Furunculosis is a localized infection of a single hair follicle in the external ear canal caused mainly by Staphylococcus aureus bacteria. It presents as a painful, blocked ear with discharge and tender swelling around the pinna. Treatment involves antibiotics, incision and drainage of abscesses, and topical antiseptic ear drops. Without treatment, it can cause scarring and narrowing of the ear canal.

1. Furunculosis
A boil (furuncle) is an
infection of a hair
follicle]
A carbuncle occurs
when a group of hair
follicles next to each
other become
infected

2. • Furunculosis is a localized form of otitis
externa resulting from infection of a
single hair follicle
• Bacterial invasion of a single hair
follicle
well-circumscribed deep skin
infection
Pustule
local abscess formation
• Associated cellulitis and oedema
• Bacteria attach initially to the cells of
the stratum corneum and proliferate
around the ostium of the hair follicle.
• There is deeper invasion of the hair
follicle between the inner and outer
root sheath

3. DIAGNOSIS
• Symptoms do not usually discriminate furunculosis from
severe diffuse otitis externa
• The affected ear is extremely painful, feels blocked and
exudes a scanty serosanguinous discharge
• The pinna and tragus are tender on palpation

4. AETIOLOGY AND EPIDEMIOLOGY
• Staphylococcus aureus (S. aureus) is the most
common organism
• leukocidal toxins commonly isolated from
pathogenic strains of S. aureus trigger lysis of
phagocytic cells and may have an important role
in cutaneous infection.
• Recurrent furunculosis---Several conditions
appear to be associated with recurrent
furunculosis including hypogammaglobulinaemia,
diabetes mellitus and dysphagocytosis.

5. • Repeated infection can cause permanent
scarring and fibrosis of the external canal with
subsequent meatal stenosis.
• Ultimately, this may also predispose to chronic
diffuse otitis externa.

6. Treatment choices include:
• Antibiotics
• Topical treatment (antibiotics, astringents, hygroscopic dehydrating
agents);
• Incision and drainage
• Oral antibiotic treatment is recommended in the early stages of the
disease.
• Severe spreading soft tissue infection should be treated with intravenous
antibiotic therapy
• Abscess formation is an indication for formal drainage. After the abscess
has discharged, surgically or spontaneously, topical treatment is
preferable.
• Topical antibiotics active against staphylococcus are usually prescribed
• Insertion of a wick into the ear canal facilitates treatment in the presence
of severe canal oedema and narrowing

7. • Glycerol and ichthammol solution has a
specific antistaphylococcal action6, 7 and is
hygroscopic, thus causing dehydration of the
canal tissue.
• Aluminium acetate solution is an astringent as
well as a hygroscopic agent.

8. For patients suffering generalized
recurrent furunculosis
• Eradication therapy with nasal mupirocin.
• Eradication therapy with oral flucloxacillin for 14 days.
• Bacterial interference therapy: deliberately
implanting a nonpathogenic strain of S. aureus
(strain 502A is the most popular) to recolonize the nares
and skin.
• It has been reported that correction of specific
biochemical abnormalities (e.g. hypoferraemia, low
serum zinc) may lead to a marked reduction in the
frequency of infections.

9. Bullous myringitis
• Bullous myringitis (myringitis bullosa
haemorrhagica) is the finding of vesicles in
the superficial layer of the tympanic
membrane
The vesicles occur
between the outer
epithelium and the
lamina propria of the
tympanic membran

10. AETIOLOGY
• Influenza virus or by Mycoplasma pneumoniae
(No evidence for this)
• occurs in all age groups

11. SYMPTOMS
• Sudden onset of severe
• usually unilateral
• often throbbing pain in the ear is the most
common presentation
• The symptoms usually set in during or following
an upper respiratory tract infection
• A bloodstained discharge can be present for a
couple of hours
• A hearing impairment (conductive and/or
sensorineural) is common in the affected ear.

12. SIGNS
• Otoscopy—
 blood-filled, serous or serosanginous
 blisters involving the tympanic membrane
 Serosanginous secretion can be seen if the blisters
rupture
 The tympanic membrane is intact
• In young children with bullous myringitis, middle ear fluid
was present in the majority (97 percent) but is an
uncommon finding in other age groups.
• The site of the sensorineural hearing loss is the cochlea;
however, the pathogenic base is not understood.

13. DIAGNOSIS
• based on physical examination.
• Vesicles in the superficial layer of the TM.
• The main differential diagnoses
 Acute otitis media,
Herpes zoster oticus or
Ramsay Hunt syndrom

14. Investigations
• Inspection of the ear using a microscope is essential for
diagnosis.
• Pneumatic otoscopy and tympanometry help determine
whether the middle ear contains fluid
• Clinical evaluation of the cranial nerves and, in particular,
the facial nerve must be carried out for to distinguish from
herpes zoster oticus or Ramsey Hunt syndrome
• Pure-tone audiogram
• Cultures from blisters are not necessary in the
management of uncomplicated cases
• A serologic sample for herpes zoster is of value in cases
with sensorineural hearing loss and may be of help in the
differential diagnosis

15. OUTCOMES
• In the vast majority of cases a complete
recovery is seen within days.
• a sensorineural hearing impariment of more
than 15 dB in two frequencies was reported in
65 percent of 18 patients referred to an ENT
clinic for bullous myringitis.

