Ear-Ext-Infect

1. External Ear
Dr. Yahia Abdelgawad
Ass. Prof. of ORL.

2. Anatomy and Physiology
all ear part intemporalbone

3. Consists of auricle and EAM.
EE Start
from
auricle
andend at TM
D
in

4. Anatomy and Physiology
• Auricle:
-mostly skin-lined cartilage,
except lobule(devoid of cartilage).
-has lateral and medial surface.
-consists of elevations and depressions
N.B: Skin over lateral surface of auricle is closely
adherant to the underlying pericondrium ? nosub
cut
an
space
sia.no
over
cartilage
Covert
External

5. Theimportan
oflocation
iiinflammation
occurtheres
no
space
for
inflammatory
edema.son
theres
inflammation
oniateraisureace
patient
wincommain
severepaindue
adnerentots.in
totneunaerying
mostimp pericondriumwitnon
epression satissue
lead
toEAC
mostimpeleration
outer

6. External auditory canal
Bonycartligenous canal
inadult_24mLGin
m
8mm Secretw

7. External auditory canal
➢ Skin-lined apparatus.
➢ Approximately 2.5 cm in length.
➢ Ends at tympanic membrane.
➢ Cartilage: outer 1/3.
➢ Bony: inner 2/3.
➢Skin linning of 2 parts differs.
Sshape
skin a
band
g
hairfollicle
sweat
gland
sebaceousr
f epidermis
devoid
of
ab
and
gse Thin
skin Bone Year
til
ageC
full
thickskin dermis
a
bandages
Bony
part
separate
EAC
fromME
lateral8mL Upward backwardmedial
Medial
16mL downwardforwardmedially
if Ineed
tostraight
theeartoseeTn pull
theear
13

8. Anatomy and Physiology
• Squamous epithelium
• Bony skin: thin
0.2mm
• Cartilage skin: thick
0.5 to 1.0 mm
Apopilosebaceous
unit.
devoidof
skinbandages
if
there
isdisease
affect
skin
abandgesitdoesnt
occur
here
egFr
uncut
ghas
additional
canal
ceruminous
glands secretewax
ecerumin
in
alllayers
dermis
epidermis
a
bandages asweat
gland
bsebaceous
chair
follicle
o

9. 1. S-shaped.
Must straightened during
examination by pulling
the pinna backward
upward and laterally.
- Has 2 constrictions:
Narrowest portion is at
bony-cartilage junction.
EAC
agriae
I nofraudedischarge
inbonypart
6mL
LateraltoTM

10. • EAC is related to following
structures:
– Tympanic membrane--
medially
– Mastoid--posteriorly
– Glenoid fossa--anteriorly
– Cranial fossa--superiorly
– Infratemporal fossa--
inferiorly
– Parotid and facial nerve--
inferiorly/anteriorly L
its
vertical
part
downin
Post
wall
Temporomandibular
jonintianterioly ofEAC
in
stylo
mastoid
foramen
interior
to
the
canal
in
their
anterior
to
canal
and
enter
parotid
gland Terminal
branch
to
external
ear

11. Anatomy and Physiology
• Innervation: cranial nerves: V, VII, X,
spinal: lesser occipital and great
auricular nerves (C2, C3).
• Arterial supply: superficial temporal,
posterior and deep auricular branches
• Venous drainage: superficial temporal
and posterior auricular veins
• Lymphatics: upper deep cervical.
richinsensory
inner
ratio
you
owlt.gr sb.J ss
x
x
x
* Teeth supply by same nerve → pain sharing
Related
Paintoear a HI
1face
nosepharynxLarynx mouen.tuyge.esopna.us
rochiea.ceruicaisPin
CIXX

12. DISEASES OF EXTERNAL EAR
May be:
1.Genetic or congenital.
2.Traumatic.
3.Inflammatory: (infectious or noninfectious).
4.Degenerative.
5.Neoplastic.
6.Mescelaneous.
MostimpfunctionofEE collection and conductionofsoundtoTMvibration
of Tn conduct
io
toIE
g
most
common
espiciallyinoldage
espiciallyinoldage
a
if destructionGAC training
loss boss
5 other

13. Otitis Externa (external otitis)
• Def: inflammation of external ear.
• Etiology: 1- infectious: bacterial, viral,
fungal, parasitic.
2- Non infectious: allergic
“eczematous”
• Classified (by time course) into: Acute,
Subacute, Chronic
accordingtoduration 523W
3w 3M 73M
Skin bone Carli
Hays

