Nipun Malhotra Maulana Azad Medical College

Auricle - formed by a framework of cartilage, except the lobule which mainly has adipose tissue

External Ear Canal (EAC) - 24 mm in length - Lateral third is cartilaginous, and has pilosebaceous units - Medial third is osseous, and is devoid of pilosebaceous units - Santorini ducts

External ear also includes the lateral part of Tympanic Membrane.

Infectious

Reactive
Exematous OE

Bacterial
Furuncle Diffuse OE

Fungal (Otomycosis)

Viral
Seborrheic OE

Neurodermatitis

Malignant OE HZ Oticus Hemorrhagic OE

Infection of apopilosebaceous unit Lateral 1/3 of external auditory canal Pathogen: Staphylococcus sp. Presents as painful well circumscribed erythematous pustule around the hair

Symptoms
Pain Hearing loss

Signs

Marked tenderness Tragal sign Edema, may obliterate post-auricular sulcus Conductive hearing loss

Treatment

Hot fomentation and analgesics Oral antibiotics Ichthammol glycerine 10% ear-pack Abcess incision and drainage If recurrent, rule out diabetes

Diffuse involvement of meatal skin Two factors responsible for this condition are Trauma to the meatal skin Invasion by pathogenic organisms Pseudomonas Staphyloccus sp. Diffuse otitis externa can be Acute Chronic

Acute phase
Severe pain, aggravated on jaw movements Discharge initially serous, later becomes purulent Marked tenderness on manipulation of tragus (Tragal Sign) or pinna Decreased hearing due to collection of debris in the canal Otoscopy diffuse inflammation of meatal skin - TM - dull

Chronic Phase
Itching (indicates chronic phase) Discharge scanty, may be absent Otoscopy inflammed meatus, debris, sometimes skin hypertrophies to cause occlusion of the meatus (stenotic OE)

Ear toilet acute phase - remove exudate and debris - dry mopping, suction-clearance or irrigation with saline - Anterior recess Medicated wicks antibiotic-steroid combination - reduce edema and increase absorption Analgesics Systemic antibiotics Chronic phase reduce swelling and itching - icthammol glycerine - or steroid-antibiotic cream Stenosis surgery

Fungal infection of External Auditory Canal skin Most common organisms: Aspergillus and

Candida

Clinical Features Itching most prominent symptom Sense of fullness Watery discharge with musty odour On examination
Aspergillus niger black growth (Wet newspaper) Aspergillus fumigatus pale blue / green growth Candida albicans ceamy white mass

Ear toileting to remove epithelial debris &discharge Topical antifungals- Clotrimazole Nystatin (Candida) Keratolytics like 2% salicylic acid to remove infected skin

Aggressive infection of external canal, progressively spreading to soft tissues, bone of skull base and ultimately to intracranial structures It is rare, occurs in elderly with Diabetes and in immunocompromised, very rare otherwise It occurs secondary to Otitis externa Pseudomonas main causative, Staph. Aspergillus most commmon fungal cause Presents with severe otalgia, otorrhea Characteristic finding granulation tissue at floor at osseo-cartilaginous junction Canal is occluded

Necrotising OE spread

Destruction of base of skull spread to dura and to intracranial structures- produces headache, vomitting Facial nerve palsy involved at stylomastoid foramen Posteriorly to mastoid air cells Medially to middle ear and petrous bone Jugular foramen and temporomandibular joint rare

Treatment

Tobramycin, Ceftazidime i.v., oral for 6 weeks Surgery- Debridement of non-viable bone and facial nerve decompression Serial gallium scans, CT scans Hyperbaric oxygen

Viral infection Varicella zoster, involving VII nerve Early phase Unilateral burning pain, fever, malaise Late phase vesicles on meatal skin, choncha, post auricular groove, otalgia, SNHL Ramsay Hunt Syndrome VII and VIII nerve involvement Treatment Acyclovir 800mg five times a day for 10 days Steroids

Postherpetic neuralgia is very common

Viral - Infuenza virus or Mycoplasmal in origin Hemorrhagic bullae on TM and skin of deep meatus Clinical Features Severe pain Serosanguinous discharge Treatment Analgesics mainstay Role of antibiotics

Eczematous OE
Occurs as allergic reaction to topical agents, commonly neomycin, or hair sprays, shampoos etc. Presents with vesicles on choncha and external canal with irritation and oozing

Seborrheic OE
Part of Seborrheic dermatitis (of scalp) Presents with greasy scales on pinna and external canal and itching, with similar symptoms of scalp

Neurodermatitis
Caused by compulsive scratching due to psychological factors Treatment psychotherapy prevention of secondary infection (ear bandage may be used)

It occurs after radiotherapy Often difficult to treat Limited infection treated like Chronic Otitis Externa Involvement of bone requires surgical debridement and skin coverage

Perichondritis and cellulitis

Cause Staphylococcus Treatment oral antibiotics

Canal Stenosis

Post chronic OE, due to fibrosis and adhesions Surgery- bone is drilled and meatus is lined by aplit skin graft

TM perforation Malignant OE

Cellulitis and Perichondritis

Post OE or trauma Distinguished by presence of induration in perichondritis Treatment oral antibiotics

Erysipelas
Cause - hemolytic Streptococci General infection of face

External Canal Cholesteatoma

Very rare Presents as OE with a bony crater filled with infected keratin debris, in the floor of the external canal May be associated with OME Erosion may extend into mastoid Treatment debridement and follow-up Differentiated from Keratosis obturans by presence of bone erosion

Granulating OE
Occurs post surgery or after treatment of OE Treatment removal of granulations and topical antibiotics and steroids

Recurrent Polychondritis
Autoimmune disease Cartilage of ear, nose and bronchus involved Treatment oral corticosteroids

Chondrodermatitis nodularis helicis

Winklers disease Nodule on helix or anti-helix Treatment excision of skin and cartilage

Lymphadenosis cutis benigna

Bfverstedts disease Nodule on lobule Cause Borrelia

Thank you for the patient hearing.