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NON-INFLAMMATORY DISEASES AND INJURIES OF THE EXTERNAL EAR

Description Etiology/Pathogenesis Signs and Symptoms Treatment

Prominent Ears aka Protruding Ear Deep concha Surgery: concha is reduced and antihelix is
Increased angle in protruding ear Normal: 20- Lack of development of the constructed done usually at school age under
30 antihelix general anesthesia
Normal congenital variant
No functional consequences
Cerumen Impaction Cerumen: Excessive cerumen secretion Pressure sensation in the ear Removal with a small instrument (hook,
Produced by ceruminous and sebaceous glands Hearing loss currette) or by aural irrigation using a blunt
Disturbance of the normal self-
in the skin of the ear canal Vertigo cannula
cleansing mechanism
Tinnitus
Forms a protective film Give cerumenolytic (wax softener) for 1 week
Cleaning using Q tips, aging,
to soften cerumen prior to removal
Protective function of cerumen: decreases sebaceous secretion; Otoscopic findings:
Acts as a vehicle fir the removal of epithelial not advised Obstruction of the ear by a IRRIGATION:
debris and contaminants away from the yellowish-brown to black material body temperature water is administered in a
There is a general tendency for
tympanic membrane postero-superior direction to allow the water to
cerumen to be drier in older
pass between the cerumen mass and the
Provides lubrication and prevents dessication individuals because of physiologic
posterior wall of the canal. After
of the epidermis with its associated fissuring atrophy of apocrine glands with
several irrigations the patient still complains of
subsequent lessening of the sweat
Fatty acids, lysozyme, and immunoglobulin blockage, suction is occasionally employed.
component of the cerumen
components are believed to be inhibitory or
Do not hit the tympanic membrane to avoid
bactericidal
perforation
Self cleansing of the ear canal: epithelial
Avoid irrigation if a tympanic membrane
migration from the tympanic membrane
perforation may exist
towards the external meatus
Prophylaxis:
The migration of the stratum corneum
Avoid improper cleaning of the ear canal
contribute to the formation of the cerumen
The most effective method to clean the ear canal
The pH of the combined ingredients is around 6,
by the patient is not clean it
an additional factor that acts to prevent infection
Foreign Bodies in the Ear Canal Children: small play objects (beads, pellets, Complications: Removal of foreign body
erasers) Middle and inner ear damage
1. Do not remove insect right away. Drown it first
secondary to tympanic membrane
Adults: noise-reducing ear plugs, objects used for with baby
perforation
manipulations in the ear canal like cotton, insect oil and when it is paralyzed, remove it with
Secondary otitis externa
forceps.
Cockroach: most common foreign bodies in the
ear canal in adults 2. Do not use forceps when removing round
objects because it will only make them slide
deeper. Irrigate instead using IV cannula

3. Contraindication for irrigation: tympanic


membrane perforation, temporal bone fracture,
ear surgery

4. Button Battery do not use ear drops prior to


removal
because its electrical charges reacts with that of
the fluid,
causing severe alkali burn
Auricular Hematoma/ Auricular A collection of blood of serous fluid between the Blunt trauma (e.g. from contact Signs and symptoms: Surgical Evacuation; aspiration / incision &
Seroma perichondrium and auricular cartilage sport) Pain drainage of collected blood under sterile
conditions
PE findings:
This condition is most frequently seen in Skin and attached perichondrium
Swelling and fluctuation of the skin
wrestlers and boxers separate from the auricular Contoured dressing: cottonball impregnated
over the lateral auricular cartilage
cartilage with oil so as not to have another
Complications: hematoma/seroma
If injury remains close, hematoma Perichondritis secondary to
or seroma formation aspiration which can lead to
infection
Cauliflower ear
Injuries to the External Auditory Canal Usually there is history of trauma Foreign bodies Sign and Symptoms: Reapproximation of detached epithelium
Harmful manipulations Tender meatal skin Packing of the ear with Gelfoam if there is
Bleeding from the ear canal bleeding
Otoscopic findings:
Epithelial injury
Bleeding Hemorrhagic bulla
Crusted blood
Complications:
Secondary infection
Cyst formation or stenosis of ear
canal secondary to
scarring
Traumatic Tympanic Membrane Probing of ear canal with a Q-tip Sudden pain Cautery of edges with silver nitrate or
Perforation Forceful syringing of the ear for cerumen of Bleeding trichloroacetic acid
foreign Tinnitus Paper patch to act as scaffold for healing
bodies Hearing loss Myringoplasty: may be needed if there is poor
Forceful change of air pressure in the ear canal healing or for larger perforations
(e.g. Blast injury, blow to the head) Optional: otic drops

