hearing loss- frequent Degree of microtia may vary

10. Grade I microtia : Small external ear and a small but present external ear canal Grade II microtia : A partially developed ear (usu. t op portion underdeveloped) with a closed external ear canal producing a CHL Grade III microtia : Most common form of microtia with an absent external ear and small peanut-like vestige structure and canal atresia Grade IV microtia : aka anotia , complete absence of the external ear with canal atresia

11. Treatment options Do nothing Surgery Ear reconstruction using own body’s skin and cartilage Ear reconstruction using MEDPOR implant Prosthesis

12. Macrotia Lop/cup ear Preauricular tag Bat ear Congenital anomalies of pinna

13. Preauricular sinus A depression in front of the crus of helix or above tragus Is an epithelial track and is due to incomplete fusion of tubercles. Gets repeatedly infected causing purulent discharge, may form abscess. Treatment of choice: surgical excision of the track.

14. Trauma to the auricle Hematoma of auricle Due to injury leading to collection of blood and serum between the auricular cartilage and its perichondrium. Extravasated blood may clot and then, organize, resulting in a typical deformity called cauliflower ear .

15. Clinical features Commonly seen on the anterior surface Swelling, bluish and tender auricle If left untreated, necrosis of cartilage and scarring of the auricle Superadded infection results perichondritis ad abscess formation.

16. Treatment Aspiration of the hematoma under aseptic condition and pressure dressing to prevent re-accumulation Incision and drainage if aspiration fails. All cases should receive antibiotic prophylaxis.

17. Laceration of auricle The auricle may be cut through-and-through or avulsed partially or totally in RTA, knife injuries, etc. Treatment includes repairment as early as possible. Broad spectrum antibiotics given for 1 week.

18. Inflammatory disorders Perichondritis Is infection of perichondrium of the auricular cartilage Results from infection secondary to lacerations, hematoma or surgical incisions . Commonly caused by Pseudomonas aeruginosa

19. Clinical features Pain, swelling and tender to touch Patient often has fever Necrosis of the cartilage, fibrosis and scarring if not treated immediately.

20. Treatment Should be prompt and vigorous High dose ciprofloxacin should be used. Local applicants- magnesium sulfate for soothing Incision and drainage and C/S if abscess formed. Surgical debridement to remove unhealthy granulations and necrosed cartilage.

21. Relapsing perichondritis A rare autoimmune disorder involving cartilage of the ear. Any cartilage can be involved. Entire auricle except its lobule becomes inflammed and tender. External ear canal becomes stenotic . Treatment consists of high dose of systemic steroids.

22. Relapsing polychondritis

23. Chondrodermatitis nodularis chronica helicis Small painful nodules near the free border of helix. Tender and patient unable to sleep on the affected side Treatment is surgical excision of the nodule with its skin and cartilage.

24. Chondrodermatitis nodularis chronica helicis

25. Tumors Benign tumors Hemangioma Sebaceous cyst Dermoid cyst Papilloma Keratoacanthoma Neurofibroma Malignant tumors Squamous cell carcinoma Basal cell carcinoma Melanoma

26. Hemangioma Benign tumors of blood vessels Congenital tumor commonly seen in children Bleeds frequently May get infected Treatment: surgical excision

27. Dermoid cyst Developmental cyst Presents as round mass over the upper part of mastoid behind the pinna Treatment: surgical excision

28. Sebaceous cyst Cysts of sebaceous glands Contains cheesy materials Common site is postauricular sulcus or below and behind the ear lobule Treatment: total surgical excision

29. Papilloma May present as a tufted growth or flat grey plaque and is rough to feel Viral in origin Treatment: surgical excision or curettage with cauterization of its base.

30. Squamous cell carcinoma It can arise anywhere in the external ear, commonly helix. May present as a painless nodule or an ulcer with raised everted edges and indurated base. Grows rapidly, invades the surrounding bone and spreads through lymphatics Treatment: Small lesions with no nodal metastasis- local excision with 1 cm of external auditory canal Lesions with nodal metastasis- total amputation of the pinna, often with en bloc removal of parotid gland and cervical lymph nodes.