14. Acute Otitis Externa (AOE)
Bacterial AOE.
Diffuse localized
Diffuse Bacterial O E.
“swimmer’s ear”
• May be:
– Mild
– Moderate
– Severe
name b kthe
most
imp
Predisposing
factor
for
bacterial
otitis
externa
isexcessuseofwater
His Isin w se
3
degreeaccording toseverly

15. AOE: Mild to Moderate Stage
• Symptoms
–Pain, fullness
–pruritus
• Signs
–Erythema, redness
–Edema, swelling
–Canal debris,
discharge (purulent).
CIP
ifinflammation
block
by
edema
thecanal
hearing
loss
1 conductive
2 tinnitus
hotness
mucupurateonlyinME
of
inflamaeion
4 s
sever
C
3

16. AOE: Severe Stage
• Severe pain, worse with
ear movement
• Signs
– Lumen obliteration
HL
– Purulent otorrhea
– Involvement of
periauricular soft tissue.
You mast diff. between AOE and A. mastoiditis?
inflammation ofPost
auricular
roof
Cbcw
pinna
and
mastoid

17. AOE: Treatment
• 4 principles:
1. Frequent canal cleaning.
2. Antibiotics: topical and
systemic.
3. Pain control.
4. Instructions for prevention.
mastoiditis mastoid
part
oftemporalbone occur insomecasesofotitimedia
howtodifferentiateifthe
causeofinflammationis
otitis
mediaorexternal
otitis
byPost
auricular
roof
obliteratedin
otitis
externa
preservedinmastoiditis
fordischarge
according to culturandsensitivedischarge
Take swab senditto
analgesic
4
Keepthe car dry and clean 4
controlhumidly
if
drops
Acace

18. Chronic Otitis Externa (COE)
• Chronic inflammatory process
• Persistent symptoms > 3 months.
• Bacterial, fungal, dermatological
etiologies
L
acute chronic dueto
i ifpredisposing
factor
continue
a inadequate
treatment
3low
resistance
e
immunity

19. COE: clinical picture
• Symptoms:
• Pruritus---itching
• Mild discomfort
• Signs:
• Dry, Flaky and
Hypertrophied skin
• purulent otorrhea (occasional)
Same ofacute
otitisexterna
but nopain
andlonger
duration 3m

20. COE: Treatment
• Similar to that of AOE;
Frequent cleanings
Topical antibiotics and Steroids
• Surgical intervention;
–Failure of medical treatment
–to enlarge and resurface the EAC
ow

21. Furunculosis
def: staph infection of a hair follicle.
•Acute localized infection
•Lateral 1/3 of canal
•Obstructed apopilosebaceous unit
•Pathogen: S. aureus
Localizedbacterialinfection
doesn'toccurin
innerbony
partof
externalcanal
cartilagepart
obstruction
in
inflammat
abscess
sman
or
ear
0
localinfection

22. Furunculosis
Symptoms
•Localized pain
•Pruritus
•Hearing loss (if
lesion occludes canal) Sign
• Edema
• Erythema
• Tenderness
• Fluctuance
• Hearing loss
itching
abscess
Localized
fluid
inside
swelling
or
cyst
fluidimi g lil

23. Furunculosis:
Treatment
1.Local heat
2.Analgesics
3.Antibiotics: (anti-staphylococcal )
Oral or IV.
4.Incision and drainage: for localized
abscess
fluctuance ow Wd
staph jl Il A
biopsy of
notnarrowspectrum
Abor not
sensitive
tostaph
spontaneous drainge ordo2
Pusmast to
0
Pass
Bodycantabsorbpas so
chronic
Pusis A
Drainage

24. Otomycosis
• Fungal infection of external ear
• Primary or secondary
• Most common organisms: Aspergillus
nigra and Candida albicans
fungal
Black
White
mostlymixed not pure
and sometimes with secondary
bacterialinfectionewetnewspaper
Ear
black white
0

25. Otomycosis
Candida albicans
Aspergillus nigra
whitefluffycottondischarge Blackish spores
Candida albicans Aspergillus nigra

26. Otomycosis
Symptoms:
1.Often indistinguishable
from bacterial OE
2.Pruritus: intractable
3.Dull pain
4.Hearing loss (obstructive)
5.Tinnitus
Sgin:
1. Canal erythema
2. Mild edema
3. White, gray or black
fungal debris (wet
newspaper).
sever
itching
signofinflammation
mixeds
bacteria
and
fungal
mainsymptom
Discharge discharge

