Diseases of External ear

1. Diseases of External Ear
Dr Sumeet Angral

2. Pinna
A. Congenital,
B. Traumatic,
C. Inflammatory or
D. Neoplastic disorders.

3. A. CONGENITAL DISORDERS
1. Anotia. complete absence
2. Microtia.
3. Macrotia. excessively large pinna.

4. 4. Bat ear:
• Abnormally protruding ear.
• The concha is large with poorly developed antihelix and scapha.

5. A. CONGENITAL DISORDERS
5. Cup Ear or Lop Ear:
• hypoplasia of upper third of the
auricle. Upper portion of helix
or pinna is cupped.
6. Cryptotia:
• Upper third of the auricle is
embedded under the scalp skin.

6. A. CONGENITAL DISORDERS
7. Coloboma.
• There is a transverse cleft in the pinna in the
middle.
8. Minor Deformities.
• Absence of tragus, Darwin’s tubercle
9. Deformities of Ear Lobule.
• They are absence of lobule, large lobule, bifid
lobule or a pixed (attached) lobule.

7. A. CONGENITAL DISORDERS
10. Preauricular Tags or Appendages.
• skin-covered tags
• line drawn from the tragus to angle of mouth.
11. Preauricular Pit or Sinus.
• depression in front of crus of helix or above tragus.
• an epithelial track
• due to incomplete fusion of tubercles (hillocks of his).
• repeatedly infected causing purulent discharge.
• Treatment is surgical excision of the track if the sinus gets
repeatedly infected

8. B. TRAUMA TO THE AURICLE
1. Haematoma of The Auricle. Cauliflower ear
(pugilistic or boxer’s ear)
• collection of blood between the auricular cartilage and its
perichondrium.
• blunt trauma in boxers, wrestlers and rugby players.
• Extravasated blood
• If infected, severe perichondritis.
• Treatment -
• aspiration of the haematoma,
• pressure dressing,
• prophylactic antibiotics.

9. B. TRAUMA TO THE AURICLE
2. Lacerations
• repaired as early as possible (2 layers).
3. Avulsion of Pinna.
• pinna is still attached to the head by a small
pedicle of skin: primary reattachment
• Completely avulsed:
• reimplanted by the microvascular techniques;
• cartilage implanted under the postauricular
skin.

10. B. TRAUMA TO THE AURICLE
4. Frostbite.
• Injury due to frostbite varies between erythema and
oedema, bullae formation, necrosis of skin and
subcutaneous tissue, and complete necrosis.
Treatment
• (a) rewarming with cotton pledgets.
• (b) 0.5% silver nitrate
• (c) analgesics
• (d) protection of bullae from rupture,
• (e) systemic antibiotics for deep infection,
• (f) surgical debridement.

11. B. TRAUMA TO THE AURICLE
5. Keloid of Auricle.
• follow trauma or piercing
• lobule or helix
• Surgical excision usually results in
recurrence.
• pre- and postoperative radiation
or local injection of steroid

12. C. INFLAMMATORY DISORDERS
1. Perichondritis:
• infection secondary to lacerations, haematoma or surgical
incisions.
• can also result from extension of infection from diffuse otitis
externa or a furuncle.
• Pseudomonas and mixed
• red, hot and painful pinna which feels stiff.
• Abscess
• necrosis of cartilage as the cartilage survives only on the
blood supply from its perichondrium.
Treatment
• systemic anibiotics and local application of 4% aluminium
acetate compresses.
• When abscess has formed: must drained

13. C. INFLAMMATORY DISORDERS
2. Relapsing Polychondritis.
• autoimmune disorder involving cartilage of the ear.
• Other cartilages, septal, laryngeal, tracheal, costal may also
be involved. The entire auricle except its lobule becomes
inflamed and tender. External ear canal becomes stenotic.
• Treatment: high doses of systemic steroids.
3. Chondrodermatitis Nodularis Chronica Helicis.
• Small painful nodules appear near the free border of helix in
men about the age of 50 years.
• Tender, unable to sleep on the affected side.
• Treatment is excision of the nodule with its skin and
cartilage.

