This document discusses diseases of the external ear and their management. It covers topics such as: 1. Congenital anomalies of the pinna including microtia and anotia. 2. Inflammatory conditions of the external ear canal including diffuse otitis externa, malignant otitis externa, and otomycosis. 3. Tumors of the external ear including basal cell carcinoma and squamous cell carcinoma. 4. Miscellaneous conditions like wax impaction, foreign bodies, and keratosis obturans are also covered. Treatment options discussed include antibiotics, antifungals, surgical excision and debridement depending on the specific condition

1. Diseases of External Ear and its
Management
Presented by
Dr. Binod Chaudhary
Department of ENT
Chitwan Medical
College

2. Anatomy

3. Anatomy

4. Disease of external ear
Divided into
1. Disease of the pinna
a. Congenital disorders
b. Trauma to the auricle
c. Inflammatory disorders
d. Tumors

5. 2. Disease of external auditory canal
a. Congenital disorders
b. Trauma
c. Inflammation
d. Tumors
e. Miscellaneous condition

6. Congenital disorders of pinna
• Due to developmental abnormalities
• May be minor variations or major
abnormalities
• Minor anomalies
– Accessory auricular tag
– Bat ear
– Lop ear
– Preauricular sinus

7. • Major anomalies
– Anotia
– Microtia

8. Anotia
Complete absence of pinna and lobule
Usually forms the part of first arch syndrome

9. Microtia
• A major developmental anomaly
• Frequently associated with anomalies of EAC,
middle ear and inner ear
• Hearing loss- frequent
• Degree of microtia may vary

10. – Grade I microtia: Small external ear and a small but
present external ear canal
– Grade II microtia: A partially developed ear (usu. top
portion underdeveloped) with a closed external ear
canal producing a CHL
– Grade III microtia: Most common form of microtia
with an absent external ear and small peanut-like
vestige structure and canal atresia
– Grade IV microtia: aka anotia, complete absence of
the external ear with canal atresia

11. Treatment options
• Do nothing
• Surgery
– Ear reconstruction using own body’s skin and
cartilage
– Ear reconstruction using MEDPOR implant
• Prosthesis

12. Macrotia
Lop/cup ear Preauricular tag
Bat ear
Congenital anomalies of pinna

13. Preauricular sinus
• A depression in front of the crus of helix or
above tragus
• Is an epithelial track and is due to incomplete
fusion of tubercles.
• Gets repeatedly infected causing purulent
discharge, may form abscess.
• Treatment of choice: surgical excision of the
track.

15. Trauma to the auricle
Hematoma of auricle
• Due to injury leading to collection of blood
and serum between the auricular cartilage
and its perichondrium.
• Extravasated blood may clot and then,
organize, resulting in a typical deformity called
cauliflower ear.

16. • Clinical features
– Commonly seen on the anterior surface
– Swelling, bluish and tender auricle
– If left untreated, necrosis of cartilage and scarring
of the auricle
– Superadded infection results perichondritis ad
abscess formation.

17. Treatment
• Aspiration of the hematoma under aseptic condition
and pressure dressing to prevent re-accumulation
• Incision and drainage if aspiration fails.
• All cases should receive antibiotic prophylaxis.

19. Laceration of auricle
• The auricle may be cut through-and-through
or avulsed partially or totally in RTA, knife
injuries, etc.
• Treatment includes repairment as early as
possible.
• Broad spectrum antibiotics given for 1 week.

21. Inflammatory disorders
Perichondritis
• Is infection of perichondrium of the auricular
cartilage
• Results from infection secondary to
lacerations, hematoma or surgical incisions.
• Commonly caused by Pseudomonas
aeruginosa

22. Clinical features
• Pain, swelling and tender to touch
• Patient often has fever
• Necrosis of the cartilage, fibrosis and scarring
if not treated immediately.

