EAR INFECTIONS

1. INFECTIONS OF AURICLE
2. INFECTIONS OF EAC
3. INFECTIONS OF TYMPANIC MEMBRANE

1. PERICHONDRITIS
2. RELAPSING
POLYCHONDRITIS

1. MYRINGITIS BULLOSA
2. MYRINGITIS
GRANULOSA

DISEASES OF
PINNA
DISEASES OF EAC
DISEASES OF
TYMPANIC
MEMBRANE
HERPES ZOSTER OTICUS
1. OTITIS EXTERNA

DEFENSE MECHANISM OF THE EAR CANAL
1. Multicellularity of the skin
2. Tight impermeable barrier formed by keratin
3. Non keratinizing cells ( melanocytes , merkel cells , langerhans)
4. Skin appendages (hairs , apopilosebaceous unit )
5. Cerumen
6. Ph - 4-5 , hydrophobic secretions
7. Lysozyme , immunoglobulins
8. Extensive collateral circulation in dermis & subdermis
9. Inflammation induced response



ACUTE LOCALISED OTITIS EXTERNA
Furuncle
Infection of a single hair follicle
Confined to lateral (cartilagenous ) part only
Microorganism Staph aureus

CLINICAL FEATURES
1. Extremely painful ear
2. Ear blockade
3. Scanty serosanguinous ear discharge
4. Auricle and tragus tender on palpation(tragal sign)
5. Edema of the canal
6. Abscess point in canal


TREATMENT
1. Oral / systemic anti staphycoccal antibiotic
2. Topical antibiotic
3. I/D
4. Ichthammol glycerine , aluminium acetate for local application
5. Eradication with nasal mupirocin or oral flucloxacillin


DIFFUSE OTITIS EXTERNA ( SWIMMERS
EAR )
An inflammatory/ infective condition of the skin of
auditory canal charecterized by general edema,
erythema , itchy discomfort & ear discharge
Prevalence 0.4 % per year

PREDISPOSING FACTORS
1. Anatomical ( narrow / obstructed canal)
2. Dermatological (eczema , seborrhoea )
3. Allergy
4. Humid climate
5. Trauma
6. Swimming



CLINICAL FEATURES
1 Pain
2 Itching
3 Erythema , edema of the canal
4 Purulent otorrhoea ,debris
5 Sensation of fullness in the ear

mc organism is pseudomonas


TREATMENT
Local care,
Topical antibiotic,
Steroid
Culture, oral antibiotic
Debridement

MALIGNANT OTITIS EXTERNA
Aggressive & potentially life threatening
infection of soft tissues of the ear canal &
surrounding structures , quickly spreading to
involve the periosteum & bone of skull base.

Predisposing factors are diabetes &
immunocompromised state

Commonest Organism is Pseudomonas /
Aspergillus ( rarely )


CLINICOPATHOLOGICAL
CLASSIFICATION
STAGES
1. Clinical evidence of MOE with infection beyond
EAC but negative bone scan.
2. Infection beyond EAC with positive bone scan.
3. As above but with CN palsy
3a single
3b multiple
4. Meningitis, empyema, sinus thrombosis or brain
abscess.
CLINICAL FEATURES












1. Pain out of proportion
2. Otorrhoea
3. Resistant to local therapy for 8-
10 days
4. Background history Diabetes or
Immunocompromised state
5. Purulent aural discharge
6. Headache , TMJ pain
7. Multiple Cranial nerve palsies
8. Granulation in the floor of EAC



INVESTIGATIONS
1. ESR
2. CRP
3. Culture & Sensitivity
4. Tc 99m Radionuclide bone scan
5. HRCT /CT
6. Ga 67 scan
7. MRI


















AGGRESSIVE
SOFT TISSUE
INFECTION
( GALLIUM SCAN
Ga 67,monitor)
BONE
INFECTION
(BONE SCAN Tc
99)
NECROTIZING OTITIS
EXTERNA
SKULL BASE
OSTEOMYELITIS
MALIGNANT OTITIS
EXTERNA
USAGE OF IMAGING
INITIAL EVALUATION







THERAPEUTIC MONITORING
BONE SCAN CONFIRMS BONE INVOLVEMENT
GALLIUM SCAN MONITOR PROGRESS / RESOLUTION
OF INFECTION
CT EXTENT OF DISEASE
GALLIUM SCAN EVERY 4 WEEK
CRITERIA TO DIAGNOSE SKULL BASE
OSTEOMYELITIS
REQUIRED POSITIVE BONE SCAN
POSITIVE GALLIUM SCAN

