Diseases of the external ear include otitis externa (inflammation due to infection or allergy), cerumen impaction, foreign bodies, trauma, perichondritis (cartilage infection), auricular hematoma etc. Skin conditions like eczema, psoriasis, and dermatitis may affect the pinna. Tumors, both benign (exostoses) and malignant (squamous cell carcinoma), also occur.
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DISEASES OF THE EXTERNAL EAR
Overview
Anatomy
Categories - Traumatic
- Infection and Inflammatory
- Tumors
- Miscellaneous
THE EXTERNAL EAR IS COMPOSED OF:
Auricle
The external auditory canal
Epithelial surface of the tympanic membrane
ANATOMY OF PINNA
Composed of fibroelastic
cartilage, to which skin
and subcutaneous tissue
is closely attached.
ANATOMY OF EXTERNAL AUDITORY CANAL
S- shaped
Approx. 2.5 cm long
Outer 1/3 rd cartilagenous, inner 2/3 rd bony
Skin of outer 1/3 rd-thicker, 0.5 – 1 mm, contains hair follicles, sebaceous and apocrine glands
Skin of bony 2/3 rd- 0.2 mm thick
Fissures of Santorini
Isthmus of bony EAC , anteroinferior recess
Fig. External auditory canal
TRAUMA TO THE AURICLE
Haematoma auris
Lacerations
Avulsions
Frostbite
Burns
Haematoma auris
Collection of blood between auricular cartilage and perichondrium.
Aetiology - Blunt trauma (boxers, rugby players, wrestlers)
Bluish swelling in entire or upper part of auricle.
If left untreated - Cauliflower ear, infection, perichondritis.
TREATMENT
Wide bore needle aspiration and pressure dressing (in small and acute case).
Adequate I & D with through and through mattress sutures.
Sharp ring curette to remove clots and dental rolls on both sides of pinna (in delayed case)
Antibiotics
Haematoma of auricle
Cauliflower ear
Laceration of pinna
Sharp trauma, RTA
Treatment:
Suture as soon as possible under aseptic condition.
Antibiotics
Avulsion of pinna
Cause- RTA
If pinna is still attached by a small pedicle- primary reattachment.
If completely avulsed- reimplantation by microvascular technique.
Frostbite of pinna
Pinna – susceptible to frostbite.
Initial vasoconstriction followed by hyperaemia and oedema and increased capillary permeability.
Ice crystallization of intracellular fluid and necrosis of tissues occur.
Ear- swollen, red, tender, bullae, necrosis.
TREATMENT
Rapid rewarming of ear (wet sterile cotton pledgets at 38 to 42 C)
Analgesics
Antibiotics
Delayed debridement
Burns
CAUSE - Fire, scalding liquids.
1st degree burn- erythema
2nd degree burn- blistering
3rd degree burn- full thickness
COMPLICATION- Perichondritis
TREATMENT
Gentle cleaning, Topical antibiotics
Antipseudomonal antibiotics
Debridement and skin grafting (late stage)
INFECTION AND INFLAMMATORY DISEASES OF THE AURICLE
CELLULITIS AND ERYSIPEALS
Infection of skin & subcutaneous tissues
Group A beta haemolytic Streptococci, Staph sp.
Minor trauma, surgery, ear pricking
Cl/f – Swelling, tenderness, erythema of auricle, fever, region of inflammation well demarcated in erysipeals.
Treatment- Antibiotics (Penicillins)
Fig. Cellulitis of pinna
ALLERGIC DERMATITIS OF AURICLE
Ear drops, ear discharge, metals.
Cl/f- Erythema, itching, swelling in allergen exposed area.
Treatment
- Removal of allergen
- Topical corticosteroids
- Oral antihistaminics
PERICHONDRITIS
Infection or inflammation involving the perichondrium of the external ear.
Aetiology – Trauma, surgery, burns, frostbite, infection of haematoma, high piercing of auricle, inadequately treated otitis externa.
Organisms – Pseudomonas aeruginosa, S. aureus
Cl/f-
Erythematous, swollen, tender pinna
Serous/ purulent exudates
Subperichondrial abscess formation in untreated cases
Loss of cartilage leads to deformity of pinna
TREATMENT
In early/mild case- Topical & oral antibiotics
In advanced case- Hospitalization,
Iv antibiotics
In auricular abscess- I & D , (all necrotic cartilage should be debrided).
RELAPSING POLYCHONDRITIS
Autoimmune disease manifested by intermittent episodes of inflammation of cartilage and connective tissues at various body parts.
May involve cartilage of ear, nasal septum, larynx, trachea, costal cartilage.
Mc Adam et al established diagnostic signs.
Auricular cartilage is most commonly involved.
Both sides involved simultaneously or alternately.
