Diseases of the external ear

1. Diseases of the
External ear
Dr. Krishna Koirala

2. Diseases of Pinna
1. Congenital
– Minor : Accessory auricular tags , Bat ear
Pre - auricular sinus
– Major : Anotia ,Microtia
2. Traumatic
– Hematoma , lacerations

3. 3. Inflammatory : Perichondritis
4. Neoplastic : Squamous cell carcinoma
Basal cell carcinoma
5. Others : Sebaceous cyst ,lipoma ,
keloids, Pseudocyst pinna

4. • Small pit leading to a blind tract that lies adjacent
to helix
• Due to incomplete fusion of first and second
branchial arches (Hillocks of His)
• Unilateral : L>R
• Bilateral : (25 - 50%), more like to be hereditary
• Mostly asymptomatic
Preauricular sinus

5. • Repeated infections
– Surgical excision of the sinus with complete
removal of tract along with a portion of
auricular cartilage
– Recurrence is common ( tracts arborize and
follow a tortuous course)

7. • Collection of blood and serum under the
perichondrium of pinna
• Pathology : Shearing forces to the auricle and pinna
resulting in separation of the perichondrium from the
underlying cartilage
• Seen in boxers, wrestlers, judo players ,athletes
• More common on the lateral surface
• Pinna : Swollen, bluish, tender on touch
Hematoma of the pinna

9. • Infection
– Perichondritis and abscess formation
– Thickening and cauliflower ear
– Necrosis of the cartilage
• Treatment
– Broad spectrum antibiotics sensitive to Pseudomonas and
Staphylococcus. Eg. Ceftriaxone, ciprofloxacin
– Wide bore needle aspiration and tight pressure dressing
– Incision and drainage
– Debridement of necrosed cartilage

10. Incision and drainage
Vaseline gauze being applied
Compression dressing on progress

11. • Inflammation of the perichondrium of auricular
cartilage
• Commonly caused by Pseudomonas
• Predisposing factors
– Laceration, piercing, mastoid surgery, otitis
externa
– Frostbite, burns, infections of pinna , relapsing
polychondritis
Perichondritis

12. • Clinical Features
– Pain & swelling of pinna
– Tender pinna
– Fluctuation +/-
– Fever +/-
• Treatment
– High dose i.v. antibiotics eg. Ciprofloxacin , Ceftriaxone,
Cefotaxime, Flucloxacillin, Amoxyclav, Cefuroxime
– Local application of Magnesium sulphate
– I & D of abscess
– Surgical debridement to remove necrosed cartilage

13. • Localized subperichondrial fluctuant swelling of the
auricle
• Etiology : Idiopathic, Viral
• Frequently encountered during monsoon season
• Presence of sterile clear fluid in subperichondrial
plane with no definite cyst wall
• Appears insidiously, mild discomfort +
• Variable size , fluctuation +
Pseudocyst of pinna

16. • Treatment
– Aspiration and quilting
– Surgical deroofing followed by buttoning
– Intralesional steroids following aspiration
– Incision and drainage with removal of a part of
cartilage

17. Diseases of the External Auditory Canal
• Congenital
– Congenital atresia of EAC
– Stenosis
• Inflammatory
– Otitis externa
• Neoplastic
– Osteoma
– Squamous cell carcinoma
– Basal cell carcinoma
• Traumatic
– Iatrogenic / Accidental
• Miscellaneous
– Wax
– Foreign bodies
– Keratosis obturans
– Acquired atresia of EAC
– Exostoses

18. Otitis Externa
Classification According to extent of lesion
• Localized : Furunculosis
• Diffuse : Idiopathic, Traumatic , Irritant, Allergic,
Bacterial/ fungal, Climatic / environmental
• Invasive : ( Granulomatous / Necrotizing / Malignant)
• Part of generalized skin condition : Seborrhic
dermatitis, Atopic, Allergic , Psoriasis
• Others : Keratosis obturans

19. Furunculosis
• Infection of hair follicle of external auditory canal by
Staph. aureus , Pseudomonas
• Painful, tender well circumscribed lesion
• Pain aggravated by jaw movements
• Meatus occluded by swelling – conductive hearing
loss
• Carbuncle / regional lymphadenitis
• May coexist with diffuse otitis externa : otorrhea ,
debris
• Postauricular swelling ( cellulitis / lymphadenopathy)

21. Treatment
 Cleaning of EAC (Aural toileting)
 Packing of EAC
 Wick soaked in steroid antibiotic cream
 Ichthamol Glycerin ( IG) : analgesic, anti inflammatory,
antibiotic, dehydrator
 Systemic antibiotics : Flucloxacillin, Ciprofloxacin
 Analgesics
 Warm saline dressings
 Incision and drainage if suppuration occurs
 Recurrence : R/O Diabetes mellitus !!!

