3. Embryology of external ear
• Development of external ear commences at 4th week of
gestation by tissue condensation of mesoderm of 1st
and 2nd branchial arch.
• With in 2 weeks six ridges known as hillock of his arise
from these tissue condensations.
• Ist arch contributes 3 hillocks which form helix, crus of
helix, tragus
• Second arch forms antitragus, antihelix, lobule
• Auricle develop from the fusion of hillocks and is
complete by 20th week of gestation.
4. At approximately 7 weeks six hillocks are fusing to
form two folds, which will later fuse superiorly.
5. • Ectoderm of first branchial groove
invaginates to form primitive eac.
• As the cells continue to grow inward they
eventually meet endodermal tissue of the
developing tubotympanum ( a derivative of
first pharyngeal pouch)
• Mesodermal anlages encroach on this area
of apposition from ventral and dorsal sites.
• Resulting solid core of tissue is named
meatal plug/plate.
6. • By the 28th week of fetal development plate
resorbs and EAC recanalizes.
• Ectodermal elements of plate form epithelial
lining of eac, lateral tympanic membrane.
• Mesodermal element contribute to the
development of cartilaginous EAC, ossificstion
centres of tympanic ring, ossicular chain.
• Failure of EAC recanalization results in
congenital eac atresia.
7. • Auricle (Pinna)
- attaches to the side of head at an angle of
about 30 degrees
- Growth parallels body growth until 5 years
of age.
- localizes sound
-Collects sound Gain of 15-20dB
Hence in microtia, patient has a loss
of 15-20 db
•
8. Isthmus the narrowest portion of the EAC, lies just medial to the
junction of the bony and cartilaginous canals. Foreign body lodged
Medial to to it get impacted & are difficult to remove
Bony canal is dehiscent posterosuperiorly abutting the mastoid air
cells, and superior canal abuts the epitympanic recess.
These air cells are seperated from the ear canal by this
thin bone.
Anterior Recess: Beyond isthmus floor dips. Difficult to
clear debris and strip skin during elevation of flap in
tympanoplasty.
Canal’s anteroinferior wall is slightly longer than
posterosuperior wall
creating acute angle between ant. canal wall and T.M.
9. Nerve supply
Lesser occipital nerve
Great auricular nerve
Nerve block- anteriorly and
superiorly to the tragus.
provides anaesthesia
to the helix and tragus
Auriculotemporal nerve
10. Anterior view Posterolateral view
Owing to the little depth of tissue between skin and
vessels,
Vessels lie in exposed position and the ear is
susceptible to frostbite
11. Measures 24 mm (along its posterior wall)
Has S-shape- outer part is part is directed
upward
backward & mediially
Inner part is directed downward forward &
medially
Visualization of TM
pinna has to be pulled
upward backward &
laterally in adults
downward and
backward in infants.
Inner 2/3rd bony
Outer 1/3rd
cartilaginious
External Auditory Canal
12. Cartilaginous part contains hair
and ceruminous and sebaceous glands.
Furuncle or acute circumscribed external
otitis is a
bacterial infection of these glands
Outer third
1-1.5mm thick
Hair, sebaceous and
ceruminous glands
present
Wax present
Bony part is devoid of
skin appendages
Inner two thirds
0.1 mm thick
Absent
Self cleansing by
centrifugal migration
of skin from umbo @
0.05mm per day
14. Blood supply of eac is same
as that of auricle with
additional contributions of
deep auricular artery
Deep auricular artery –
branch of first part of
internal maxillary artery
Anterior half –
Auriculotemporal nerve
Posterior half - Auricular
branch of vagus ( Arnold’s
Nerve)
● Blood supply Nerve supply
External auditory canal
15. Fissures of santorini- these are the vertical fissures in the
anterior portion of external auditory canal in the region of
bony cartilaginous junction.
Infectious process of eac may spread to the tmj and
periparotid soft tissue via fissures of santorini.
Foramen of huschke- developmental defect located at
the anteroinferior aspect of bony external auditory canal.
Huschke’s foramen permits similar spread of infection to
preauricular tissue.
16. EAC is closed off at its medial end by the TM which separates EAC from
middle ear cavity.
TM is thin almost round str inserted into a sulcus within the medial end of
the tympanic portion of the temporal bone.
