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1. DISEASES OF THE EAR

2. EAR - Anatomy and Physiology
• organ of hearing & balance
• has three parts
1. external ear -attached to lateral
aspect of the head
2. middle ear-a cavity in the petrous
part of the temporal bone
,separated from the EAC by a
membrane
3. internal ear -series of cavities
within petrous part of Temporal
bone between the middle ear
laterally and the internal acoustic
meatus medially

4. EAR - Anatomy and Physiology
External ear
– Skin-lined
– Ends at tympanic membrane
– consists of two parts
• 1.auricle (pinna)- cartilage covered
with skin
– in a pattern of various elevation
and depressions
– assists in collecting sound.

5. EAR - Anatomy and Physiology
2. External auditory meatus
• Lateral -1/3 -Cartilage:
• Medial -2/3 -Bony:
• S-shaped
• Narrowest portion at
bony-cartilage junction
• Function -Amplification
-Localization of sound source
-produce cerumen

6. Tympanic membrane
•separates EAC from the middle ear
•semi transparent and pearly gray
•2 parts- pars flaccida and pars tensa
•3 layers -Skin, middle fibrous layer and inner mucosal layer
•At center, concavity is produced by the attachment to handle of
malleus( umbo)
•Anteroinferior to the umbo -cone of light
•FUNCTION - Amplification /17x
- protects the middle ear space from foreign material ,
infection

7. Middle ear cavity
• An air-filled, mucous membrane-lined
Contents
• the ossicular chains(malleus, incus &
stapes), facial N, ET opening ,muscles
,nerves ,small blood vessels
• 3 compartments -mesotympanium
-epitympanium
-hypotympanum
• communicates with the mastoid area
Posteriorly and the naso pharynx
anteriorly

8. Middle ear…
◊Oval window - It is the point of
attachment for the foot plate of stapes bone.
- With the chain of bones it transfers vibrations
initiated by the tympanic membrane in to the
cochlea of inner ear.

9. Eustachian tube
• connects the middle ear with the
nasopharynx -36mm
• Lateral1/3-bony & medial 2/3-
fibrocartilaginous
• Closed at rest but open during
swallowing and yawning
• Function –equalize air pressure
and drain the middle ear
Mastoid –it contains air field
cavities lined by mucous
membrane
• the air cells are arranged in
group

10. Nerve supply of the ear
Sensory supply
• Auricle and external auditory canal :
CNs V, VII, IX, X, and greater auricular n
•Middle ear-by tympanic branch of the glossopharyngeal
nerve
Motor supply
• Facial nerve- the auricle and the stapidus muscle
• Mandibular nerve-supply the tensor tympani muscle

11. Internal ear
• convey information to the brain about balance and hearing
1. bony labyrinth –filed with perilymph consists of
– The bony cochlea ,
– The bony vestibule and
– Three semicircular canals
2. membranous labyrinth -within bony cavity filed with endolymph
consists of
– semicircular ducts
– cochlear duct
– two sacs (utricle and saccule)
– Endolymphatic sac and duct

12. Inner ear…

13. Internal ear…
• cochlear duct is the organ of hearing
• semicircular ducts, utricle, and saccule are the
organs of balance
• The nerve for these functions is vestibulocochlear
nerve [VIII], which divides into vestibular (balance)
and cochlear (hearing) parts

14. Hearing
• external ear collects sound pressure
to TM
• ossicles transmit the sound waves
to cochlea
• creates a wave in the fluid filled
chochlea
• The impulses go to the brain
through the vestibulo cochlear
nerve, where they are interpreted
as sound.

15. Diseases of the external ear
Diseases of the Auricle
a) Congenital - anotia ,microtia ,macrotia
 Shape anomalies - bat ear(loop ear)
 accessory auricle
 pre auricular fistula and sinus -a tiny opening in front of the auricle
and can be infected. Has to be completely excised.
b) Traumatic
• Haematoma; collection of blood between the auricular cartilage and its
perichondrium.
 Its painful and cystic.
 Complications; perichondritis , Cauliflower ear.
 Treatment ; aspiration & Abxs for 01 wk(eg. Po cloxacilln or
amoxacillin
• Laceration - mild skin laceration to avulsion.
c) Inflammatory disorders –perichondritis
Rx- broad spetrum Abxs eg. Po Ciprofloxacillin
- if it forms abscess drain promptly + Abxs
D) Neoplastic…….benign and malignant tumours
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16. Congenital auricular abnormalities