14. D: Tumors - Benign
• 1. Preauricular sinus or cyst.
• 2. Sebaceous Cyst. Common site is postauricular sulcus or below and behind the ear lobule. Treatment is total surgical excision.
• 3. Dermoid Cyst. Usually presents as a rounded mass over the upper part of mastoid behind the pinna.
• 4. Keloid.
• 5. Haemangiomas. congenital tumours often seen in childhood. They are of two types:
• (a) Capillary haemangioma. It is a mass of capillary-sized blood vessels and may present as a “port-wine stain.” It does not regress
spontaneously.
• (b) Cavernous haemangioma (also called strawberry tumour). endothelial-lined spaces filled with blood. It increases rapidly during the first
year but regresses thereafter and may completely disappear by the fifth year.
• 6. Papilloma (wart). tufted growth or flat grey plaque and is rough to feel. It is viral in origin.
• 7. Cutaneous Horn. It is a form of papilloma with heaping up of keratin and presents as horn-shaped tumour.
• It is often seen at the rim of helix in elderly people. Treatment is surgical excision.
• 8. Keratoacanthoma. It is a benign tumour clinically resembling a malignant one. It presents as a raised nodule with a central
crater. Initially, it grows rapidly but slowly regresses leaving a scar. Treatment is excision biopsy.
• 9. Neurofibroma. It presents as a nontender, firm swelling. Treatment is surgical excision, if tumour occludes ear canal or presents
a cosmetic problem.

15. D: Tumors - Malignant
1. Squamous Cell Carcinoma.
• It may present as a painless nodule or an ulcer with raised everted edges and indurated base. Metastases to regional
lymph nodes occur very late.
• Treatment. Small lesions with no nodal metastases are excised locally with 1 cm of healthy area around it.
2. Basal Cell Carcinoma.
• It presents as a nodule with central crust, removal of which results in bleeding. Ulcer has a raised or beaded edge.
• Treatment. Superficial lesions, not involving cartilage, can be irradiated and cosmetic deformity avoided. Lesions
involving cartilage may require surgical excision as in cases of squamous cell carcinoma.
3. Melanoma. It may occur anywhere over the auricle.
• Treatment.
• Superficial melanoma, less than 1 cm is managed by wedge resection and primary closure.
• Superficial melanoma, larger than 1 cm, infiltrative melanomas,
• are treated by resection of pinna, parotidectomy and radical neck dissection.

16. II. DISEASES OF EXTERNAL AUDITORY CANAL
Congenital disorders
Trauma
Inflammation
Tumours
Miscellaneous conditions

17. A. CONGENITAL DISORDERS
1. Atresia of External Canal.
• Congenital atresia of the meatus may occur alone or in association with microtia.
When it occurs alone, it is due to failure of canalization of
2. Collaural Fistula.
• abnormality of the first branchial cleft.
• The fistula has two 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.
• The track of the fistula traverses through the parotid in close relation to the facial
nerve.

18. B. TRAUMA TO EAR CANAL
Minor lacerations of canal skin
• result from scratching the ear with hair pins, needles or matchstick)
• They usually heal without sequelae.
Major lacerations
• result from gunshot wounds, automobile accidents or fights.
• These cases require careful treatment.
• Stenosis of the ear canal is a common complication.

19. C. INFLAMMATIONS OF EAR CANAL
Otitis externa may be divided, on aetiological basis, into:
1. Infective Group
• Bacterial
• Viral
• Fungal
2. Reactive Group
• Eczematous otitis externa
• Seborrhoeic otitis externa
• Neurodermatitis

20. C. INFLAMMATIONS OF EAR CANAL
(a) Furuncle (Localized Acute Otitis Externa).
• staphylococcal infection of the hair follicle.
• severe pain and tenderness which are out of proportion
to the size of the furuncle. Jaw movements also cause
pain.
Treatment:
• systemic antibiotics, analgesics and local heat.
• An ear pack of 10% ichthammol glycerine provides
splintage and reduces pain.
• If abscess has formed, incision and drainage should be
done.