Circumference of the TMis fixed in the sulcus is thickened to a
fibrocartilaginous ring. Sulcus is deficient superiorly at the Notch of
Rivinus.
From the ends of this notch two bands the anterior & posterior malleolar
folds strech to lateral process.
Triangular portion of TM above these folds is called pars flacida it is highly
vascularized & perforation have a better chance of spontaneous
clouser than in the pars tensa.
Handle of Malleus is being enclosed b/w fibrous & endothelial layer draws
TM towards the middle ear cavity forming a depression in its center
called the umbo.
TYMPANIC MEMBRANE
17. Figure 2.1 Right ear.
Normal tympanic
membrane.
1 = pars flaccida;
2 = short process of the
malleus;
3 = handle of the malleus;
4 = umbo;
5 = supratubal recess;
6 = tubal orifice;
7 hypotympanic air cells;
8 = stapedius tendon;
c = chorda tympani;
I = incus
; P = promontory;
o = oval window;
R = round window;
T = tensor tympani;
A = annulus
18. TM forms an angle of 55 degree
with the Floor of external auditory
meatus.
vertical diameter- 9-10 mm
Horizontal diameter- 8-9mm
Thickness 0.1 mm
19. ● Pars tensa
3 layers
-outer: thin layer of skin
continuous with skin of EAC
-intermediate fibrous layer
Radiating fibers
•Form the lateral
portion
•Attached to
manubrium
•Extend to annulus
of TM
Circular fibers
•In the medial
aspect
•Concentrated
peripherally
•to form a fibro
cartilaginous ring
Thicker than Pars tensa.
Has 3 layers
-outer: 5-10 layers of
epithelial cells.
-middle: irregularly
arranged elastic &
collagen fibres.
-inner: non keratinizing
squamous mucosal
cells
Pars flaccida
20. BLOOD SUPPLY OF
TYMPANIC MEMBRANE.
-It is derived from superficial
temporal artery and posterior
auricular artery.
-Deep auricular artery branch of
internal maxillary artery forms a
peripheral ring from which arise
branches destined for tympanic
membrane’s lateral surface.
-Internal maxillary artery via its
anterior tympanic branch
supplies medial surface of T.M.
Blood supply of TM
21. Nerve supply of TM
● medially – IX nerve
● laterally
a) Auriculotemporal N.
b) Arnolds N.
22. Developmental Anomalies of The External
Ear
1. Preauricular Sinus
2. Preauricular appendages
3. Microtia and Congenital canal atresia
24. ● Opening of preauricular sinus is found in front of helix.
● Leads into a sinus tract lined by squamous epithelium.
● Tortuous and branching course.
● Terminally adherent to the cartilage of the helix.
● Lies in the subcutaneous tissue ,lateral to temporalis
facsia superiorly and parotid fascia inferiorly.
25. ● Two theories are postulated for its development:
1.Defective or Incomplete fusion of Hillocks of His
2. Isolated or localised folding of ectoderm during auricular
embryogenesis.
● Sporadic :Unilateral
● Inherited: Bilteral
26. ● Indications for surgery:
1. Increased frequency and severity of infective episodes.
2. Chronicity of sinus discharge.
3. Unsightly overlying skin inflammation.
● Acute infections are best treated by intravenous
antibiotics and in severe cases needle aspiration.
28. Microdissection:
- Identification of extent of sinus and its branches is done
using lacrimal probe and methylene blue dye.
-Sinus is then excised.
Wide Local Excision:
-Supra auricular approach involves identification of plane of
temporalis fascia.
-Dissection of soft tissue between this plane and helix of
pinna.
-Lowest recurrence rate.
30. ● Result from abnormalities of embryogenesis of external
ear.
● Have a fibrofatty core and often contain a cartilaginous
component.
● Found along a line drawn from tragus to angle of
mandible.
31. ● SURGICAL TECHNIQUE:
● Surgery is usually done after one year of age.
● Complete excision of the skin and soft tissue
components with partial resection of the superficial part
of the cartilaginous core.
32. Microtia
● Malformed or Underdeveloped pinna .
● May be associated with Congenital canal atresia.
● Incidence : 1 in 10000.
● Children with Microtia and CCA usually have conductive
hearing loss.