27. Otomycosis:
Treatment
1.Thorough cleaning and drying
of canal.
2.Ear washing.
3.Topical antifungals.
s
wet dry
dry suction
mobbing
notantibioticonlyif it'smixed
infection
but
give
antifungal
first
c
local Systemic
a
man
by
cotton

28. Granular Myringitis (GM)
• Localized chronic inflammation of pars tensa with
granulation tissue formation.
• causative organisms: Pseudomonas, Proteus
Symptoms:
1. Foul discharge.
2. Slight irritation.
3. Fullness
4. No hearing loss
5. No pain
External
partofTnis
par
TM ofexternal
canal
to to deala
grantees on outersurfaceofTM
ofupper
surfceofTM

29. GM: Signs
• Pus on the surface
of TM.
• Granulations t.
• No perforations.

30. GM: Treatment
1. Careful and frequent debridement
2. Topical anti-pseudomonal antibiotics
3. Occasionally combined with steroids
4. At least 2 weeks of therapy
5. careful destruction of granulation
tissue if no response
cleaningcantibiotic

31. Viral otitis externa
A. Herpes simplex:
occurs with fevers e.g. influenza and common cold.
vesicles in external canal, T.M. and nose
B. Herpes zoster:
caused by varicella zoster v.
Ramzy Hunt Synd.: consists of: otalgia, facial palsy,
sensorineural hearing loss and tinnitus. treatment: 1.
rest, fluid, warm compresses.
2.analgesic, steroids , antivirals.
3.corneal protection.
URI rare causecomplication I 3 weeks severpain
with orwithout
mouth genitalia
severe
pain
on
affectsensorynerve
ganglion cause
inflammation vesiclesindermatomotsensorynerr
EW II
varied
zoster
infection
offacial
nervesometimes
cause
reside
in
EAC
or
concha
penerpeszosterotitis
O her
motor
neuron
lesion
different
biwapper
and
can't
close
againstdryness lower
motor
neuron
lesion
the
eye Hsiao
due
to
palsy
Resolvespontinusly
aroundorificofbody
f
stomatitis sonic
8en
O

32. herpes
Zoste
vesicles
with
ramzy
syndrome
Smallarea Supply by 7thHerve
Concha

33. C. Bullous otitis externa (myringitis):
•Viral infection
•Large vesicles in bonny canal, T.M.
•Primarily involves younger children.
•Severe pain followed by bloody or
serosanguinious ear discharge.
•treatment:
Analgesic, steroids, antibiotics ( local
and systemic).
Decompression of vesicles in severe
pain.
external
layer
ofTninfection
rupture fluid
fined
large
buttons us
serosanginious
discharge
noperforationofdrum
orotitismedia
serum blood
2uryinfection win
Mainly No
hearingloss
Noostitismedia

34. Necrotizing External Otitis (NEO) “Malignant
OE.”
• Potentially lethal infection of EAC
and surrounding structures (skull
base).
• Typically seen in elderly diabetics and
immunocompromised patients
• Pseudomonas aeruginosa is the usual
causative organism
name
malignant
doesn't
indicate
cancer
itsinflammation
but
due
tobadprognosis
notlocalizingto skinlayer
spread
tounderlyingboneofskull
43 of cases death
only Uncontrolled
i
micro
involveboneandcartilage

35. NEO: Symptoms
• Poorly controlled diabetic.
• Deep-seated aural pain
• Chronic purulent otorrhea
• Aural fullness
• Symptoms of cranial nerve palsy.
severe
Extensionofinflammationtounderlying
temporal
ban
inflammationofcranial
nerve
2
facialandlowerfour
CN 1011,12
Pus
a
5
to
Glossopharyngeal vagusaccessory hypoglossal

36. NEO: Signs
1. Inflammation and
granulation
2. Purulent secretions
3. Occluded canal
and obscured TM
4. Cranial nerves
involvement
in EE
polyp 6 conductivehearing
loss
Fsign
and
symptomsofcranialnervepalsy

37. NEO: Imaging
1. Plain films
2. C T – most used
3. Technetium-99 – reveals osteomyelitis
(diagonosis)
4. Gallium scan – useful for evaluating
(response)
5. Magnetic Resonance Imaging (MRI).
Badprognosis requireadmission 1investigationforosteomyelitis
xray
isotopescan
to
1