17. Auricular hematoma
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18. perichondritis
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19. Diseases of the External auditory canal
a) Congenital atresia- failure of canalization of external auditory canal
 CT scan and audiologic evaluation.
 Treatment…hearing aid and surgical reconstruction
b) Traumatic
Laceration….self inflicted and Iatrogenic
Treatment ……antibiotic ear drop and avoid entry of water.
c) Foreign body
 Animate FB eg insect….kill it FIRST using chemicals like Hydrogen
peroxide.
 Inanimate FB…. Vegetable eg. seed and non vegetable FB eg.small
stones.
 Can be removed by –forceps ,suction ,syringing & postauricular
approach
 Anaesthesia is necessary for impacted ones and uncooperative
patients
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20. Diseases of the External auditory canal…
d) Inflammatory -Otitis externa is inflammation of the skin lining EAC
Types: -bacterial, fungal ,viral(HZ ,HSV)
 Bacterial
i) Localized otitis externa(Furuncle)…….Localized suppurative infection
of a hair follicle,
 usually caused by S.aures.
• Symptoms
 Severe earache, pain during mastication and hearing loss
• Signs
 Localized red tender swelling in the outer cartilaginous part.,
scanty and purulent otorrhoea, tenderness and lymphadenitis.
• Treatment - systemic antibiotics
- analgesics
- aural toilet( ear cleaning).
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21. Diseases of the External auditory canal…
ii) Diffuse otitis externa…diffuse inflammation of the skin lining
the external canal & may spread to the pinna & epidermal layer
of TM
– predisposing factors are- skin lacerations(scratching) and
skin maceration( swimmer’s ear)
– May be acute or chronic
– Symptoms- burning sensation ,pain aggravated by
movement of the jaw ,ear discharge
– otoscopy… diffusely inflamed EAC ,skin is thick & swollen
– Treatment-Ear toilet
Antibiotic- systemic
Analgesics like Paracetamol
Topical steroid/Abx combined preparation eg.
Trecothil ointment if the EAC is so edematous.

22. Diseases of the External auditory canal…
iii) Malignant (necrotizing) otitis externa
- also called Skull base osteomyelitis
-invasive and potentially fatal bacterial infection, which
extends beyond the external canal to T.B
 elderly and uncontrolled diabetic.
Caused by Pseudomonas aeruginosa
• Symptoms
similar to other OE except that it doesn’t respond to
the usual treatment.
• Signs
granulation tissue in the floor of the EAC.
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23. Diseases of the External auditory canal…
iii Malignant (necrotizing) otitis externa…..
• Investigations…. CT scan,Culture & sensitivity, biopsy
• Complications …….spread of infections to the skull
base and cranial nerve palsy.
• Treatment includes
control of diabetes
six weeks of IV antibiotics
- quinolones such as Ciprofloxacillin or
- third generation cephalosporines like
Ceftriaxone.

24. Diseases of the External auditory canal…
 Fungal otitis externa (Otomycosis)
Aspergilus and candida albicans.
Seen in hot & humid climates
Predisposing factors… prolonged use of local
antibiotics.
Symptom - Itching is the main ,ear discharge
• Otoscopy - The lumen contains a whitish/black/blue
green fungal mass or fungal hyphea in the external canal.
Treatment -removal of the fungal mass(ear toilet)
-anti fungal ear drops or creams
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25. Diseases of the External auditory canal…
e) Neoplastic ..
• Benign tumour…exostoses is the
most common benign tumour
• malignant ……SCC is the
commonest
– presented with earache,
blood stained offensive
otorrhea and
– otoscopy examination -
friable mass
– Causes conductive hearing
loss.
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26. Diseases of the External auditory canal …
f) Wax accumulation
It is an oil material which consists of mixture of
secretions of sebaceous and ceruminous glands in the
outer cartilaginous part with desquamated skin cells.
it protect the skin with its acidity and lysozyme enzyme.
Usually expelled spontaneously outside of the canal.
• Predisposing factors
 Narrow external canal, and attempts by the patients
• Causes Hearing loss and tinnitus, itching
• Brownish mass seen in the EAC.
• Can be removed by ear wash or instruments/wax hook.