34. ● Management of significant microtia:
1. Autologous ear reconstruction :
-Construction of a cartilaginous framework :
Autologous rib cartilage is harvested and
used to carve the new cartilage framework.
-Soft tissue cover
-Projection of the reconstructed pinna.
36. ● Osseointegration of titanium plate.
● Gold retention bar is attached to the abutments.
● Silicone ,closely matched skin colour, prosthetic ear
clipped onto this bar.
● Recurrent soft tissue inflammation and traumatic fixture
loss may complicate the use of percutaneous abutments.
38. Furunculosis
● It is a localized form of otitis externa resulting from
infection of a single hair follicle.
● Lateral 1/3 of posterosuperior canal.
● Obstructed apopilosebaceous unit.
● Pathogen: S. aureus
41. Treatment
• Local heat
• Analgesics
• Oral anti-staphylococcal antibiotics(penicillinase resistant penicillin,
macrolide, cephalosporin, clindamycin)
• Topical treatment (antibiotics,astringents,hygroscopic dehydrating
agents )
• Formal incision and drainage is recommended if an abscess forms.
• Severe associated soft tissue infection or cellulitis is an indication
for systemic antibiotic therapy.
42. Perichondritis of External Ear
• Infection or inflammation involving the perichondrium of
the external ear: auricle and external auditory canal.
• However, it is commonly used to describe a continuum
of conditions of the external ear, from erysipelas
(infection of the overlying skin), through cellulitis
(infection of the soft tissue), and true perichondritis to
chondritis (infection involving the cartilage itself).
43. • Prasad et al. described staging of perichondritis as :
• Stage 1 : Early perichondritis without fluctuant abscess.
• Stage 2 :Perichondritis with fluctuant abscess.
• Stage 3 :Perichondritis with fluctuant abscess and
cartilage destruction.
44. AETIOLOGY :
• The thin skin, minimal subcutaneous tissue and vulnerable
anatomical position make conchal cartilage particularly susceptible
to trauma with subsequent infection.
• Perichondritis usually happens secondary to trauma. Such trauma
may include laceration of the auricle, surgery to the external ear,
frostbite, burns, chemical injury, infection of a haematoma of the
pinna, aspiration or incision of a haematoma and, in recent years,
'high' piercing of the(cartilaginous) portion of the auricle for the
insertion of earrings.
45. • Superficial infections of the skin (erysipelas) or subcutaneous
tissue (cellulitis) of the external auditory meatus or pinna may
spread deeply to involve the perichondium (perichondritis) or
cartilage (chondritis).
• The organisms most commonly isolated are Pseudomonas
aeruginosa and Staphylococcus aureus and streptococcus .
• Other organisms cultured include Gram negatives (proteus and
Escherichia coli).
46. • The presentation is with a dull pain increasing in severity and the
classical signs of inflammation involving the cartilaginous pinna .
• The lobule, which contains no cartilage, is spared.
• The severity of the pain and swelling of the pinna are indicators for
true perichondritis as opposed to the more superficial conditions of
erysipelas and cellulitis.
• The diagnosis is clinical .
• A background history of underlying trauma to the external ear
should be sought.
Symptoms
47. Signs
● Tender auricle
● Induration
● Edema
● Advanced cases
○ Crusting & weeping
○ Involvement of soft tissues
Perichondritis of the right ear. There is an
associated subperichondrial abscess in this
case.
48. Treatment
• Mild (Cellulitis and Prasad stage 1) : Debridement, topical & oral
antibiotic.
• Fluctuant sub perichondrial abscess requires drainage.
• Advanced : hospitalization, IV antibiotics
• In severe cases, where the entire area is involved, total
chondrectomy via an incision in the helical margin, the ear being
split in bivalve fashion, the necrotic cartilage resected, and a layer of
fine mesh gauze placed between the flaps and changed daily.
49. Herpes Zoster Oticus: Symptoms
● Early: Auricular pain is
often the first symptom,
f/b headache, malaise
and fever
● Late (3 to 7 days):
vesicles, facial paralysis
OUTCOMES
In untreated patients, over 60
percent develop a complete facial
paralysis within a week .