31. Squamous cell carcinoma

32. Basal cell carcinoma Commonly seen over helix and tragus More common in men beyond 50 yrs Presents as nodule with central crust, removal of which results in bleeding. Ulcer has a raised or beaded edge Lesion often extends circumferentially into the skin, may penetrate deeper to cartilage or bone Treatment: Superficial lesion not involving cartilage- irradiation and avoidance of cosmetic deformity Lesions involving cartilage- surgical excision as in SCC

33. Basal Cell Carcinoma

34. Diseases of External A uditary Canal Congenital disorders Trauma Inflammation Tumors Miscellaneous conditions

35. Congenital anomalies Congenital atresia of the EAC May be either complete or incomplete . Due to failure of canalization of the ectodermal core that fills the dorsal part of the first brachial cleft. The outer meatus is obliterated with fibrous tissue or bone while deep meatus and TM are normal Usually a/w anotia , middle ear and/or inner ear deformities Hearing loss may be CHL, SNHL or mixed .

36. Treatment Reconstructive surgery for atresia of EAC (unsatisfactory results) BAHA or Bonebridge implant system to achieve good hearing system.

37. BAHA implant Bonebridge implant

38. Collaural fistula An abnormality of the first branchial cleft. The fistula has 2 openings: one situated in the neck just below and behind the angle of mandible and the other in the external canal or the middle ear.

39. Treatment: surgical exploration and excision

40. Trauma to the ear canal May range from minor laceration of EAC wall to fracture of the bony wall Foreign body in the EAC may cause trauma to the wall of ear canal. There may be pain together with bleeding due to laceration. May get infected if treatment is delayed

41. Treatment: Minor injuries require no treatment. Oral and local antibiotics in more severe cases Ribbon gauze soaked in 10% ichthyol in glycerine as an ear pack Reduction of fracture only necessary if the fracture produces occlusion of the EAC

42. Inflammations of EAC May be divided into Infective group Bacterial Localized otitis externa (furuncle) Diffuse otitis externa Malignant otitis externa Fungal otomycosis Viral Herpes zoster oticus Otitis externa hemorrhagica

43. Reactive group Eczematous otitis externa Seborrhoeic otitis externa neurodermatitis

44. Furuncle (Localized otitis externa ) Infection of hair follicle in the outer cartilaginous part of the EAC Commonly caused by Staphylococcus aureus . Follows trauma like scratching or cleaning of the EAC by matchsticks, cotton buds, hair clips, nails, etc. Symptoms Earache Swelling/abscess Discharge Hearing loss

45. Signs Inflamed skin and swelling Tenderness: tragal tenderness and also with movement of auricle Discharge Granulations Hearing loss Furuncle at posterior meatal wall causes oedema over the mastoid with obliteration of the retroauricular groove. Preauricular l.n . may be enlarged and tender

46. Treatment Analgesics and local heat Antibiotics ( cloxacillin ) Ear packing with 10% ichthyol in glycerine or other medicated wick Incision and drainage if abscess formed

47. Diffuse otitis externa Diffuse inflammation of meatal skin which may spread to involve the pinna and epidermal layer of TM Commonly seen in hot and humid climate and in swimmers. Most common factors are Trauma to the meatal skin Invasion by pathogenic organisms ( S. aureus , P. pyocyaneus ) Clinical features very similar to localized otitis externa .

48. Differentiating features from localized form are: Entire EAC is uniformly inflamed and swollen and there is discharge. No abscess formation No swelling in the areas adjoining the EAC in diffuse otitis externa

49. Treatment Ear toilet Medicated wicks: aluminium acetate(8%) or silver nitrate(3%) Antibiotics: cloxacillin or flucloxacillin or ciprofloxacin together with pseudomonas coverage analgesics

50. Malignant otitis externa Aka necrotizing otitis externa It is an inflammatory condition caused by Pseudomonas infection usually in the elderly diabetics, or in those on immunosuppressive drugs. Early manifestation resemble diffuse otitis externa but there is excruciating pain and appearance of granulations in the ear canal. Facial paralysis is common Infection may spread to the skull base and jugular foramen causing multiple cranial nerve palsies.