27. Diseases of the External auditory canal…
• Ear wash
Indications
 excessive or impacted wax
 Non vegetable and non impacted FB
 Otomycosis
 Caloric test
Contraindications
 Perforated TM
 Impacted or vegetable FB
 Otitis externa
Technique : to the postero-superior direction. And has to be warm
water.
Complications: injury to the canal or TM, infection, stimulation of
inner ear, stimulation of the vagus.
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28. Ear Wax….contd
. Educate about non instrumentation of their ear
canals.
. When to refer to ENT clinic:
. Patients known to have a tympanic membrane
perforation or previous ear surgery (need
microsuction)
. Only one hearing ear
. Syringing fails
. Causes pain or vertigo,
. Hearing loss persists after wax removal

29. Otitis Media
• Inflammation of the muco-periosteal linning of the middle ear cleft
• Types
1.Acute otitis Media
2. Chronic non suppurative otitis media
3. Chronic suppurative otitis media
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30. Acute otitis media
 Acute inflammation of the mucosal lining of the middle ear cleft.
 Strept. Pneumoniae, H. influenza, M.catarrhalis
 anaerobes (newborns) , gram negative enterics (infants) , viral
 Risk factors….young age, bottle feeding, daycare and medical
conditions
• 60 to 70% of children have at least 1 episode of AOM before 3 years
• 18 months to 6 years most common age group
 Routes of infections
a) Through the eustachian tube
 Upper respiratory infections
 Infected material passing through the tube
b) Through tympanic membrane perforation
 Bathing, swimming and ear wash.

31. Acute otitis media …
 Pathology and clinical picture.
Has four stages.
a) Stage of tubal cataharral
 inflamed ET…….ET obstruction……..negative middle ear pressure.
 symptoms - Hearing loss and tinnitus
 Signs…speculum exam…….retracted tympanic membrane
- tuning fork tests….. conductive hearing loss.
b) Stage of catarrhal OM
 Infection spreads to the mucosal lining of the middle ear with
serous exudate
 Symptoms…..HL, tinitis and dull earache
 Signs - otoscopic examination….cart-wheel appearance.
- tunning fork…….CHL
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32. Acute otitis media …
c) Stage of suppurative otitis media
 The exudate becomes muco-purulent.
 Symptoms…. Hearing loss and tinnitus
sever and throbbing pain and general symptoms.
 otoscopic examination shows bulging and red TM
d) Stage of TM perforations/Stage of recovery.
 Due to pressure necrosis of the pars tensa.
 The general symptoms subside and otorrhoea starts.
 Signs..perforated tympanic membrane, muco-purulen discharge
and inflamed middle ear mucosa
E) Stage of Complication- if virulence of organism is high or resistance of
patient is poor.
Investigations
 otoscopy
 C&S,
 Pure tone audiometry (PTA)
 imaging 32

34. Acute otitis media …
Treatment
1) Before perforation
a) Medical treatment
 antibiotics(Augmentin is prefered) for 7-10 days
 analgsics and antipyretic like paracetamol
 Decongestant nasal drops eg. Xylomethazoline
b) surgical treatment
 Myrigotomy – if patient has persistent fever or febrile seizure,
severe earache despite the above medical treatment.
2) after perforation
a) Medical treatment
 aural toilet/ear cleaning
 Antibiotics- Ciprofloxacillin ear drop 3 drops BID fer 7-10 days if
the perforation is big
- Cipro ear drop + po Augmentin for 7-10 days
 Prevent re infection by avoiding entry water to the affected ear
using vaseline soaked cotton. 34

35. Acute otitis media …
Complications of AOM
• otologic
– TM perforation
– chronic suppurative OM
– ossicular necrosis
– persistent effusion (often leading to hearing loss)
– cholesteatoma
• Intra temporal
– mastoiditis
– labyrinthitis
– Petrositis
– facial nerve paralysis

36. intracranial
• meningitis
• brain abscess
• Sub dural abscess
• Epidural abscess
• sigmoid sinus thrombophlebitis

