Earache discharge and ear ache

This presentation discusses ear discharge, ear ache and their management.

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Ear ache & Ear discharge
Dr T Balasubramanian

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Anatomy
External ear
Middle ear
Internal ear

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External ear
Pinna
External auditory canal
Lateral surface of ear drum

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PINNA - ANATOMY

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PINNA INNERVATION

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Pinna Innervation

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External auditory canal
Outer 1/3 cartilagenous
Inner 2/3 bony
About an inch long
Postero-superior wall – 25 mm
Antero-inferior wall – 31 mm

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External canal - Innervation

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Innervation of middle ear
Sensory supply to middle
ear is via
glossopharyngeal
component of tympanic
plexus
Jacobson's branch of
glossopharyngeal nerve
is the precise supply
Medial portion of ear
drum is supplied via
chorda tymopani

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Inner ear innervation
Inner ear is supplied by vestibulocochlear nerve
This nerve doesnt have pain fibers, significant
pathologies of inner ear can develop without painful
symptoms
Vestibulocochlear nerves are sensitive to stretch. In
Meniere's disease considerable enlargment of
membranous labyrinth can cause stretching of these
nerves leading on to a sense of fullness in the ear

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Otalgia
Is defined as pain localised to the ear
It can either be primary / referred
Primary otalgia is caused by pathology localized to the
ear
Referred otalgia is caused by disorders not related to
the ear but to its nerve supply

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Primary otalgia
External ear causes
Middle ear causes
Inner ear causes

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External ear causes of otalgia
Also known as otitis externa
This is a very painful condition
Patient usually lose sleep
Tragal sign positive

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Otitis externa classification
Acute diffuse otitis externa (commonly bacterial)
Acute localised otitis externa (Furuncle)
Chronic otitis externa
Eczematous otitis externa
Fungal otitis externa
Malignant otitis externa

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Otitis externa – Predisposing factors
Absence of cerumen
Removal of cerumen by ear buds
Frequent exposure to water

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Anti infective role of cerumen
Protects external canal skin from moisture
It has antibacterial properties
Lowers the pH of external canal making the
environment difficult for pathogens to colonize

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Role of water in otitis externa
Macrerates skin lining of external canal
Increases the pH of external canal making the
environment favorable for bacterial colonization

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Furuncle
Tragal sign positive
Affects cartilagenous
portion of external
canal because of hair
follicles
Staph aureus is the
common infecting
organism

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Acute diffuse otitis externa
Also known as swimmer's ear
Skin of external canal is involved in a diffuse manner
Water exposure is the common cause
External canal is itchy
External canal diameter is reduced due to oedema
Conductive deafness (rare)

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Chronic otitis externa
Unrelenting pruritus
Mild pain
External canal skin appears dry
Fungal infections commonly cause this problem
Dermatological condition like eczema

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Managment
Treatment of infection
Removal of epithelial debris
IG paint dipped wick to reduce oedema
Anti-inflammatory drugs

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Otomycosis

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Malignant otitis externa
Misnormer
Common in elderly diabetics
Pseudomonas is the causative organism
External canal granulation
Facial paralysis
Erosion of temporal bone
Nocturnal otalgia

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Malignant otitis externa (contd)
History of trivial trauma (ear bud use) +
Granulation begins at the bony cartilagenous junction
Discharge from external canal scanty
No fever / constitutional symptoms

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Malignant otitis externa (Images)

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Bullous myringitis
Also known as bullous otitis externa
Acute infection of ear drum and external auditory
canal
There is intra epithelial fluid collection
Bullae may be present over the lateral surface of ear
drum
Bullae may also be present in the external auditory
canal
Otalgia with serous / bloody ear discharge common

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Management of Bullous myringitis
Decompression of bullae – if otalgia is intense
Topical / oral antibiotics
Steroids
Analgesics

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Middle ear causes of otalgia
Acute otitis media (AOM)
Eustachean tube dysfunction
Otitis barotrauma

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AOM
Ear drum could be seen
bulging
Accumulation of fluid in
the middle ear cavity
Preceded by URI
Common in children
Pain subsides when drum
perforates

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Ramsay Hunt Syndrome
Herpes zoster oticus
Otalgia +
Facial palsy (LMN)
Rash over ipsilateral pinna / external canal
Otalgia is due to irritation of 7th nerve due to Herpes
virus infection

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Ramsay Hunt syndrome (Contd)

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Relapsing polychondritis
Involves cartilage of pinna and external auditory canal
Intense otalgia is seen
End stage is fibrosis
Sparing of lobule differentiates it from cellulitis

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Neoplasms
Primary neoplasms of pinna / external canal
Neoplasms involving skull base
Malignancy involving ceruminous glands

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Miscellaneous causes
Trauma
Hematoma
Seroma
Frost bite
Burns / Thermal injuries

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Referred otalgia
TM joint disorders
Eagle syndrome
Gerd
Neuralgias
Neoplasms of oropharynx/oral cavity
Cervical arthritis

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Ear discharge
Wax (Normal)
Pus
Mucous
Blood
CSF
Saliva

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Purulent discharge
Acute suppurative otitis media
Chronic suppurative otitis media
Rupturing furuncle of external auditory canal

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Sinister ear discharge
Scanty
Purulent
Discharge associated with excessive otalgia
Discharge associated with giddiness
Discharge associated with head ache
Discharge associated with tinnitus

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Otoscopy

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Complications of discharging ear
Deafness
Extracranial Intra temporal complication
Extra cranial complication
Intra cranial complication
Facial nerve paralysis
Lateral sinus thrombosis

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Thank you

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Management
Aural toilet
Culture
Topical antibiotics – CSOM
Systemic antibiotics – ASOM / AOM
Resistant cases / unsafe - surgery