SUGGESTED GRANULATION TISSUE IN FLOOR OF EAR
CANAL.
RESISTANT TO LOCAL THERAPY FOR 8-10
DAYS
POSITIVE PSEUDOMONAS CULTURE
CRANIAL NERVE PALSIES
DIABETES MELLITUS /
IMMUNOCOMPROMISED STATE
TREATMENT

1.Aural toilet ( Control granulation & improve local pain )
2.Systemic antibiotics ( FLOROQUINOLONES &THIRD GENERATION
CEPHALOSPORINS for 6 weeks / RIFAMPICIN )
3.Topical Antibiotics (Role controversial )/ Local GENTAMYCIN Beads
may be used
4.Hyperbaric Oxygen
5.Surgery ( Remove sequestration , collection of pus , debride
necrotic tissue / granulation / skullbase abscess )


OTOMYCOSIS
10% of all cases
Common in hot humid climate , secondary to prolong antibiotic
usage, diabetes, immunocompromised state
Microorganism
1. Aspergillus (80 90 %)
2. Candida (10 - 20 %)
CLINICAL FEATURES
1. Black(Aspergillus) , grey , green , yellow , white(candida)
discharge
2. Debris resemble wet newspaper / cotton ball/ ink
blot
3. Itching
4. Otalgia
5. Deafness


TREATMENT
1. Aural toilet
2. Topical Antifungal Ear drops ( 1% CLOTRIMAZOLE &
TOLNAFATE , 1% SALICYLIC ACID , 2% ACETIC ACID )
3. Avoid water
4. Discontinue antibiotics
5. Immunotherapy with dermatophtye extract in
resistant cases
HERPES ZOSTER OTICUS
Ramsay Hunt syndrome
Herpetic vesicular rash on the concha EAC , pinna with
LMN facial palsy ipsilateral side.

Reactivation of Varicella Zoster infection from dormant
viral particles resident in geniculate ganglion of facial
nerve, and spiral & vestibular ganglion of eighth cranial
nerve
CLINICAL FEATURES
1. Hearing loss
2. Tinnitus
3. Vertigo
4. Otalgia
5. Vesicular rash on
concha, canal, pinna
6. LMN type facial nerve
palsy



TREATMENT
1. ACYCLOVIR & PREDNISOLONE oral within 3 days of onset.
2. FAMCYCLOVIR / VALACYCLOVIR
3. Bacitracin ointment
4. Surgical decompression of Facial nerve
BULLOUS MYRINGITIS
Vesicles in superficial layer of tympanic membrane b/w outer
epithelial & lamina propia
Etiology
Influenza virus
Mycoplasma pneumoniae


CLINICAL FEATURES
1. Adolescent age group
2. Otalgia(sudden onset,throbbing, U/L)
3. Symptoms usually during an episode of URTI
4. Blood stained discharge
5. Blood filled, serous ,serosanguinous blister in tympanic
membrane & in medial aspect of ear canal
6. Hearing impairement
7. Tympanic membrane is usually intact


INVESTIGATIONS

Microscopy
Pneumatic otoscopy
Tympanometry
PTA
TREATMENT
1. Analgesics

2. Antibiotic (middle ear seems affected)

3. Spontaneous resolution

GRANULAR MYRINGITIS
Granulation tissue in the lateral aspect of
tympanic membrane & ear canal

PATHOLOGY
Occurs due to non specific injury of lamina
propia of tympanic membrane
ETIOLOGY
1. High ambient temperature
2. Swimming
3. Lack of hygiene
4. Local irritation
5. Foreign body
6. Bacterial / fungal
7. Complication of Tympanic membrane graft
CLINICAL FEATURE
1.Foul smelling discharge
2.Fullness / irritation
3.Hearing impairement
4.Tinnitus
5.Purulent secretion
6.No perforation
7.Granulations in posterosuperior part

INVESTIGATIONS

Microscopy
PTA
Pneumatic otoscopy

TREATMENT
1. Microscopic debridement under LA or GA
2. Antibiotic ear drops
3. Removal of granulation tissues
4. Caustic agents ( silver nitrate )
5. Laser

PERICHONDRITIS
Infection/Inflammation of perichondrium of external ear
Micro organisms
P.aeruginosa ( 75-80%)
S.aureus
ETIOLOGY
1. Post traumatic
2. Iatrogenic / post operative
3. Post infective ( Malignant otitis externa , herpes zoster )
4. Burns
5. Frost bite
6. Unknown

PATHOLOGY
Thickening of perichondrium and destruction of cartilage by phagocytes
CLINICAL FEATURES

1. Antecedent history of trauma / surgery/ ear
piercing/hematoma auris.
2. Dull pain in the ear
3. Diffuse red swelling of the auricle
4. Lobule is spared