51. Diagnosis Severe otalgia in an diabetic patient with granulation tissue in the EAC. CT scan may show bony destructions Gallium -67 scan Technetium 99 bone scan

52. Treatment Control of diabetics Toilet of ear canal. Remove discharge, debris and granulations or any dead tissue or bone and send for culture sensitivity. Antibiotic treatment continued for 6-8 weeks Gentamicin combined with ticarcillin Third generation cephalosporins : ceftriaxone 1-2 g/day iv or ceftazidime 1-2 g/day iv combined with aminoglycosides Quinolones are also effective: combined with rifampin

53. Otomycosis Is a fungal infection of the EAC caused either by Candida albicans or Aspergillus niger . Seen in hot and humid climate. Occurs commonly after entry of water in the EAC, after putting oil and after prolonged use of topical antibiotic eardrops. Commonly occurs together with CSOM which is actively discharging

54. Clinical features Itching Aural fullness Discomfort and pain Discharge Tenderness (in severe case) Examined with otoscope , A. niger appears as black headed filamentous growth and C. albicans appear as yellowish deposit.

55. Treatment: Thorough cleaning Broad spectrum topical antifungals ( clotrimazole for 10 days) If there is discharging COM, treat COM as well.

56. Herpes zoster oticus Aka Ramsay Hunt Syndrome An infection caused by Varicella Zoster virus. Usually disease of adults Characterized by formation of vesicles on the tympanic membrane, meatal skin, concha and postauricular groove. Patient is ill, complains of severe earache and may have fever. May involve CN VII and VIII Triad of SNHL, vertigo and facial palsy

57. Treatment Oral acyclovir along with high dose steroids . Labrynthine sedatives for vertigo

58. Otitis externa hemorrhagica Viral in origin and may be seen in influenzae epidemics. Characterized by formation of hemorrhagic bullae on the tympanic membrane and deep meatus. Severe pain and bloody discharge when bullae rupture

59. Treatment Analgesics for pain relief Antibiotics for secondary infection of the middle ear if the bulla has ruptured.

60. Eczematous otitis externa Result of hypersensitivity to infective organisms or topical ear drops such as chloromycetin or neomycin. Characterized by intense irritation, vesicle formation, oozing and crusting in the canal. Treatment is withdrawal of causative agent and application of steroids.

61. Miscellaneous conditions Wax Secreted by sebaceous gland. Two types: hard and soft. Seen when self-cleansing mechanism of the ear is disturbed. So, cleaning with cotton buds, hair clips, matchsticks should be avoided.

62. Clinical features Discomfort/itching Feeling of blocked ear Hearing loss Tinnitus Cough vertigo

63. Treatment Wax without pain Suctioning Removal by jobson horne probe Syringing

64. Wax with pain ( a/w otitis externa ) A ntibiotic ear drops followed by wax softners . Oil based antibiotic eardrop such as chloramphenicol is preferred to other antibiotic because it also softens the wax to some extent. Then removed as described above.

65. Foreign body Common in children than adults. Common foreign bodies in the EAC Children Inanimate FB- pieces of paper, eraser, sponge, lead of pencil, etc Vegetable matter- beans, seeds, etc Insects- flea, tick, housefly, maggots, etc Adults Inanimate FB- cotton wool Insects- flea, tick, housefly, maggots, etc

66. Clinical features Children often do not tell their parents that they have put a FB in the ear due to fear; incidental finding Small inanimate FB- no symptoms Mild hearing loss Intense pain – live insects Examination reveals FB in the EAC

67. Treatment Live insects should be first killed by putting oil or water and then only be removed Methods of removal 1. Removal under microscope

68. 2. Removal by ear syringing

69. 3. Use of head mirror and ear instruments

70. Keratosis obturans A condition characterized by excess accumulation of hard whitish- yellow debris consisting of desquamated epithelium in the bony part of EAC. Eventually cause pressure on the bony walls of the EAC and cause resorption of the bone Clinical features Blocked ear Pain and discharge if a/w otitis externa Cholesteatoma like mass (pearly white hard debris covered by wax) Automastoidectomy

71. Treatment Removal as done for wax General anesthesia may be required because of the pain Recurrent collection of desquamated epithelium, so regular follow up required.