Presents as recurrent episode of red, swollen, tender auricle.
Treatment – Corticosteroids, Recently use of anti- CD4 monoclonal antibodies and oral Minocycline reported. (Scott Brown’s 7th Edition)
CHONDRODERMATITIS NODULARIS CHRONICA HELICIS
Painful nodule on the rim of helix with grayish crust on the surface.
Affects older men.
Treatment –
Corticosteroid injection for pain relief.
Excision with a wedge of cartilage.
TOPHI
Deposits in helix of sodium biurate crystals.
Moderately painful salmon pink nodules.
On compression, tophi exudes whitish, chalky substance.
Treatment –
Analgesics
Treatment of gout
TUMORS OF THE AURICLE
BENIGN
Hemangioma
Sebaceous cyst
Keloids
Keratoacanthoma
Cutaneous horn
Chondroma
Papilloma
MALIGNANT
Squamous cell carcinoma
Basal cell carcinoma
Melanoma
HEMANGIOMA
Congenital tumors, manifest in childhood.
Parts of face or neck may be involved.
Capillary hemangioma – spider nevus or portwine stain.
Portwine stain- Increases in size till adolescence.
Cavernous hemangioma (strawberry tumor)-
Regress spontaneously.
Treatment – Surgical excision and skin grafting, Cryosurgery, electrolysis, tattooing for portwine stain
SEBACEOUS CYST
Sites- Posterior surface of lobule, skin over mastoid process, below the ear lobule
Treatment – Surgical excision
KELOIDS
Excessive scar at site of trauma ( ear piercing, surgery)
Genetic predisposition
Black population
Ear – lobule, helix
Treatment- Excision followed by periodic injection of Triamcinolone
Low dose radiation therapy
KERATOACANTHOMA
Benign tumor, actinic exposure.
Common site – Anterior to tragus.
Cl/f – Raised nodule with central crater (keratin plug)
Treatment – Excision biopsy
SQUAMOUS CELL CARCINOMA
Auricle – 6% of all skin cancer (Ballenger)
55% of all malignancy of auricle is SCC.
Risk factors – Prolonged sun exposure, fair skin.
Cl/f – Painless nodule or ulcer with everted edges, indurated base on the helix.
Treatment – Wide excision and reconstruction.
BASAL CELL CARCINOMA
Age > 50yrs
Site – Helix, tragus
Cl/f – Painless, well circumscribed ulcer with raised/beaded margin, bleeds easily.
Lesion may extend deeper tissues or circumferentially
Treatment – Wide excision and post-op radiotherapy
MELANOMA
Risk factors – Prolonged sun exposure, fair skin
Any part of auricle, nodular pigmented lesion which tends to enlarge rapidly or ulcerate.
Metastasis – 16-50%
Treatment- Surgery is planned according to extent of disease.
PSEUDOCYST OF AURICLE
Common in China
Localised, subperichondrial cystic swelling in upper part of anterior aspect of pinna.
Degenerate of cartilage, straw colored fluid.
Treatment – Under aseptic condition aspiration with syringe followed by through and through sutures.
EAR LOBE CREASE
Diagonal crease across the ear lobule.
Old age
Increased cholesterol
DISEASES OF EXTERNAL AUDITORY CANAL
TRAUMA OF EAC
Injury to EAC skin – Hair pins, match-stick, unskilled instrumentation
Minor trauma- No treatment, Antibiotics, Medicated ear pack.
Fracture of EAC – Head injuries, strong blow to the mandible
Treatment – Repositioning lacerated tissues & bone in the canal & packing canal with medicated gauze.
INFECTION AND INFLAMMATION OF EAR CANAL
FURUNCULOSIS
Staphyloccocal infection of the hair follicle.
Acute localised otitis externa.
Cartilagenous part of EAC.
Single, sometimes multiple.
Diabetes
Clinical features-
Severe earache, feels ear blocked, sometimes scanty serosanguinous discharge.
Tragal tenderness,movement of pinna tender.
Furuncle on posterior meatal wall causes oedema over mastoid & obliteration of retroauricular groove.
Preauricular lymphadenopathy.
TREATMENT
Antibiotics(Penicillinase resistant penicillin, Cephalosporins)
I G ear pack
Analgesics
If abscess, I & D
In recurrent case – Exclude DM & find other sources.
DIFFUSE OTITIS EXTERNA
Diffuse inflammation of skin of EAC with oedema, erythema, itchy discomfort and usually an ear discharge.