21. C. INFLAMMATIONS OF EAR CANAL
(b) Diffuse Otitis Externa.
•Diffuse inflammation of meatal skin which may spread to involve the pinna and epidermal layer
of tympanic membrane.
•Aetiology. commonly seen in hot and humid climate and in swimmers.
•Excessive sweating - changes the pH - acid to alkaline - favours growth of pathogens.
•Two factors(i) trauma to the meatal skin and (ii) invasion by pathogenic organisms.
•Common organisms: Staphylococcus aureus, Pseudomonas pyocyaneus, Bacillus proteus and
Escherichia coli.
•Hot burning sensation in the ear, followed by pain which is aggravated by movements of jaw.
•Meatal lining becomes inflamed and swollen. Meatal skin which is thick and swollen may also
show scaling and fissuring.
•Rarely changes to chronic stenotic otitis externa.
Treatment.
•(i) Ear toilet: All exudate and debris gently removed.
•(ii) Medicated wicks. a gauze wick soaked in antibiotic steroid preparation is inserted in the ear
canal. Wick is changed daily for 2–3 day.
•(iii) Antibiotics. Broad-spectrum systemic antibiotic.
•(iv) Analgesics. For relief of pain.

22. Otomycosis

23. C. INFLAMMATIONS OF EAR CANAL
(c) Otomycosis.
• occurs due to Aspergillus niger, (A. fumigatus or Candida albicans).
• Treatment consists of thorough ear toilet to remove all discharge and epithelial debris, broad-spectrum antifungal
agents include clotrimazole and povidone iodine.
(D) Otitis externa haemorrhagica:
• formation of haemorrhagic bullae on the tympanic membrane and deep meatus. It is probably viral in origin
• causes severe pain
• Treatment with analgesics is directed to give relief from pain.
• Antibiotics are given for secondary infection of the ear canal, or middle ear if the bulla has ruptured into the middle ear.
(e) Herpes Zoster Oticus.
• It is characterized by formation of vesicles
• on the tympanic membrane, meatal skin, concha and postauricular groove.
• The VIIth and VIIIth cranial nerves may be involved.

24. C. INFLAMMATIONS OF EAR CANAL
(f) Malignant (Necrotizing) Otitis Externa.
• It is an inflammatory condition caused by pseudomonas infection usually in the elderly diabetics.
• 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.
• Anteriorly, infection spreads to temporomandibular fossa,
• posteriorly to the mastoid and medially into the middle ear and petrous bone.
CT scan may show bony destruction but is often not helpful.
Gallium-67 is more useful in diagnosis and follow-up of the patient. It can be repeated every 3 weeks to monitor the disease
and response to treatment.
Technetium 99 bone scan reveals bone infection but test remains positive for a year or so and cannot be used to monitor the
disease.
Treatment. It consists of:
• (i) Control of diabetes.
• (ii) Toilet of ear canal. Remove discharge, debris and granulations or any dead tissue or bone.
• (iii) Antibiotic treatment against causative organism, which in most ears is P. aeruginosa, Antibiotic treatment is continued for 6–8 weeks, sometimes more.

25. C. INFLAMMATIONS OF EAR CANAL
(g) Eczematous Otitis Externa.
•hypersensitivity to infective organisms or topical ear drops such as chloromycetin or neomycin, etc.
•It is marked by intense irritation, vesicle formation, oozing and crusting in the canal.
•Treatment is withdrawal of topical antibiotic causing sensitivity and application of steroid cream.
(h) Seborrhoeic Otitis Externa.
•It is associated with seborrhoeic dermatitis of the scalp.
•Itching is the main complaint.
•Greasy yellow scales are seen in the external canal, over the lobule and postauricular sulcus.
•Treatment consists of ear toilet,
•application of a cream containing salicylic acid and sulfur, and attention to the scalp for seborrhoea.
(i) Neurodermatitis.
•It is caused by compulsive scratching due to psychological factors.
•Patient’s main complaint is intense itching.
•Treatment is sympathetic psychotherapy and that meant for any secondary infection. Ear pack and bandage to the ear are helpful to
prevent compulsive scratching