50. Herpes Zoster Oticus
• It is defined as a herpetic vesicular rash on the concha , external
auditory canal or pinna with a lower motor neuron palsy of the
ipsilateral facial nerve.
• It is commonly known as Ramsay Hunt syndrome.
• The disease is a reactivated varicella zoster infection from dormant
viral particles resident in the geniculate ganglion of the facial nerve
and the spiral and vestibular ganglia of the VIIIth nerve.
• The VIIIth nerve may be involved to a variable degree, resulting in
hearing loss, tinnitus and/or vertigo.
• Herpes zoster oticus the second commonest cause of unilateral
facial palsy after idiopathic Bell's palsy.
52. Treatment
• Improved outcomes were obtained if individuals were
commenced on acyclovir and prednisolone within three
days of the onset of symptoms.
• Treatment of intravenous acyclovir plus steroids
produced a 90 percent recovery to grade 1,compared to
64 percent if only steroid was given.
• The early treatment of herpes zoster infections with
antiviral agents is also known to significantly reduce the
prevalence of post-herpetic neuralgia.
53. Hematoma auris
• Haematoma auris is a collection of blood between the
auricular cartilage and perichondrium.
• The haematoma is usually produced by trauma, although
occasionally the spontaneous rupture of a blood vessel may
be the cause.
• Subcutaneous haematomas resorb without consequence,
subperichondrial serosanguinous fluid stimulates the
proliferation of mesenchymal cells in the overlying
perichondrium, with these chondroblasts forming new
cartilage in seven to ten days which results in 'cauliflower ear'
deformity.
54. • This occurs almost exclusively on the anterior surface of
the auricle where the skin is tightly adherent to the
underlying perichondrium, so that shearing forces
applied to the ear separate the perichondrium from the
cartilage.
• On the posterior surface, intervening areolar tissue
allows the skin to glide over the perichondrium.
• Rarely, a tear through the cartilage can allow
haematomas to collect under the perichondrium on both
sides of the cartilage.
55. ●MANAGEMENT :
• The haematoma requires evacuation observing strict
asepsis. This is achieved through either aspiration with a
thick bore needle or, if this is inadequate, an incision.
• Aspiration alone results in a very high incidence of re-
collection until the perichondium is again firmly adherent
(about seven days).
• In order to prevent this, the following options have been
devised:
56. • The use of moulded pressure bandages or splints of various
materials applied on both sides of the pinna
• A drain left in the incision site.
• A posterior incision, with excision of a disc of cartilage and
placement of a suction drain.
• Through-and-through 'mattress' or 'quilting' sutures to apply
compression with or without materials to distribute the compression
more evenly. These include buttons and silicone rubber splints.
• After seven to ten days, aspiration is ineffective and surgery for
removal of the organizing haematoma and newly formed cartilage
with/without overlying perichondrium is necessary.
57. (a) Subperichondrial haematoma of the scaphoid and triangular
fossae of the right ear. (b) The same ear after drainage of the
haematoma. 1 mm thick silastic and a quilting nylon suture have
been used to prevent fluid re-collection.
59. ● Keratosis obturans :Accumulation of large plug of
desquamated keratin in the external auditory canal.
● A geometrically patterned keratin plug is seen within
lumen of expanded EAC.
● Keratin squamous shed from the complete
circumference of deep ear canal forming onion like skin
arrangement.
60. ● Primary Auditory Canal Cholesteatoma : Invasion of
squamous epithelium into localized area of bony
erosion with or without bony necrosis.
● Benign Necrotising Otitis Externa : Formation of an
avascular bony sequestrum of the inferior tympanic bone
with secondary inflammation of the overlying soft tissue
and skin.
● S.Aureus is most common organism in all three
conditions.
64. Aetiology
Keratosis obturans Auditory canal
Cholesteatoma
Benign necrotizing
otitis externa
Abnormal epithelial
migration.
Abnormal bone
leading to epithelial
migration into bone.
Avascular bone
leading to
inflammation of
overlying skin.