TREATMENT

1. Antibiotics
Antipseudomonal
IV / oral
2 I & D ( sub perichondrial abscess )
3. Excision of necrosed cartilage and overlying skin
& subcutaneous tissue
4. Total chondrectomy with the placement of a
mesh gauge in b/w the layers
5. Continous drainage & irrigation

COMPLICATIONS
1. Cauliflower ear
2. Collapse of the auricular
cartilage
3. Cellulitis


ACUTE OTITIS MEDIA
Acute suppurative otitis media is defined as suppurative
infection involving the mucosa of the middle ear cleft. By
convention it is termed acute if the infection is less than 3 weeks
in duration.
S Pneumoniae, H. Influenza, and M Catarrhalis.
STAGES
1. Stage of hyperemia

2. Stage of exudation

3. Stage of suppuration

4. Stage of resolution.

TREATMENT
Acute suppurative otitis media is a self limiting condition. If appropriate
antibiotics is started early then it resolves. Amoxycillin is the drug of
choice.
CHRONIC SUPPURATIVE OTITIS MEDIA
Chronic suppurative otitis media is defined as a chronic
infection of the mucosa lining the middle ear cleft. Middle
ear cleft include the eustachean tube, hypotympanum,
mesotympanum, epitympanum, aditus and mastoid air
cell system.
Chronic suppurative otitis media is of two types:
1. Tubotympanic disease (safe type) mucosal
2. Atticoantral disease (unsafe type) squamosal

CLINICAL FEATURES OF TUBOTYMPANIC
DISEASE:

1. The discharge in this condition is profuse and mucopurulent in nature.
2. The discharge is not foul smelling.
3. Since the infected area is open at both ends i.e. the eustachean tube end
and the perforation in the ear drum, the discharge doesnot accumulate in
the middle ear.
4. The ossicular chain is not at risk in this type of disorder, the conductive
deafness caused is due to the presence of perforation in the tympanic
membrane and thickening of the tympanic membrane.
5. Conductive deafness may also be accentuated by thickening of round
window membrane due to the presence of secretions. Hearing loss is usually
about 30 - 40 dB.
6. These patients have poorly pneumatised / sclerosed mastoid air cell system.
This feature has been attributed to repeated attacks of middle ear infections
during childhood causing inadequate pneumatisation of mastoid air cell system.
In patients with pneumatised mastoid air cell system repeated middle ear
infections can cause sclerosis with evidence of new bone formation. Mastoids
in these patients may be sclerotic.
Ps. aeruginosa, E. coli, and B. proteus
TREATMENT

Antibiotics
Oral / topical
Antihistaminics
Treat any focal URI/ DNS
ATTICOANTRAL TYPE OF DISEASE (UNSAFE TYPE
OF DISEASE)

This is termed as unsafe because dangerous intra cranial and extra cranial
complications can occur, proving fatal to the patient. This disease spreads by
erosion of the bony wall of the attic. Cholesteatoma is commonly present in
this condition. This disease is commonly seen in sclerosed mastoid cavities.
Presence of granulation tissue is also common in this disorder.

MANAGEMENT
PUS C/S
PTA
X RAY MASTOIDS
HRCT
MASTOID EXPLORATION
WAX
SEBUM
DESQUAMATED
EPITHELIUM, HAIR ,
FOREIGN BODY
CERUMEN
IMPACTED
WAX
2 Phenotypes ( Dry & Wet )

May be golden brown / light gray in colour

Composition
1. Lipid 46% - 73%
2. Protein
3. Free amino acid
4. Trace minerals
Mean mass produced 2.81 mg/week

Antibacterial & antifungal properties ( lysozyme ,
immunoglobulins , PUFA )

Hydrophobic action

Incidence 2% -6%

Causes
1. Excessive formation
2. Excessive desquamation
3. Less oily sebaceous secretion
4. Stiff hair
5. Narrow canal
6. Presence of exostosis
7. Excess obliquity of the canal
8. Occupational factors
9. Hot & dry climate
10. Apprehensive patients
CLINICAL FEATURES






TREATMENT

1. Decreased hearing
2. Irritation & itching
3. Otalgia
4. Tinnitus / vertigo
5. Cough reflex


1. Syringing
2. Removal using hook /
forceps
3. Waxolytic agents



DESTINY IS NOT A MATTER OF CHANCE, IT IS A
MATTER OF CHOICE ,IT IS NOT A THING TO BE
WAITED FOR , IT IS A THING TO BE ACHIEVED
WILLIAM JENNING BRYAN


Thank You