Predisposing factors:
Hot, humid climate
Swimming
Trauma to canal (scratching)
Narrow EAC
Obstruction of EAC (foreign body, exostosis, impacted wax)
Allergy
Diabetes
Microbiology of otitis externa (Scott Brown’s 7th edition)
Pseudomonas spp. 50-65%
Other gram negative org. 25-35%
Staphylococcus aureus 15-30%
Streptococci 9-15%
PATHOLOGY
Clinical course divided into 3 stages:
Pre-inflammatory
Acute inflammatory (mild, moderate, severe)
Chronic inflammatory
Diagnosis:
Pain, itch, oedema, erythema of EAC.
Purulent otorrhoea and debris in meatus.
Sometimes lymphadenopathy.
Outcomes:
Cellulitis of surrounding tissues
Perichondritis, chondritis, parotitis
Fig. Diffuse otitis externa
Treatment:
Aural toilet
Topical medication (Medicated wick or drops)
Antibiotics
Analgesics
Prevention- Keep ear dry.
Avoid scratching.
CHRONIC OTITIS EXTERNA
Low grade, diffuse infection and inflammation of EAC that persist for months or years.
Clinical features:
- Irritation, itching, ear discharge.
- Thickening of meatal skin with reduced lumen.
- Pus and debris in meatus.
Fig. Chronic Otitis externa
Treatment:
Aural toilet
Topical antibiotics and steroids
If canal stenosis – canalplasty.
ECZEMATOUS OTITIS EXTERNA
Hypersensitivity to topical ear drops, ear discharge.
Cl/f – Intense irritation, vesicles, oozing, crusting in the canal.
Treatment- Withdraw offending agent
Aural toilet
Steroid cream
SEBORRHOEIC DERMATITIS
Associated with dandruff of scalp
May lead to diffuse otitis externa
Cl/f – Itching
Scales in EAC, postauricular sulcus
Treatment-
Ear toilet
Cream with salicylic acid & sulphur
Treatment of seborrhoea of scalp
Fig. Seborrhoeic Dermatitis
NEURODERMATITIS
Compulsive scratching due to psychological factors.
Intense itching leads to otitis externa.
Treatment-
Local steroid preparation
Bandage
Psychotherapy
MALIGNANT OTITIS EXTERNA
Aggressive, life threatening infection of external ear and surrounding structures rapidly spreading to involve the periosteum and skull bone.
Synonym- Necrotizing external otitis.
Pseudomonas aeruginosa-95%, Rarely Aspergillus.
Elderly diabetic, Immunocompromised.
Term coined by Chandler in 1968.
Infection from EAC progresses to cellulitis, chondritis, periostitis, osteitis and finally osteomyelitis.
Clinical features –
Aural pain
Otorrhoea
Sense of aural fullness
Inflammation and granulations in EAC
Exudates
Oedema of EAC
Cranial nerve involvement
Fig. Malignant otitis externa
IMAGING
High resolution CT scan – demonstrate bone destruction
Tc-99 radionuclide bone scan- reveals osteomyelitis
Gallium scan – useful monitor of treatment
MRI
OUTCOMES AND COMPLICATIONS
Extensive skull base osteomyelitis
Spread of infection to sphenoid, carotid, TM joint, parapharyngeal space
Facial nerve palsy (60%)
IX, X, XI cranial nerve palsies
Lateral sinus thrombophlebitis
Mortality – Presence of cranial nerve palsy (80%)
TREATMENT
Hospitalization, early & aggressive treatment
Antipseudomonal antibiotics for prolonged duration
Aural toilet (daily debridement of EAC)
Analgesics, control of diabetes
Hyperbaric oxygen therapy
Surgery (debridement of sequestra, granulations)
OTOMYCOSIS
Fungal infection of EAC
Aspergillus (80-90%), Candida (10-20%)
Risk factors – Prolonged topical antibiotic use, DM, Immunosuppression, hot & humid climate.
Cl/f – Itchy ear, sense of ear blockage, hearing loss, ear discharge, pain in ear.
On examination -
Canal erythema
White, gray, black fungal debris in canal
Mild canal oedema
TREATMENT
Thorough aural cleaning and drying.
Topical antifungal
HERPES ZOOSTER OTICUS
J.Ramsay Hunt described it first in 1907.
Viral infection caused by varicella zooster.
Reactivation of dormant viral particles in the geniculate ganglion of VII nerve.
Ramsay Hunt Syndrome – herpes zooster of pinna with otalgia and facial paralysis.
Clinical features -
Auricular pain, fever, malaise
Vesicles in pinna, EAC, TM
Hearing loss, tinnitus, vertigo
Facial nerve palsy
Zoster sine herpete
TREATMENT-
Oral Acyclovir & Prednisolone within 3 days of onset.
TUMORS OF EAC
BENIGN
Osteoma
Exostosis
Adenoma(ceruminoma)
Papilloma
MALIGNANT
Squamous cell carcinoma
Basal cell carcinoma
Adenoid cystic carcinoma
Ceruminous adenocarcinoma
Melanoma
EXOSTOSIS
Benign growth of periosteal bone.