65. Symptoms and Findings
• Keratosis
obturans
• Auditory Canal
Cholesteatoma
• Benign
Necrotising Otitis
externa
• Severe otalgia
• Conductive
Hearing loss
• Lung or Sinus
disease
• Younger
• Occasionally
bilateral
• Mild Otalgia
• No Hearing loss
• Itchiness
• Older
• Usually
Unilateral
• Blocked feeling
• Chronic painless
infected
otorrhoea
• Localised
exposed bone in
canal 3-10 mm
diameter
• Dehiscent skin
66. Pathology
• Keratosis
obturans
• Auditory canal
Cholesteatoma
• Benign
necrotising otitis
externa
• Keratin plug
• Tympanic
membrane
thickened .
• Widened deep
canal
• Hyperaemia of
skin canal with
granulations.
• Keratin in
random pattern.
• TM normal
• Localised
osteitis/erosion
of ear canal
usually postero
inferior.
• Sequestration of
bone.
• Chronic
inflammation
with no
associated
keratin and no
cholesteatoma
deep to
sequestrum.
• Commensals on
bacteriology.
67. Management
• Keratosis obturans :
• Removal of plug under GA.
• Canaloplasty
• Auditory Canal Cholesteatoma :
• Conservative treatment : where extent of cholesteatoma
erosion can be seen.
• When extent not seen : Excision of necrotic bone and
cholesteatoma via mastoid and defect repair using
temporalis fascia.
68. • Benign Necrotising Otitis Externa :
• Removal of bony sequestrum once it separates
spontaneously with local toilet.
• Local treatment to control infection.
• When disease progression occur after intensive local
and systemic treatment and if necrosis is beyond
tympanic plate: Surgical removal of sequestrum down to
healthy bone along with adjunctive hyperbaric oxygen.
69. Acquired atresia of the external
ear
● Toss defines acquired atresia of the external ear
“intraluminal sequelae of either intraluminal or
extraluminal processes of varying aetiology, resulting in
a blind sac in the external acoustic meatus”.
● Atresia may be solid or membranous.
70. • Solid Atresia : Continuous block of fibrous or fibrous
and bony material, which is continuous with the structure
of the tympanic membrane.
• Membranous Atresia: Fibrous tissue that has a
covering of ear canal skin on both sides, separating ear
canal into medial and lateral segment.
• Medial part collects keratin from desquamation of
skin,may become an erosive process and defined as an
External canal cholesteatoma.
74. Aetiology
● Inflammation :Due to
-Otitis Externa
-Psoriasis , Eczema
-Active chronic otitis media
● Trauma
● Burns
● Surgery
75. Pathogenesis
● Solid Atresia :
● Cases associated with Otitis Externa and Media
,granulations of tympanic membrane develops that
become fibrotic and the ear drum becomes thickened as
the medial meatal mass is re epithelialized.
● Fibrous Atresia : Originates in the lateral meatus as
web formation which is precipitated by circular irritation
from inflammation ,trauma ,burns or ulceration.
76. Management
● Medical :During wet phase , medial granulations can be
removed by aspiration and cauterization with silver
nitrate or trichloroacetic acid and ear packed with ribbon
gauze.
77. ● Surgical Management :
● FIBROUS ATRESIA :
● Principle : Remove the fibrous tissue by elevating it
from the ear canal bone , the fibrous annulus ,and
lamina propria of tympanic membrane.
● Steps: A speculum is inserted into external ear canal via
trans canal approach.
● A circumferential incision is made lateral to atretic plate.
78. • A plane of dissection developed between the bone of ear
canal and the canal skin , followed by the atretic plate
and finally lateral to fibrous annulus and lamina propria
of tympanic membrane.
• Epithelial defect is filled by split skin graft .
• Ear canal is packed with antiseptic ribbon gauze.
79. ● MEMBRANOUS ATRESIA :
• Steps : Ear speculum inserted into ear via trans canal approach.
• Fibrous plate is excised via circumferential incision , just lateral to its
margin.
• Whole lesion is excised with sacrifice of minimal surrounding
epithelium .
• Silastic sheets overlaid , holding medial and lateral skin edges against
the bone of ear canal.
• Retro auricular approach is used in case of thick atretic plate.
80. Foreign bodies
• Foreign bodies in the external auditory meatus are most commonly
seen in children who have inserted them into their own ears.
• Children may present asymptomatically, or with pain or a·
discharge caused by otitis externa.
• Adults are often seen with cotton wool or broken matchsticks which
have been used to clean or scratch the ear canal.
• Live insects in the ear can be found.