26. TUMOURS OF EXTERNAL AUDITORY CANAL:
BENIGN TUMOUR
1. Osteoma.
•arises from cancellous bone and presents as a
•single, smooth, bony, hard, pedunculated tumour,
•often arising from the posterior wall of the osseous meatus, near its outer end
(Figure 16.4).
•Treatment is surgical removal by fracturing through its pedicle or removal with a
drill.
2. Exostoses.
•They are multiple and bilateral
•presenting as smooth, sessile, bony swellings in the deeper part of the meatus
near the tympanic membrane.
•seen in persons exposed to entry of cold water in the meatus as in divers and
swimmers.
•Treatment.
•When small and asymptomatic, no treatment .
•Larger ones, which impair hearing or cause retention of wax and debris, may be
removed with high speed drill to restore normal sized meatus.

27. 3. Ceruminoma.
• tumour of modified sweat glands which secrete cerumen.
• presents as a smooth, firm, skin-covered polypoid swelling in outer part of the meatus,
• generally attached to the posterior or inferior wall.
• It obstructs the meatus leading to retention of wax and debris. Tumour has a tendency to recur,
therefore wide surgical excision should be done.
4. Sebaceous Adenoma.
• It arises from sebaceous glands of the meatus and presents as a smooth, skin-covered swelling in
the outer meatus.
• Treatment is surgical excision.
5. Papilloma.

28. MALIGNANT TUMOURS
1. Squamous Cell Carcinoma.
2. Basal Cell and Adenocarcinomas.
3. Malignant Ceruminoma.
4. Malignant Melanoma. Rare tumour.

29. E. MISCELLANEOUS CONDITIONS
• 1. Impacted Wax or Cerumen.
• Wax is composed of secretion of sebaceous glands, ceruminous glands, hair, desquamated epithelial debris, keratin and dirt.
• Secretion of both these glands mixes with the desquamated epithelial cells and keratin shed from the tympanic membrane
and deep bony meatus to form wax.
• Wax has a protective function
• it lubricates the ear canal
• entraps any foreign material.
• It has acidic pH and is bacteriostatic and fungistatic.
• Normally, only a small amount of wax is secreted, which dries up and is later expelled from the meatus by
movements of the jaw. As some people sweat more than others, the activity of ceruminous glands also
varies; excessive wax may be secreted and deposited as a plug in the meatus. It may dry up and form a hard
impacted mass.
• Treatment of wax consists in its
• removal by syringing or instrumental manipulation.
• Hard impacted mass may sometimes require prior softening with wax solvents.
• Technique of syringing the ear
• stream of water from the ear syringe is directed along the posterosuperior wall of the meatus.

30. E. MISCELLANEOUS CONDITIONS
2. Foreign Bodies of Ear.
(a) Nonliving.
•a piece of paper or sponge, grain seeds (rice, wheat, maize), slate pencil, piece of chalk or metallic ball bearings, broken end of matchstick, or an overlooked cotton swab.
•Vegetable foreign bodies tend to swell up with time and get tightly impacted in the ear canal or may even suppurate.
Methods of removing a foreign body include:
•(i) Forceps removal
•(ii) Syringing
•(iii) Suction
•(iv) Microscopic removal with special instruments
•(v) Postaural approach
(b) Living.
•Flying or crawling insects like mosquitoes, beetles, cockroach or an ant may enter the ear canal and cause intense irritation and pain.
•No attempt should be made to catch them alive.
•First, the insect should be killed by instilling oil (a household remedy), spirit or chloroform water.
Maggots in the ear.
•Flies may be attracted to the foul smelling ear discharge and lay eggs which hatch out into larvae called maggots.
•Treatment consists of instilling chloroform/turpentine oil water to kill the maggots, which can later be removed by forceps.