22. Diffuse Otitis externa
• Tropical ear/ Singapore ear
• Aggravating factors : Local trauma , heat, humidity, bathing
• Causative agents : Pseudomonas, Proteus, Staph. aureus
• Stages
– Acute
•Earache aggravated by jaw movement
•Swelling of the soft tissue around the ear
•Red, swollen, tender canal skin
•Pus / debris in the meatus
•TM dull & injected

23. – Chronic
•Irritation of ear/discharge
•Decreased hearing
•Thickened meatus skin / reduced lumen with pus &
debris
•Granulations in the TM
• Treatment
– Careful cleaning of meatus preferably under the
Microscope
– Steroid - antibiotic ear packing or Antibiotic - steroid ear
drops
– Systemic antibiotics

24. Otomycosis
• Fungal infection of EAC
• Organisms : Aspergillus niger, Candida, Dermatophytes
• Predisposing conditions : Extremely moist, hot environment,
Chronic bacterial otitis externa
• Symptoms : Itching , aural fullness, earache, discharge,
swelling
• Signs
– Grayish white debris resembling wet filter paper filling the
meatus ( Candida)
– Black specks in the debris (conidiophores of Aspergillus)
– Injected canal wall

27. Treatment
• Thorough cleaning of all accumulated debris
• Antiallergics, analgesics
• Topical antifungals
– Nystatin, clotrimazole (1%) for 2-3 wks
– Topical gentian violet solution
• Burrow's solution ( 5% aluminum acetate solution )
– Reduces the swelling and removes the debris

28. • Rapidly progressive bacterial infection of external
auditory meatus, surrounding soft tissues and skull
base
• Predisposing factors
– Elderly , poorly controlled diabetics, atherosclerosis,
immunosuppressed, prolonged steroid use,
hypogama - globulinemia , AIDS
Malignant Otitis externa ( Skull base
Osteomyelitis)

29. • Causative organisms
– Pseudomonas, Staph. epidermidis, Aspergillus
fumigatus
• Hallmark of disease
– Granulation tissue at the junction of cartilaginous
and bony EAC
– Pain out of proportion of the disease in EAC

30. EAC
Secondary osteomyelitis of petrous Apex
Thrombosis of lateral sinus,
superior and inferior petrosal sinus
IX, X, XI,XII cranial nerve
palsy
Tympanic plate, Mastoid tip Tympanomastoid suture,
Adjacent soft tissues
Parotid gland ,TMJ
Facial Palsy
Spread of Disease
Floor of MCF, Basisphenoid

31. • Investigations
– CBC, RBS / Urea
– CT Scan / MRI
– Gallium bone scan
• Treatment
– Control of diabetes and other predisposing factors
– Debridement of necrotic tissues
– Administration of antibiotics( high dose , broad spectrum)
•Ciprofloxacin 750 mg twice daily for 6-12 weeks
•Ceftriaxone 1 gm I.V. BD 7-10 Days

32. Exostoses of EAC Osteoma of EAC
More common Less common
Smooth, sessile, hemispherical Pedunculated ,round
In deep bony meatus At outer part of bony
meatus
Dense ivory bone ( V-notch : Di’s
notch )
Osteoid bone
Aggravated by surfing in cold
water
Unknown
Usually bilateral Usually unilateral
Seperated by suture lines Arises from suture
lines
Less recurrent More recurrent

33. Keratosis obturans
• Keratotic mass of desquamated epithelium in bony portion of
EAC obstructing it
• Pearly white / obscured by wax
• Common age : 5 -20 yrs
• Etiology
– Idiopathic
– Chronic hyperemia  desquamation of keratin 
epidermal debris
– Faulty migration of squamous epithelial cells
– May be associated with bronchiectasis & sinusitis

34. Clinical Features
• Pain in the ear, aural fullness
– Bilateral symptoms in children
– Unilateral predominately in adults
• Hearing loss (conductive) , otorrhea (rare), tinnitus
• Geometrically patterned keratin plug within the lumen of
expanded ear canal( onion skin )
• Erosion and abnormal widening of deep osseous meatus
(eburnated bony canal , ballooning of EAC)
• TM usually intact
• Mucopurrullent discharge (rare)

35. Treatment
• Removal of the Keratotic mass by
instrumentation (LA /GA)
• Treatment of inflammation
• Keratolytics - not helpful
• Canalplasty ( recurrent cases)
• Regular follow – up , May recur!!