• The foreign bodies found most commonly in the ear are, in order,
cotton wool, insects, beads, paper, small toys and erasers.
81. ● Prior to embarking upon removal, it may be useful to
consider three aspects of the situation:
1. The nature of the foreign body;
2. The precise location of the foreign body;
3. The patient.
● Inexpert or ill-advised attempts at removal may cause
serious complications such as canal lacerations,
tympanic membrane perforations and ossicular fractures
or dislocations.
82. Techniques of removal advised for different types of
foreign body.
● Type of foreign body Method of removal
1.Living insects First kill with oil
2.Irregular/graspable Remove with crocodile
forceps objects
3.organic/vegetabIe Do not syringe
4.Button batteries Do not syringe
5.Round, hard, smooth, Syringe/remove with
non-graspable wax hook / removal
83. drtbalu's
otolaryn
gology
online
Exostosis
• An exostosis of the EAC is a benign growth of periosteal
bone, which forms a smooth, sessile, hemispherical
swelling in the deep part of the meatus, adjacent to the
TM.
• Usually multiple and bilateral.
• Associated with swimming(73.5 % in surfing population)
• Usually asymptomatic but when enlarge to cause a
stenosis of greater than 80% of canal lumen,can cause
recurrent otitis externa ,chronic infection ,wax and
conductive hearing loss.
84. ● Important to differentiate from osteoma which is
unilateral,pedunculated ,solitary ,discrete mass arising from lateral
part of bony EAC.
85. Multiple exostosis of the right external
auditory canal. One exostosis is anterior and
two are posterior.
86. Treatment
• Recurrent episodes of otitis externa or cerumen
impaction may be associated with exostoses and should
be managed medically in the first instance with
microsuction and antibiotic ear drops.
• In the majority of cases, no treatment is required as the
patient is asymptomatic.
• General advice about avoidance of cold water should
be given, with a recommendation to use earplugs or a
wet suit hood, for water sports.
87. • Surgery to remove the exostoses and enlarge the
meatus by a meatoplasty procedure is indicated for
cases refractory to medical treatment, causing recurrent
or persisting otitis externa, frequent cerumen obstruction
causing hearing loss and cases where wider access is
required for middle ear surgery.
•
• Surgery is carried out, either via a postaural , endaural or
per meatal approach.
88. Otomycosis
• Aka fungal otitis externa.
• Accounts for approx. 10% of all cases.
• It is more common in hot, humid climates and is often
secondary to prolonged treatment with topical antibiotics.
• Diabetes and immune compromised states also
predispose to the condition.
• Aspergillus accounts for 80-90 percent of cases while
Candida being responsible for the remaining 10-20
percent.
90. Signs
● The most common
finding is a black, grey,
green, yellow or white
discharge with debris
that is often said to
resemble wet
newspaper. Sometimes
debris is seen with visible
fungal hyphae.
● Canal erythema
● Mild edema
Otomycosis with Aspergillus niger.
91. Treatment
• Aural toilet and removal of debris.
• Topical anti fungal ear drops (clotrimazole or
flumethasone with clioquinol ) are used.
• Resistant Otomycosis :Immunotherapy with
dermatophyte extract is treatment of choice.
• In immune compromised patients , Invasive otitis externa
may occur : Aggressive systemic anti fungal therapy is
required.
92. Otitis Externa
● Otitis externa is a generalized condition of the skin of the
external auditory canal that is characterized by general
oedema and erythema associated with itch , pain and
ear discharge.
● It is a Bacterial infection
● Categorized by time course
○ Acute
○ Sub acute
○ Chronic
93. Predisposing factors for otitis externa.
Type Factor
Anatomical Narrow external auditory meatus
(hereditary, iatrogenic, exostoses
etc.)
Obstruction of normal meatus
(keratosis obturans, foreign
body, hearing aid, hirsute canal,
etc.)
DermatologicalI Eczema, seborrhoeic dermatitis
Allergic Atopy , non atopic allergy, exposure to
topical medications
physiological Humid environment,
immunocompromisation
Traumatic Skin maceration (bathing), ear probing, laceration, radiotherapy
Active chronic otitis media, exposure to
P. aeruginosa or fungi
95. Pre Inflammatory Stage
● Protective lipid /acid balance of ear is lost.