37. .
Chronic non Suppurative Otitis media
• Chronic non purulent inflammation of middle ear Xized by presence
of intact TM
• Types
A) Adhesive otitis media
B) Secretory otitis media
A.) Adhesive otitis media
 Presence of fibrous adhesion in the middle ear.
• Symptoms
 Hearing loss and tinnitus.
• Sign
 Tympanic membrane is retracted and dull grey.
• Treatment
 Tympanoplasty
 Hearing aid.
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39. 39

40. Chronic non Suppurative Otitis media…
B. Secretory otitis media (Otitis Media with Effusion )
 Accumulation of a non purulent sero mucoid effusion in ME
Causes - Eustachian tube obstruction, allergy and infections
- Inadequate treatment of acute otitis media
 The commonest cause of conductive hearing loss in children.
• Symptoms
 Mild to moderate CHL, ear fullness and tinnitus.
• Signs
– Otoscopy ………….signs of retraction and signs of middle ear
effusion (discolouration – dull grey with “glue” ear , fluid level )
 Tunning fork tests………..conductive hearing loss.
• Investigations
 PTA….CHL

41. Chronic non Suppurative Otitis media…
.Treatment
a) Conservative treatment– 90% resolve by 3 months
 Treat predisposing factors,
 antibiotic therapy, antihistamines, decongestants clear disease
faster
 Promote autoinflation of the eutachian tube by encouraging
frequent swallowing eg. Chewing gum.
b) Surgical treatment
 Myringotomy and insertion of a ventilation tube.
Temporary…Grommet
Permanent…T-tube
If the effusion is recurrent one, adenoidectomy may be done.
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42. Complications of Otitis Media with Effusion (OME)
• hearing loss, speech delay, learning problems in
young children
• chronic mastoiditis
• ossicular erosion
• cholesteatoma
• retraction of tympanic membrane, atelectasis,
ossicular fixation

43. Otitis media with Effusion

44. Chronic suppurative otitis media
Chronic inflammation of the muco periosteal lining of Middle ear
cleft Xized by presence of TM perforation and intermittent or
continuous otorrhoea.
• Commonest organisms are Pseudomonas aeruginosa and proteus
species.
• Staph.aueus and anaerobes
Types
a) Tubo tympanic disease/safe
b) Attico-antral diseases./unsafe
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45. Chronic suppurative otitis media…
A) Tubo tympanic disease
Etiology: It follows acute suppurative otitis media
 Organism factors……recurrence and virulence.
 Treatment factors…..inadequate dose and inadequate
drainage.
 Patient factor…………decreased resistance
• Symptoms- otorrhoea ,hearing loss and tinnitus.
• Signs. Otoscopy- perforation, inflamed middle ear mucosa,
aural polyp.
• Tunning fork- CHL

46. • Treatment
 Control of infection
Regular aural toilet
Antiseptic or antibiotic
 Avoid re-infection
Treat predisposing factors
Avoid entry of water to the canal.
• Surgical intervention
Tympanoplasty – definitive long term management

47. 47

48. Chronic suppurative otitis media
B) Attico-antral disease (cholesteatoma)
 Is the presence of keratinized squamous epithelium in the middle
ear cleft.
 It is a sac lined with keratnizing stratified squamous epithelium
which is called matrix. And filled with concentric sheets of
desquamated keratin.
 chronic inflammatory process causes progressive destruction of
surrounding bony structures
 Etiology
i) Congenital cholestatoma….occurs behind an intact TM.
 Developed from embryonic cell rests
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49. Cholesteatoma…
ii) Primary acquaired cholestatoma
 Occurs with out history of otitis media.
 Invagination theory…formation of retraction pocket
 Invasion theory…….abnormal migration of squamous layer of the TM
iii) Secondary acquired cholesteatoma
 Occurs after otitis media
 Migration theory….migration through the perforation
 Metaplasia theory….due to chronic irritation of the ME mucosa.
 Course of the disease.
 Expands gradually & exposed to secondary bacterial infections.
 secreats osteolytic enzymes - errosion of surrounding bony structure.
• Symptoms…..HL, tinnitus and otorrhoea.
49