38. NEO: Treatment
1. Control diabetes.
2. Local canal cleaning.
3. Pain control.
4. Systemic antibiotics: (anti pseudomonas)
for at least 4 weeks, with serial gallium
scans monthly.
5. Topical agents “controversial”
6. Hyperbaric oxygen “experimental”
7. Surgical debridement for refractory cases
first hospital admission
analgesic
resistance
microorganism
cleaning
4thgenerationcephalosporin
f
antibiotic

39. Perichondritis/Chondritis
• Infection of perichondrium/cartilage
• Result of trauma to auricle
• May be spontaneous (overt diabetes)
Symptoms
1. Pain over auricle
and deep in canal
2. Pruritus
g Ii e
or deadtissue
Spreadnot
limitedto skin
cause Cali
flowerear shrunk
ing
anddisfigurementofauricle
asceticdis
function
Q

40. Perichondritis: Signs
• Tender auricle
• Induration
• Edema
• Advanced cases
– Crusting & weeping
– Involvement of soft
tissues
x

41. Perichondritis: Treatment
• Mild: debridement, topical & oral
antibiotic
• Advanced: hospitalization, IV
antibiotics
• Chronic: surgical intervention with
excision of necrotic tissue and
otoplasty.
x

42. Foreign body of the ear
• Mostly in children and mentally retarded
adults.
• Types:
A.Animate FB: insects eg; flies, larvae.
B.Inanimate FB:
vegetable: beans, seeds
no vegetable: buttons, stones,…
living
Common

43. FB.(cont.)
• Clinical picture:
1.History given by his relatives.
2.Severe irritation and noise in case of animate
FB.
3.Conductive H.L.
4.Otitis externa.
5.Drum rupture and bleeding (sharp. pointed
FB.). Trauma of EE and TM P

44. TREATMENT:
“Removal”
• Animate FB: killed first by oily drops, then
wash or suction.
• Inanimate FB :
-Vegetable: by hook.
- non vegetable : wash or hook.
If pt. is uncooperative or FB. is deeply
impacted, need G A.& microscope to avoid
injury.
nowash
d
surgical general
removal anesthesia
and Lary

45. Ear wash
• Indications:
1.Impacted wax.
2.Foreign body.
3.Otomycosis.
4.Caloric test.
5.Pretest, or preoperative.
Main

46. (Cont.)
• Contraindications:
1.Perforation of the T.M.
2.Vegetable and impacted foreign body.
3.Chronic suppurative otitis media.
4.Postoperative after ear operations.
▪Techniques:
fry or withdischarg
Skill Lab

47. wash
• Complications:
1.Traumatic rupture of the tympanic
mewbrane.
2.Truma to the skin of external canal.
3.Vertigo: due to caroric stimulation.
4.Otitis externa.
5.Reflex coughing .
or
Perforation
in
bleeding
µif
water
very
coldorvery
not
unclear
water
excessstimulationofvagusnerve
r
k
somepeoplehavefrasovagalattack
syncopalattack severhypotension Bradycardia lossof
consciousness
of vestibular
Part ofIE
nose
imp
area
to in EE Larynx Epigastric
way

48. Questions:
• Describe the anatomy of the ears?
• Describe the main functions of the ears?
• Describe the pathophysiological changes in
the external ear?
• Describe the main treatment modality of
external ear diseases?

49. The ear wash is indicated in the following conditions
except:
A. Animate foreign bodies in the external ear
after killing them.
B. Dry perforation of tympanic membrane.
C. Impacted wax after softening.
D. Otomycosis.
E. Pretest and preoperative.
O

50. The following lesions may cause
referred otalgia except:
A. Acute tonsillitis via the glossogharyngeal
nerve .
B. Cervical spine lesions via the fibers of C2 and
C3 nerves.
C. Laryngeal cancers via the vagus nerve.
D. Teeth disorders via the trigeminal nerve.
E. Tongue lesions via the hypoglossal nerve.
q
10
5
00 x
if viaglossopharyngeal
a

51. • The otomycosis is characterized by the
following except:
A. It is caused by asprgillous Niger or Candida
albicans.
B. It may need ear washing.
C. Pruritis is the main presenting symptom.
D. The local cleaning and topical antibiotics
drops is the main treatment.
E. The patient may complain of conductive
hearing loss