● Edema of stratum corneum and plugging of apo pilosebaceous unit.
● Symptoms: Pruritus and sense of fullness
● Signs: Mild edema
● Starts the itch/scratch cycle , disruption of the epithelial layer and
invasion of resident or introduced micro organism occurs.
97. ● Progressive
infection
● Symptoms
○ Pain
○ Increased pruritus
● Signs
○ Erythema
○ Increasing edema
○ Canal debris
○ Discharge
○ Mild : little or no obliteration of lumen
○ Moderate : Sub total obliteration
98. Severe Stage
● Severe pain, worse with ear
movement
● Signs
○ Complete Lumen obliteration
○ Purulent otorrhea
○ Involvement of periauricular
soft tissue
○ Cervical lymphadenopathy
99. Treatment
• Most common pathogens: P. aeruginosa and S. aureus
• Four principles
• Frequent canal cleaning
• Topical antibiotics
• Pain control
• Prevention of aetiological factors that could lead to
exacerbation or recurrence.
103. Treatment
• Similar to that of AOE
• Topical antibiotics, frequent cleanings
• Topical Steroids
• Surgical intervention
• Failure of medical treatment
• Goal is to enlarge and resurface the EAC
104. drtbalu's
otolaryn
gology
online
Malignant otitis externa
● Is an aggressive & potentially life threatening infection of
the soft tissues of the external ear & surrounding
structure , quickly spreading to involve the periosteum &
bone of the skull base.
● Caused by pseudomonas.
● Facial palsy is also common.
● Manifest in elderly patients with diabetes.
● Begins as external otitis and progresses to osteomyelitis
of temporal bone , spread outside EAC through fissure
of Santorini and osseo cartilaginous junction.
105. Figure 236e.1 Malignant otitis externa with
granulations of the floor of the right external
auditory canal.
106. Imaging
● Computerized tomography – most commonly used.
● Technetium-99 – reveals osteomyelitis .Isotope taken up
by osteoblast and osteoclast ,as bone remodelling
continues after the infection is resolved ,scan will remain
positive for upto 9 months.
● Gallium scan : Absorbed by leucocytes and is more
sensitive monitor of infection.
● Magnetic Resonance Imaging
107. Clinicopathological classification system.
Stages-
1.Clinical evidence of malignant otitis externa with
infection of soft tissues beyond the external auditory
canal, but negative Tc-99 bone scan.
2. Soft tissue infection beyond external auditory canal with
positive Tc-99 bone scan.
3. As above, but with cranial nerve paralysis
3a Single
3b Multiple
4. Meningitis, empyema, sinus thrombosis or brain abscess
108. ● Management :
• Meticulous glucose control .
• Mild cases : Oral Flouro quinolones (Ciprofloxacin ) is given.
• Severe cases : Inj flouro quinolone , inj ceftazidime
,aminoglycoside is used.
• If Aetiology is fungal then Amphotericin is given to the patient.
• Treatment should always be culture based.
• If resistant to above medical management ,surgical debridement
and hyper baric oxygen is used.
• Treatment must continue for at least 6 weeks or till symptoms are
resolved.
109. Osteoradionecrosis of the temporal
bone
● It is defined as exposure and necrosis of a variable portion of
previously irradiated petrous temporal bone which fails to heal
over a period of three months.
● Because of its density, bone absorbs a greater proportion of
radiation than soft tissues. Osteoradionecrosis and chondro
radionecrosis may occur in various sites in the head and neck
following high-dose radiotherapy.
● This occurs far more commonly in the mandible
110. ● Osteoradionecrosis of the petrous temporal bone
occurs as a result of high -dose radiotherapy
administered to and around the petrous temporal
bone for malignancies of the parotid gland, external
auditory canal, middle ear, maxilla, nasopharynx and
pituitary.
● The radiation causes inhibition of mitosis and the
capacity for tissue repair, and a vasculitis leading to
obliteration of blood vessels and avascular necrosis.
111. ● PATHOLOGY
● The tissues affected include bone, overlying subcutaneous tissues
and skin.
● The histological changes in bone include death of osteocytes and
osteoblasts resulting in empty lacunae, preponderance of
osteoclasts, demineralization, osteolysis, loss of marrow substance,
reparative fibrosis and often secondary infection.