23. Treatment
• Should be prompt and vigorous
• High dose ciprofloxacin should be used.
• Local applicants- magnesium sulfate for
soothing
• Incision and drainage and C/S if abscess formed.
• Surgical debridement to remove unhealthy
granulations and necrosed cartilage.

24. Relapsing perichondritis
• A rare autoimmune disorder involving
cartilage of the ear.
• Any cartilage can be involved.
• Entire auricle except its lobule becomes
inflammed and tender.
• External ear canal becomes stenotic.
• Treatment consists of high dose of systemic
steroids.

25. Relapsing polychondritis

26. Chondrodermatitis nodularis chronica
helicis
• Small painful nodules near the free border of
helix.
• Tender and patient unable to sleep on the
affected side
• Treatment is surgical excision of the nodule
with its skin and cartilage.

27. Chondrodermatitis nodularis chronica helicis

28. Tumors
Benign tumors
• Hemangioma
• Sebaceous cyst
• Dermoid cyst
• Papilloma
• Keratoacanthoma
• Neurofibroma
Malignant tumors
• Squamous cell
carcinoma
• Basal cell carcinoma
• Melanoma

29. Hemangioma
• Benign tumors of blood
vessels
• Congenital tumor commonly
seen in children
• Bleeds frequently
• May get infected
• Treatment: surgical excision

30. Dermoid cyst
• Developmental cyst
• Presents as round mass
over the upper part of
mastoid behind the pinna
• Treatment: surgical excision

31. Sebaceous cyst
• Cysts of sebaceous glands
• Contains cheesy materials
• Common site is postauricular
sulcus or below and behind
the ear lobule
• Treatment: total surgical
excision

32. Papilloma
• May present as a tufted
growth or flat grey plaque and
is rough to feel
• Viral in origin
• Treatment: surgical excision or
curettage with cauterization of
its base.

33. Squamous cell carcinoma
• It can arise anywhere in the external ear, commonly
helix.
• May present as a painless nodule or an ulcer with
raised everted edges and indurated base.
• Grows rapidly, invades the surrounding bone and
spreads through lymphatics
• Treatment:
– Small lesions with no nodal metastasis- local
excision with 1 cm of external auditory canal
– Lesions with nodal metastasis- total amputation of
the pinna, often with en bloc removal of parotid
gland and cervical lymph nodes.

34. Squamous cell carcinoma

35. Basal cell carcinoma
• Commonly seen over helix and tragus
• More common in men beyond 50 yrs
• Presents as nodule with central crust, removal of which
results in bleeding.
• Ulcer has a raised or beaded edge
• Lesion often extends circumferentially into the skin,
may penetrate deeper to cartilage or bone
• Treatment:
– Superficial lesion not involving cartilage- irradiation
and avoidance of cosmetic deformity
– Lesions involving cartilage- surgical excision as in
SCC

36. Basal Cell Carcinoma

37. Diseases of External Auditary Canal
• Congenital disorders
• Trauma
• Inflammation
• Tumors
• Miscellaneous conditions

38. Congenital anomalies
Congenital atresia of the EAC
• May be either complete or incomplete .
• Due to failure of canalization of the ectodermal
core that fills the dorsal part of the first brachial
cleft.
• The outer meatus is obliterated with fibrous
tissue or bone while deep meatus and TM are
normal
• Usually a/w anotia, middle ear and/or inner ear
deformities
• Hearing loss may be CHL, SNHL or mixed.

39. Treatment
• Reconstructive surgery for atresia of EAC
(unsatisfactory results)
• BAHA or Bonebridge implant system to achieve good
hearing system.

40. BAHA implant
Bonebridge implant

41. Collaural fistula
• An abnormality of the first branchial cleft.
• The fistula has 2 openings: one situated in the
neck just below and behind the angle of
mandible and the other in the external canal
or the middle ear.