Bilateral, multiple, sessile, smooth, broad based protrusion from deeper part of EAC.
Related to cold water exposure.
Cl/f – Asymptomatic, retention of cerumen or debris, recurrent otitis externa, chronic infection, hearing loss.
Treatment – Periodic cerumen disimpaction
Surgical excision via postaural or endaural approach.
Fig. Exostosis
OSTEOMA
Benign tumor of bone.
Arises from cancellous bone.
Unilateral, single, smooth, bony hard, pedunculated mass from lateral EAC.
Cl/f similar to exostosis.
Treatment- Surgical excision
Fig. Osteoma
CERUMINOMA
Adenoma of sweat gland origin.
Solid, cystic or papillary pattern.
Biopsy to r/o malignancy.
Treatment – Wide excision due to local recurrence.
ADENOID CYSTIC CARCINOMA
Display cribriform, tubular or solid growth pattern surrounded by cystic spaces.
Local tissue destruction, perineural & perivascular invasion, lymphnode metastasis.
Treatment – Aggressive surgical resection + radiotherapy
SQUAMOUS CELL CARCINOMA
Commonest malignant tumor.
May arise from meatus or middle ear.
Clinical features:
Pain in ear
Otorrhoea
Bleeding
Aural fullness
Hearing loss
On examination
Bleeding polypoid mass in EAC
Granulations or ulceration in EAC
Facial nerve palsy
Regional lymphadenopathy
MANAGEMENT
EUM
Biopsy
CT scan or MRI
Treatment – Wide surgical excision with post-op radiotherapy.
CERUMEN
Secretions of sebaceous gland, ceruminous gland, epithelial debris, keratin, dirt.
Wet phenotype – Caucasians, Negroes
Dry phenotype – Mongolians
Protect from infection
Factors for impaction of wax:
Narrow EAC
Exostosis
Excess sweating
Geriatic & mentally retarded patients
Clinical features –
Blocked ear
Hearing loss
Tinnitus
Giddiness
Reflex cough
Earache
TREATMENT
Removal by syringing or instrument
If impacted – Wax solvent (5% soda bicabonate + glycerine)
FOREIGN BODY
Common in paediatric age group.
Example – Paper, grain seeds, cotton, slate pencil, metallic ball, broken matchstick, button batteries, Living insects
Cl/f – Asymptomatic, pain or ear discharge.
Living insect cause intense irritation & pain.
Fig. Foreign body in ear
TYPE OF FOREIGN BODY & REMOVAL METHOD
Living insect First kill by oil instillation
Irregular object Forceps removal
Organic objects Avoid syringing
Button batteries Remove urgently
Round, hard, smooth, non
graspable object
KERATOSIS OBTURANS
Mass of desquamating squamous epithelium
Aetiology- uncertain, faulty migration
Unilateral pain, CHL , otorrhoea, young pts
Association- Bronchiectasis, Sinusitis
Signs- Pearly white mass in EAC, bony canal ballooning.
Treatment- Removal, canalplasty
Fig. Keratosis obturans
CHOLESTEATOMA OF EAC
Localised bone erosion by squamous tissue from ear.
Aetiology – Uncertain, postsurgical or post-traumatic.
Pathology – Localised erosion of EAC, sequestration of bone.
Cl/f – Chronic otorrhoea, itchy, pain in ear, older age.
Treatment - Surgery
ACQUIRED STENOSIS OF EAC
Formation of fibrous tissue lateral to tympanic membrane.
EAC becomes blind skin lined pouch.
Aetiology – Chronic otitis externa, trauma, surgery, burns, psoriasis, eczema.
Cl/f – CHL, Oedema and hypertrophy of canal wall skin.
Treatment- Medical, surgical (wide meatoplasty)
DISEASES OF TYMPANIC MEMBRANE
Bullous myringitis
Granular myringitis
BULLOUS MYRINGITIS
Vesicles in the superficial layer of tympanic membrane.
Aetiology – Virus (Influenza), M. pneumoniae
Cl/f – Sudden unilateral otalgia, hearing loss,
Serosanguinous blisters on tympanic membrane and medial eac.
Treatment – Analgesic , topical ear drops
Fig. Bullous myringitis
GRANULAR MYRINGITIS
Inflammation of tympanic membrane with granulation tissue on lateral aspect of pars tensa.
Aetiology – Local trauma or infection
Cl/f – Unilateral foul smelling ear discharge, aural fullness, irritation, granulation in tympanic membrane diffusely or localised.
Treatment – Microscopic debridement, topical steroids & antibiotics, topical chemical therapy for granulations.