● Macroscopically, there is loss of skin and soft tissue exposing bone,
bony sequestration and frequently the complication of secondary
infection. Of the parts of the temporal bone, the tympanic ring
appears particularly susceptible.
112. Radionecrosis of the right ear. In this ear, there is a
bony defect of the posterior canal wall, a bone
sequestrum have been extruded.
113. ● DIAGNOSIS, CLINICAL PICTURE,NATURAL HISTORY
AND OUTCOMES
• The time interval between radiotherapy and clinically evident
osteoradionecrosis can vary considerably – from less than 12
months to 23 years.
• Ramsden et al. divided cases into localized and diffuse
(extensive) forms.
• The localized form presents mild otalgia and otorrhoea, with
small areas of exposed bone in the external auditory canal.
• It generally occurs when the petrous bone was in the
periphery of the irradiated field.
• Computed tomography (CT) scanning shows only small
areas of sequestration.
114. • The Diffuse or extensive form occurs generally when
irradiation is directed at the petrous temporal bone, and
has more severe symptoms of pain and otorrhea.
• CT imaging shows widespread bony destruction.
• Erosion of the facial canal and extension to the inner ear
can occur, as well as intracranial complications, brain
abscesses, meningitis and death.
• Radical surgical debridement and repair is often
necessary to prevent complications and effect healing.
115. MANAGEMENT
LOCALIZED NECROSIS
• Successfully managed conservatively, with
toilet, careful removal of sequestra, local
antibiotics and analgesics.
• Use of a local rotational flap from postauricular
skin to cover small exposed areas of bone in the
external auditory canaL
116. DIFFUSE NECROSIS
• Conservative management is inadequate here.
• Radical surgical debridement required.
• Marx et aI. demonstrated the effectiveness of hyperbaric
oxygen and its superiority over penicillin in preventing
osteoradionecrosis of the mandible in previously
irradiated patients undergoing dental extraction.
117. Acute Bullous Myringitis
● Acute inflammatory condition of tympanic membrane .
● Characterised by presence of bullae or vesicles on the
surface of tympanic membrane.
● Develop between outer squamous and middle fibrous
layer of tympanic membrane.
● Streptococcus pneumoniae is predominant pathogen in
BM.
● Age group :2-8 years
118. Symptoms
• Sudden onset of severe otalgia.
• Usually unilateral.
• Associated with URTI.
• Conductive hearing loss is very common,mixed or SNHL is also well
documented.
• Scanty sero-sanguinous otorrhoea,associated with bulla rupture.
• Vertigo (54%)
120. Treatment
• Self-limiting
• Analgesics
• Warm compresses
• Topical antibiotics to prevent secondary infection
• Incision of blebs is unnecessary and may have a risk of
secondary infection.
121. Granular Myringitis
● Chronic inflammatory condition characterized by de-
epithelialization of the outer (squamous) layer of
tympanic membrane and replacement with granulation
tissue,in absence of middle ear disease.
● Toynbee described in 1860
● Histology :Oedematous granulation tissue with capillaries
and diffuse infiltration of chronic inflammatory cells .
122. Aetiology
● Non specific injury to lamina propria, such as trauma or
infection, impair epithelialization and promote granulation
tissue formation.
● Infectious agent: Pseudomonas , S.Aureus,
Corynebacterium, proteus mirabilis.
123. Symptoms
● Persistent inflammation confined to squamous layer of
TM for at least 12 weeks.
● Persistent or recurrent malodorous painless otorrhoea.
● Intrameatal itch or fullness
● Mild conductive hearing loss.
124. Signs
● TM obscured by pus .
● Following microsuction ,TM
reveals granulation tissue .
● Segmental/Focal type
granulations is more
common.
● Postero superior segment
of ear drum most commonly
affected.
● No TM perforations
125. Management
• Topical Antibiotics and Antifungals,with a steroid /anti
inflammatory agent.
• Topical antiseptic agents:Acetic acid ,Aluminium
acetate,phenol , hydrogen peroxide .
• Debulking of granulation tissue with cold steel (curettage
/cupped forceps ), silver nitrate cautery or laser
debridement .
• Surgical excision with grafting.