42. • Treatment: surgical exploration and excision

43. Trauma to the ear canal
• May range from minor laceration of EAC wall
to fracture of the bony wall
• Foreign body in the EAC may cause trauma to
the wall of ear canal.
• There may be pain together with bleeding due
to laceration.
• May get infected if treatment is delayed

45. • Treatment:
– Minor injuries require no treatment.
– Oral and local antibiotics in more severe cases
– Ribbon gauze soaked in 10% ichthyol in glycerine
as an ear pack
– Reduction of fracture only necessary if the
fracture produces occlusion of the EAC

46. Inflammations of EAC
May be divided into
1. Infective group
– Bacterial
• Localized otitis externa (furuncle)
• Diffuse otitis externa
• Malignant otitis externa
– Fungal
• otomycosis
– Viral
• Herpes zoster oticus
• Otitis externa hemorrhagica

47. 2. Reactive group
– Eczematous otitis externa
– Seborrhoeic otitis externa
– neurodermatitis

48. Furuncle (Localized otitis externa)
• Infection of hair follicle in the outer cartilaginous part
of the EAC
• Commonly caused by Staphylococcus aureus.
• Follows trauma like scratching or cleaning of the EAC
by matchsticks, cotton buds, hair clips, nails, etc.
• Symptoms
– Earache
– Swelling/abscess
– Discharge
– Hearing loss

49. • Signs
– Inflamed skin and swelling
– Tenderness: tragal tenderness and also with
movement of auricle
– Discharge
– Granulations
– Hearing loss
• Furuncle at posterior meatal wall causes oedema
over the mastoid with obliteration of the
retroauricular groove.
• Preauricular l.n. may be enlarged and tender

50. • Treatment
– Analgesics and local heat
– Antibiotics (cloxacillin)
– Ear packing with 10% ichthyol in glycerine or other
medicated wick
– Incision and drainage if abscess formed

51. Diffuse otitis externa
• Diffuse inflammation of meatal skin which may
spread to involve the pinna and epidermal layer of
TM
• Commonly seen in hot and humid climate and in
swimmers.
• Most common factors are
– Trauma to the meatal skin
– Invasion by pathogenic organisms (S. aureus, P.
pyocyaneus)
• Clinical features very similar to localized otitis
externa.

52. • Differentiating features from localized form are:
– Entire EAC is uniformly inflamed and swollen and there is
discharge.
– No abscess formation
– No swelling in the areas adjoining the EAC in diffuse otitis
externa

53. • Treatment
– Ear toilet
– Medicated wicks: aluminium acetate(8%) or silver
nitrate(3%)
– Antibiotics: cloxacillin or flucloxacillin or
ciprofloxacin together with pseudomonas
coverage
– analgesics

54. Malignant otitis externa
• Aka necrotizing otitis externa
• It is an inflammatory condition caused by
Pseudomonas infection usually in the elderly diabetics,
or in those on immunosuppressive drugs.
• Early manifestation resemble diffuse otitis externa but
there is excruciating pain and appearance of
granulations in the ear canal.
• Facial paralysis is common
• Infection may spread to the skull base and jugular
foramen causing multiple cranial nerve palsies.

55. Diagnosis
• Severe otalgia in an diabetic patient with granulation
tissue in the EAC.
• CT scan may show bony destructions
• Gallium -67 scan
• Technetium 99 bone scan

56. Treatment
• Control of diabetics
• Toilet of ear canal. Remove discharge, debris and
granulations or any dead tissue or bone and send for
culture sensitivity.
• Antibiotic treatment continued for 6-8 weeks
– Gentamicin combined with ticarcillin
– Third generation cephalosporins: ceftriaxone 1-2 g/day iv
or ceftazidime 1-2 g/day iv combined with
aminoglycosides
– Quinolones are also effective: combined with rifampin

57. Otomycosis
• Is a fungal infection of the EAC caused either by
Candida albicans or Aspergillus niger.
• Seen in hot and humid climate.
• Occurs commonly after entry of water in the EAC,
after putting oil and after prolonged use of topical
antibiotic eardrops.
• Commonly occurs together with CSOM which is
actively discharging

58. Clinical features
• Itching
• Aural fullness
• Discomfort and pain
• Discharge
• Tenderness (in severe case)
Examined with otoscope, A. niger appears as black
headed filamentous growth and C. albicans appear as
yellowish deposit.

