Diseases of the external ear are common conditions to be encountered in ENT practice. This presentation is about the major conditions of pinna and EAC including pinna defects, pseudocyst of pinna, perichondritis, hematoma, pseudocyst of pinna, otitis externa, otomycosis, malignant otitis externa, keratosis obturans etc.

1. Diseases of the
External ear
Dr. Krishna Koirala

2. Diseases of Pinna
1. Congenital
– Minor : Accessory auricular tags , Bat ear
, Pre - auricular sinus
– Major : Anotia ,Microtia
2. Traumatic
– Hematoma , lacerations

3. 3. Inflammatory : Perichondritis
4. Neoplastic : Squamous cell carcinoma
Basal cell carcinoma
5. Others : Sebaceous cyst ,lipoma ,
keloids, Pseudocyst pinna

4. • Small pit leading to a blind tract that lies adjacent
to helix
• Due to incomplete fusion of first and second
branchial arches (Hillocks of His)
• Unilateral : L>R
• Bilateral : (25 - 50%), more like to be hereditary
• Mostly asymptomatic
Preauricular sinus

5. • Repeated infections
– Surgical excision of the sinus with complete
removal of tract along with a portion of
auricular cartilage
– Recurrence is common (tracts arborize and
follow a tortuous course)

7. • Collection of blood and serum under the
perichondrium of pinna
• Pathology : Shearing forces to the auricle and pinna
resulting in separation of the perichondrium from
the underlying cartilage
• Seen in boxers, wrestlers, judo players ,athletes
• More common on the lateral surface
• Pinna : Swollen, bluish,thick, tender on touch
Hematoma of the pinna

9. • Infection
– Perichondritis and abscess formation
– Thickening and cauliflower ear
– Necrosis of the cartilage
• Treatment
– Broad spectrum antibiotics sensitive to Pseudomonas and
Staphylococcus. Eg. Ceftriaxone, ciprofloxacin
– Wide bore needle aspiration and tight pressure dressing
– Incision and drainage
– Debridement of necrosed cartilage

11. Incision and drainage
Vaseline gauze being applied
Compression dressing on progress

12. • Inflammation of the perichondrium of auricular
cartilage
• Commonly caused by Pseudomonas
• Predisposing factors
– Laceration, piercing, mastoid surgery, otitis
externa
– Frostbite, burns, infections of pinna , relapsing
polychondritis
Perichondritis

13. • Clinical Features
– Pain & swelling of pinna
– Hot, tender, thick pinna
– Fluctuation +/-, Fever +/-
• Treatment
– High dose broad spectrum i.v. antibiotics eg. Ciprofloxacin ,
Ceftriaxone, Cefotaxime, Flucloxacillin, Amoxyclav,
Cefuroxime
– Local application of Magnesium sulphate
– I & D of abscess/ surgical debridement of necrosed
cartilage

14. • Localized subperichondrial fluctuant swelling of the
auricle
• Etiology : Idiopathic, Viral
• Frequently encountered during monsoon season
• Presence of sterile clear fluid in subperichondrial
plane with no definite cyst wall
• Appears insidiously, mild discomfort +
• Variable size , fluctuation +
Pseudocyst of pinna

17. • Treatment
– Aspiration and quilting
– Surgical deroofing followed by buttoning
– Intralesional steroids following aspiration
– Incision and drainage with removal of a part of
cartilage (Posterior cartilage window technique)

18. Diseases of the External Auditory Canal
• Congenital
– Congenital atresia of EAC
– Stenosis
• Inflammatory
– Otitis externa
• Neoplastic
– Osteoma
– Squamous cell carcinoma
– Basal cell carcinoma
• Traumatic
– Iatrogenic / Accidental
• Miscellaneous
– Wax
– Foreign bodies
– Keratosis obturans
– Acquired atresia of EAC
– Exostoses

19. Otitis Externa (Classification as per extent of lesion
• Localized : Furunculosis
• Diffuse : Idiopathic, Traumatic , Irritant, Allergic,
Bacterial/ fungal, Climatic / environmental
• Invasive : Granulomatous / Necrotizing /
Malignant
• Part of generalized skin condition : Seborrhic
dermatitis, Atopic, Allergic , Psoriasis
• Others : Keratosis obturans

20. Furunculosis
• Infection of hair follicle of external auditory canal by
Staph. aureus , Pseudomonas
• Painful, tender ,well circumscribed lesion
• Pain aggravated by jaw movements
• Meatus occluded by swelling – conductive hearing
loss
• Carbuncle / regional lymphadenitis
• May coexist with diffuse otitis externa : otorrhea ,
debris
• Postauricular swelling ( cellulitis / lymphadenopathy)

22. Treatment
• Cleaning of EAC (Aural toileting)
• Packing of EAC
− Wick soaked in steroid antibiotic cream
− Ichthamol Glycerin (IG) : analgesic, anti inflammatory,
antibiotic, dehydrator
• Systemic antibiotics : Flucloxacillin, Ciprofloxacin
• Analgesics/warm saline dressings
• Incision and drainage if suppuration develops
• Recurrence : R/O Diabetes mellitus !!!