31. E. MISCELLANEOUS CONDITIONS
3. Keratosis Obturans.
• Collection of a pearly white mass of desquamated epithelial cells in the deep
meatus is called keratosis obturans.
• by its pressure effect - causes absorption of bone - widening of meatus - facial
nerve may be exposed and paralyzed.
• Examination, ear canal full of pearly white mass of keratin material disposed in
several layers.
• Removal of this mass may show widening of bony meatus with ulceration and
even granuloma formation.
• Treatment. Keratotic mass is removed either by syringing or instrumentation,
similar to the techniques employed for impacted wax.

32. E. MISCELLANEOUS CONDITIONS
4. Acquired Atresia and Stenosis of Meatus.
• It can result from:
• Infections, e.g. chronic otitis externa
• Trauma, e.g. lacerations, fracture of tympanic plate, surgery on ear canal or mastoid.
• Burns—thermal or chemical.
Treatment is meatoplasty. Using a postaural incision, scar tissue and
thickened meatal skin are excised, bony meatus is enlarged and the raw
meatal bone is covered with pedicled flaps from meatus or split-skin grafts.

33. III. DISEASES OF
TYMPANIC MEMBRANE
May be primary or secondary to conditions affecting external ear, middle ear or eustachian
tube.
1. Retracted Tympanic Membrane.
• It appears dull and lustreless. Cone of light is absent or interrupted. Handle of malleus appears foreshortened. Lateral
process of malleus becomes more prominent. Anterior and posterior malleal folds become sickle shaped
• A retracted tympanic membrane is the result of negative intratympanic pressure when the eustachian tube is blocked.
2. Myringitis Bullosa.
• painful condition characterized by formation of haemorrhagic blebs
• on the tympanic membrane and deep meatus.
• It is probably caused by a virus or Mycoplasma pneumoniae

34. III. DISEASES OF
TYMPANIC MEMBRANE
3. Herpes Zoster Oticus.
•viral infection involving geniculate ganglion of facial nerve.
•characterized by appearance of vesicles on the tympanic membrane, deep meatus, concha and retroauricular sulcus.
•It may involve VIIth (more often) and the VIIIth cranial nerves.
4. Myringitis Granulosa.
•Nonspecific granulations form on the outer surface of tympanic membrane. It may be associated with impacted wax, long-
standing foreign body or external ear infection.
5. Traumatic Rupture.
•Tympanic membrane may be ruptured by:
•(a) Trauma due to a hair pin, matchstick or unskilled attempts to remove a foreign body.
•(b) Sudden change in air pressure, e.g. a slap or a kiss on the ear or a sudden blast. Forceful Valsalva may rupture a thin atrophic
membrane.
•(c) Pressure by a fluid column, e.g. diving, water sports or forceful syringing.
•(d) Fracture of temporal bone.

35. III. DISEASES OF
TYMPANIC MEMBRANE
6. Atrophic Tympanic Membrane.
• In serous otitis media, the middle fibrous layer gets absorbed leaving a thin drumhead which easily gets collapsed with
eustachian tube insufficiency.
• A perforation of tympanic membrane also heals only by epithelial and mucosal layers without the intervening fibrous
layer.
7. Retraction Pockets and Atelectasis.
• When the tympanic membrane is thin and atrophic, a segment of it or the entire membrane may collapse inwards due
to eustachian tube insufficiency. It may form a retraction pocket or get plastered onto promontory and also wrap round
the ossicles.
• A deep retraction pocket may accumulate keratin debris and form a cholesteatoma.
8. Tympanosclerosis.
• It is hyalinization and later calcification in the fibrous layer of tympanic membrane.
• It appears as chalky white plaque.
• Mostly, it remains asymptomatic

36. • Thank you