59. Treatment:
• Thorough cleaning
• Broad spectrum topical antifungals (clotrimazole
for 10 days)
• If there is discharging COM, treat COM as well.

60. Herpes zoster oticus
• Aka Ramsay Hunt Syndrome
• An infection caused by Varicella Zoster virus.
• Usually disease of adults
• Characterized by formation of vesicles on the
tympanic membrane, meatal skin, concha and
postauricular groove.
• Patient is ill, complains of severe earache and may
have fever.
• May involve CN VII and VIII
• Triad of SNHL, vertigo and facial palsy

61. Treatment
• Oral acyclovir along with high dose steroids.
• Labrynthine sedatives for vertigo

62. Otitis externa hemorrhagica
• Viral in origin and may be seen in influenzae
epidemics.
• Characterized by formation of hemorrhagic bullae on
the tympanic membrane and deep meatus.
• Severe pain and bloody discharge when bullae
rupture

63. Treatment
• Analgesics for pain relief
• Antibiotics for secondary infection of the middle ear
if the bulla has ruptured.

64. Eczematous otitis externa
• Result of hypersensitivity to infective organisms or
topical ear drops such as chloromycetin or neomycin.
• Characterized by intense irritation, vesicle formation,
oozing and crusting in the canal.
• Treatment is withdrawal of causative agent and
application of steroids.

65. Miscellaneous conditions
Wax
• Secreted by sebaceous gland.
• Two types: hard and soft.
• Seen when self-cleansing mechanism of the
ear is disturbed.
• So, cleaning with cotton buds, hair clips,
matchsticks should be avoided.

66. Clinical features
• Discomfort/itching
• Feeling of blocked ear
• Hearing loss
• Tinnitus
• Cough
• vertigo

67. Treatment
• Wax without pain
Suctioning
Removal by jobson horne probe
Syringing

68. • Wax with pain (a/w otitis externa)
– Antibiotic ear drops followed by wax softners.
– Oil based antibiotic eardrop such as
chloramphenicol is preferred to other antibiotic
because it also softens the wax to some extent.
– Then removed as described above.

69. Foreign body
• Common in children than adults.
• Common foreign bodies in the EAC
Children
 Inanimate FB- pieces of paper, eraser, sponge, lead of
pencil, etc
 Vegetable matter- beans, seeds, etc
 Insects- flea, tick, housefly, maggots, etc
Adults
 Inanimate FB- cotton wool
 Insects- flea, tick, housefly, maggots, etc

70. Clinical features
• Children often do not tell their parents that they
have put a FB in the ear due to fear; incidental
finding
• Small inanimate FB- no symptoms
• Mild hearing loss
• Intense pain – live insects
• Examination reveals FB in the EAC

72. Treatment
Live insects should be first killed by putting oil or water
and then only be removed
• Methods of removal
1. Removal under microscope

73. 2. Removal by ear syringing

74. 3. Use of head mirror and ear instruments

75. Keratosis obturans
• A condition characterized by excess accumulation of
hard whitish- yellow debris consisting of desquamated
epithelium in the bony part of EAC.
• Eventually cause pressure on the bony walls of the EAC
and cause resorption of the bone
• Clinical features
– Blocked ear
– Pain and discharge if a/w otitis externa
– Cholesteatoma like mass (pearly white hard debris
covered by wax)
– Automastoidectomy

76. Treatment
• Removal as done for wax
• General anesthesia may be required because of the
pain
• Recurrent collection of desquamated epithelium, so
regular follow up required.