51. Cholesteatoma…
• Signs
 Purulent, offensive and scanty ear discharge
 The perforation is in the pars flaccida or it is mariginal.
 Aural polyps.
 Tunning fork tests ……….CHL.
 Investigations………… Pure tone audiometry, CT and C&S.
 Treatment
 It is all surgical.
• mastoidectomy ± tympanoplasty ± ossicle reconstruction
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52. Cholesteatoma…
Complications
• ossicular erosion: conductive hearing loss
• facial paralysis
• Meningitis
• sensorineural hearing loss from inner ear erosion
• sigmoid sinus thrombosis
• dizziness from inner ear erosion or labyrinthitis
• intracranial abscess (subdural, epidural, cerebellar)
• temporal bone infection: mastoiditis, petrositis

53. Complications of otitis media
• Cranial and intra cranial
A. Cranial complications
 Coalecent mastoiditis
 Chronic mastoiditis
 Abscess(post auricular,bezold and temporal root abscess)
 Supprutaive labryntitis
 Facial nerve palsy
B. Intra cranial complications
 Meningitis
 Abscess
 Sigmoid sinus thrombophlibitis
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54. Mastoiditis
• infection of mastoid air cells,
• commonly seen two weeks after onset of untreated or
inadequately treated acute otitis media
Etiology
• acute -same organisms as AOM: S. pneumoniae, S. pyogenes,
S. aureus, H. influenzae

55. Clinical Features
• classic triad
– otorrhea
– tenderness to pressure over the mastoid
– retroauricular swelling with protruding ear
• fever, hearing loss, ± TM perforation (late)
Treatment
• IV antibiotics plus myringotomy and ventilating tube
• Mastoidectomy -if failure of medical treatment after 48 hours
& symptoms of intracranial complications

56. 56

57. Disease of the Inner Ear
Sensorineural Hearing Loss
• Hereditary Defects
• Prenatal TORCH Infections
- toxoplasmosis, rubella, cytomegalovirus (CMV), herpes simplex,
others (e.g. HIV)
• Perinatal
- Rh incompatibility
- anoxia
- hyperbilirubinemia
- birth trauma (hemorrhage into inner ear)
• Postnatal
- meningitis
- mumps
- measles

58. Presbycusis
Definition
• sensorineural hearing loss associated with aging (5th
and 6th decades)
• is the most common cause of sensorineural hearing
loss.
Etiology
• age related degeneration of cochlear neuron & cells .

59. Presbycusis…
Clinical Features
• progressive, gradual bilateral hearing loss
• loss of discrimination of speech especially with background noise
present – patients describe people as mumbling
• inability to tolerate loud sounds
• tinnitus
Treatment
• hearing aid
• For the tinnitus with sleep disturbance –amytryptiline12.5mg po
nightly can be given.

60. Sudden Sensorineural Hearing Loss
• HL of < 3 days with > 30dB loss in at least three frequencies
• presents as a sudden onset of significant hearing loss (usually
unilateral) ± tinnitus, aural fullness
• usually idiopathic, rule out other causes:
– autoimmune causes – ESR, rheumatoid factor, ANA
– Tumour ,ischemic/hemorrhagic stroke
Treatment
• Oral corticosteroids within 3 days of onset: prednisone 1-2
mg/kg/day, tapering over 2 weeks

61. Ototoxic Drugs
A. Aminoglycoside antibiotics
Streptomycin
Gentamycin
Tobramycin
Neomycin
Kanamycin
B. Diuretics
Furosemide
C. Antimalarials
• Quinine
• Chloroquin
D. CytotoxiC drugs
Cisplatin
Carboplatin

62. • toxic to hair cells by : oral, IV, topical ( if the TM is perforated)
• ototoxicity occurs days to weeks post-treatment
• duration of treatment is the most important predictor of
ototoxicity
• Treatment: stop immediately the ototoxic drug
E. Analgesics
Salicylates
Indomethacine
Ibuprofen
F Chemicals
Alcohol, tobaco, marijuana
Others:erythromycin,ampicillin,propranolol

63. Noise-Induced Sensorineural Hearing Loss
Pathogenesis
• 85 to 90 dB over months or years & single sound impulse >135 dB
causes cochlear damage
Treatment
• hearing aid