16. MANAGEMENT OPTIONS
• In cases without middle ear affection and without sensorineural
hearing loss
only analgesics are recommended.
• When the middle ear is affected
antibiotics can be used as in the treatment of acute otitis media.
• In children less than two years of age, acute bullous myringitis
should be treated as acute otitis media.
• in cases with sensorineural hearing impairment- Antibiotics have
also been recommended

17. Effect of management
• Spontaneous resolution of the blisters and
middle ear effusion, if present, is the norm.
• Complete recovery of the sensorineural
impairment within three months occurred in
between 60 and 100 percent of affected
patients treated with amoxicillin.
(this study was not controlled)

18. Granular
myringitis
Granular myringitis is a
specific form of external otitis.
It is characterized by
granulation tissue on the
lateral aspect
of the tympanic membrane
with possible involvement of
the external ear canal.
various names
Granulating myringitis,
Myringitis granulosa,
Otitis externa granulosa,
Otitis externa with granulations,
Granulomatous otitis externa,
Granulomatous myringitis,
Acute granulomatous myringitis,
Chronic myringitis

22. PATHOLOGY
• Microscopic examination--oedematous
granulation tissue with capillaries and diffuse
infiltration of chronic inflammatory cells
• Large areas of the granulation tissue have no
covering epithelium
• It has been suggested that a nonspecific injury
involving the lamina propria of the tympanic
membrane suppresses epithelialization which
leads to the development of granulation tissue.

23. AETIOLOGY
• Not related to sex, age, systemic disease or season.
• High-ambient temperature, swimming, lack of hygiene,
local irritants and foreign bodies have all been
suggested as causative factors.
• Bacterial and sometimes fungal infection is present in
the affected ear in all reports.
• The incidence of granular myringitis has been
calculated to be a quarter of that of cholesteatoma
• Granular myringitis is also occasionally seen as a
postoperative complication of tympanic membrane
grafting.

24. SYMPTOMS
• Foul-smelling discharge from the affected ear.
• There is usually little or no pain.
• Some individuals have a sensation of fullness
or irritation in the ear.
• The hearing is either not at all or only slightly
impaired.
• Associated tinnitus is uncommon. Some
patients can be asymptomatic.

25. SIGNS
A moderate amount of purulent secretion is
seen in the affected ear .3 The tympanic
membrane is covered with secretions that
sometimes crust.
After aural toilet the granulation tissue is
revealed.
localized form of granular myringitis:
most common
Small areas of the drum are affected
one or more polyps are present
Most commonly, the granulations are
situated posterosuperior on the eardrum
and may affect the adjacent canal wall.
Diffuse form:
slightly raised carpet of granulations, which covers
the tympanic membrane
Perforation of the tympanic membrane is not
present

26. DIAGNOSIS
• Discharge from the ear is present.
• Inflammation and granulation tissue are seen on
the lateral aspect of the tympanic membrane
with possible involvement of the external ear
canal.
• Differential diagnoses:
chronic (suppurative) otitis media and diffuse
external otitis
• The lack of a conductive hearing impairment and
a normal computed tomography (CT) scan
excludesm chronic otitis media

27. Investigations
• Microscope
• Pneumatic otoscopy and tympanometry should be used to confirm
that the middle ear is normal and no perforation is present.
• Pure-tone audiometry should be performed to exclude a
conductive hearing impairment due to chronic otitis media.
• Culture:Gram-negative bacteria (Pseudomonas aeruginosa, Proteus
species and Staphylococcus aureus) and Candida albicans are most
commonly cultured.
The bacterial culture does not differ from specimens found in
external otitis and chronic otitis media.
• If there is doubt as to whether the middle ear and mastoid is
involved, a high resolution CT scan can help exclude chronic otitis
media
• If the granulations do not resolve with treatment, biopsy for
histological examination should be carried out to exclude carcinoma

28. OUTCOMES, NATURAL HISTORY AND
COMPLICATIONS
• Many patients are asymptomatic
• Granular myringitis has a chronic course and
granulations may continue to grow slowly for years
,however, healing may happen spontaneously.
• The inflammation in the epithelial layer and lamina
propria of the tympanic membrane sometimes leads to
replacement with proliferating granulation tissue,
fibrosis and an atresia forming from the medial part of
the ear canal.
• When the fibrosis and atresia has extended laterally,
the atresia ceases to grow.

29. MANAGEMENT OPTIONS

30. • Topical treatment with ear drops containing steroids and antibiotic
and/or antifungal agents based on the results from the culture
should be given
• The treatment should be continued for a longer period than in otitis
externa.
• Various antiseptic agents have been employed, but none of them
have been evaluated in a controlled way.
• A solution of 0.5 percent formalin or trichloroacetic acid applied
once a week has been given, with good results
• Strong caustic agents may harm the fibrous middle layer of the
eardrum and should be avoided.
• Removal of granulations by physical methods should be considered
if conservative treatment fails.
• If a perforation does happen, immediate repair with the temporalis
fascia should be carried out.

31. Effect of management
• variable

32. Benign necrotizing otitis externa
Benign necrotizing otitis externa is the clinical
condition of idiopathic necrosis of a localized
area of bone of the tympanic ring, with
secondary inflammation of the
verlying soft tissue and skin
OTHER NAMES--
•Benign necrotizing otitis externa;
•Benign necrotizing osteitis of the external
auditory meatus canal;
•Benign osteonecrosis of the external auditory
meatus;
•Aseptic necrosis of the external auditory meatus;
•Idiopathic tympanic bone necrosis;
•Necrosis and sequestration of the tympanic bone;
•Necrosis and sequestration of the tympanic part
of the temporal bone;
•Focal or circumscribed osteonecrosis of the
external auditory meatus.

35. Malignant otitis externa
Malignant otitis externa is
an aggressive and
potentially life-threatening
infection of the soft tissues
of the external ear and
surrounding structures,
quickly spreading to involve
the periostium and bone of
the skull base.

47. Otitis externa

49. Fungal otitis externa

55. otomycosis

57. aspergil
losis

58. Candida albical

59. Aspergillus fumigatus

60. otomycosis

61. Perichondritis of external ear

65. Relapsing polychondritis

67. Exostosis of external auditory canal