23. Diffuse Otitis externa
• Tropical ear/ Singapore ear
• Aggravating factors : Local trauma , heat, humidity,
bathing
• Causative agents : Pseudomonas, Proteus, Staph. aureus
• Stages
– Acute
•Earache aggravated by jaw movement
•Swelling of the soft tissue around the ear
•Red, swollen, tender canal skin
•Pus / debris in the meatus; TM dull & injected

24. • Chronic
– Irritation of ear/discharge
– Decreased hearing
– Thickened meatus skin / reduced lumen with pus &
debris
– Granulations in the TM
• Treatment
– Careful cleaning of meatus preferably under the
Microscope
– Steroid - antibiotic cream (ear packing) or ear drops
– Systemic antibiotics

25. Otomycosis (Fungal infection of EAC)
• Organisms : Aspergillus niger, Candida, Dermatophytes
• Predisposing conditions : Extremely moist, hot
environment, Chronic bacterial otitis externa
• Symptoms : Itching , aural fullness, earache, discharge,
swelling
• Signs
– Grayish white debris resembling wet filter paper filling
the meatus ( Candida)
– Black specks in the debris(conidiophores of Aspergillus)
– Injected canal wall

28. •Treatment
– Thorough cleaning of all accumulated debris
– Antiallergics, analgesics, antifungals
– Topical antifungals
•Nystatin, clotrimazole (1%) for 2-3 wks
•Topical gentian violet solution
– Burrow's solution ( 5% aluminum acetate solution-
Reduces the swelling and removes the debris )

29. • Invasive/ granulomatous/ necrotizing otitis externa
• Skull base osteomyelitis
• Rapidly progressive bacterial infection of external auditory
meatus, surrounding soft tissues and skull base
• Predisposing factors
− Elderly , poorly controlled diabetics, prolonged steroid
use, atherosclerosis, immunosuppressed, hypogama -
globulinemia , AIDS
Malignant Otitis externa

30. • Causative organisms
– Pseudomonas, Staph. epidermidis, Aspergillus
fumigatus
• Hallmark of disease
– Granulation tissue at the junction of cartilaginous
and bony EAC
– Pain out of proportion of the disease in EAC

31. EAC
Secondary osteomyelitis of petrous Apex
Thrombosis of lateral sinus,
superior and inferior petrosal sinus
IX, X, XI,XII cranial nerve
palsy
Tympanic plate, Mastoid tip Tympanomastoid suture,
Adjacent soft tissues
Parotid gland ,TMJ
Facial Palsy
Spread of Disease
Floor of MCF, Basisphenoid

32. • Investigations
– CBC, RBS / Urea
– CT Scan / MRI
– Gallium bone scan
• Treatment
– Control of diabetes and other predisposing factors
– Debridement of necrotic tissues
– Administration of antibiotics( high dose , broad spectrum)
•Ciprofloxacin 750 mg twice daily for 6-12 weeks
•Ceftriaxone 1 gm I.V. BD 7-10 Days

33. Exostoses of EAC Osteoma of EAC
More common Less common
Smooth, sessile, hemispherical Pedunculated ,round
In deep bony meatus At outer part of bony
meatus
Dense ivory bone ( V-notch : Di’s
notch ) group of 3
Osteoid bone
Aggravated by surfing in cold
water
Unknown
Usually bilateral Usually unilateral
Seperated by suture lines Arises from suture
lines
Less recurrent More recurrent

35. Keratosis obturans
• Keratotic mass of desquamated epithelium in bony
portion of EAC obstructing it
• Pearly white / obscured by wax
• Common age : 5 -20 yrs
• Etiology
– Idiopathic
– Chronic hyperemia  desquamation of keratin 
epidermal debris
– Faulty migration of squamous epithelial cells
– May be associated with bronchiectasis & sinusitis

36. Clinical Features
• Severe pain in the ear, aural fullness
– Bilateral symptoms in children
– Unilateral predominantly in adults
• Hearing loss (conductive) , otorrhea (rare), tinnitus
• Geometrically patterned keratin plug within the lumen of
expanded ear canal (onion skin)
• Erosion and abnormal widening of deep osseous meatus
(eburnated bony canal , ballooning of EAC)
• TM usually intact
• Mucopurulent discharge (rare)

37. •Treatment
− Removal of the Keratotic debris
by instrumentation (LA /GA)
− Treatment of inflammation
− Keratolytic - not helpful
− Canalplasty ( recurrent cases)
− Regular follow – up , May recur!!