Most linear tears heal spontaneously


INFLAMMATORY DISEASES OF THE EXTERNAL EAR
DESCRIPTION ETIOLOGY/PATHOGENESIS SIGNS AND SYMPTOMS TREATMENT
ECZEMA AND DERMATITIS OF THE AURICLE An inflammatory condition of the Jewelry items Itching Eliminate the causes
auricle confined to the Soaps and Cosmetics Burning with little pain Antibiotics if with bacterial
dermis Listening aids Skin is erythematous and may be dry and scaly superinfection
Thermal injury or moist and weeping When a considerable portion of
Differentiation between a primary Contours of the auricle remain unchanged the auricle is involved and the
dermatosis and lesion seems to be spreading, wet
infection may be difficult (for Complications: dressing using a solution such as
example: seborrheic dermatitis vs. Pyoderma Burows may be advisable for 34-
Skin reaction to neomycin) Perichondritis 48 hours, at which time
Cellulitis fluorinated steroid ointment and
solution are employed
PERICHONDRITIS OF THE AURICLE An acute inflammation of the skin and Staphylococcus Severe pain of rapid onset Systemic antibiotics against Staph
perichondrium that also involves the Pseudomonas Feeling of tension and Pseudomonas
auricular cartilage Effaced auricular contours, earlobe is spared Incision and drainage of pus
Swelling of the concha with marked tenderness Cleansing of the auricle and ear
Develops when trauma or Painful and enlarged regional LNs canal
inflammation causes an Fever Application of antiseptic or
effusion of serum or pus between the antibiotic-containing
layer of the perichondrium and the Complication: ointment
cartilage of the external ear Cartilage destruction with permanent auricular NSAIDs
deformity (cauliflower ear)
Changes are localized (do not spread
beyond auricular cartilage)

Caused by a bacterial infection


stemming from a small injury in the
conchal cavity or auricle
AURICULAR CELLULITIS An acute streptococcal infection of the Streptococci gain access to the auricle Redness, swelling and warmth of the auricle and High-dose regimen of penicillin,
subcutaneous tissue involving the through small injuries in the concha its surroundings preferably by IV administration
auricle and its surroundings or external meatus Earlobe and adjacent facial skin are involved NSAIDs
Malaise with fever and otalgia Cleansing the auricle and ear
canal
DDx:
Dermatitis - no fever and systemic effects
Perichondritis - surrounding tissues and earlobe
are NOT involved
Zoster oticus - concomitant involvement of CN VII
HERPES ZOSTER OTICUS RAMSAY HUNT SYNDROME Caused by reactivation of the Ear pain or burning on one side in the absence of Systemic therapy with Acyclovir
dormant varicella zoster PE findings vesicles erupt hearing loss, Corticosteroids
The onset of facial paralysis, when virus in ganglion cells vestibular complaints, facial nerve palsy Local Antiseptics on lesions
accompanied by otalgia and a Other combinations of symptoms may exist Treatment is mainly symptomatic
herpetic eruption involving portions Involves CNs VII &/or VIII owing to progressive involvement of vestibular
of the external ear is caused by a (occasionally IX & X) and acoustic fibers of the eighth cranial nerve
viral infection involving the
geniculate ganglion Vesicular skin involvement may be PE findings:
limited to the specific area of the Herpetiform vesicles on the meatus and concha
external ear canal innervated by a and occasionally on the pinna
small sensory branch of the CN, Lymphadenitis
extend to the auricle or have faded Facial nerve palsy
by the time the patient is seen
Complications:
Secondary bacterial infection (Staphylococci or
pseudomonas
Zoster meningoencephalitis
Neuralgia
DIFFUSE OTITIS EXTERNA AND ECZEMA OF An inflammatory condition of the Gm (-) predominantly Pseudomonas Itching Meticulous, repeated cleansing
THE EAR CANAL external auditory canal and less often Staphylococcus albus, Pain (severe) and drying of the ear canal

involving the canal skin (eczema, E. coli, and Enterobacter aerogenes Crusting
Antiseptic, antibiotic drops
dermatitis due to mechanical injury, Anaerobes Purulent discharge

toxicity, or allergy) acute bacterial Conductive hearing loss Due to the degree of the canal
infection of the skin Presence of tender regional adenopathy wall edema, a wick may be required
Also known as swimmers ear Tragal tenderness to bring medication into contact
Occurs during hot, humid weather with most of the canal.

Only severe cases should systemic


The stroma overlying the bone of the inner third of drugs be considered
the canalvis very thin, allowing minimal room for
swelling. Thus, the subjective discomfort the patient
experiences is often out of proportion to the extent
of the disease visualized

Absence of acute infection:


o Dry, cracked and scaly canal skin
o Thickened skin with sites of desquamation

Presence of acute infection:
o Diffuse swelling of the canal skin with discharge
or crusting
CIRCUMSCRIBED OTITIS EXTERNA Confined to the fibrocartilaginous Pathogenesis: Very painful, tender swelling Treatment depends on the
portion of the external auditory Mild hearing loss secondary to swelling furuncle size and surrounding
meatus (furuncle) Local mechanical trauma and Otorrhea reaction
contamination of the ear canal Afebrile Meticulous cleaning of the ear
Circumscribed lesion caused by an
canal
acute bacterial infection of the Obstruction of the hair follicles or PE findings: Antibiotic and steroid-containing
cartilaginous portion of the ear canal
glandular ducts Tragal tenderness drops
Pronounced swelling of the ear canal with debris NSAIDs
Staphylococcal infection of the In severe cases, surrounding cellulitis may extend Systemic antibiotics
pilosebaceous units (usually beyond this area Heat
aureus or albus) Eventually, abscess formation occurs and a
point may form, at which time drainage can be
establishes by needle
NECROTIZING OTITIS EXTERNA Malignant otitis externa Simple OE Insiduous, persistent OE that does not heal Local debridement and cleaning
Exclusively in older patients with DM Moderate pain which may become severe of the ear canal
Common in warm climates Infection with Pseudomoas Fetid aural discharge
High doses of antibiotic effective
A severe infection involving the aeruginosa
against P. aeruginosa x 6 weeks
temporal bone and soft
(systemic antibiotics is the 1st line
tissue of the ear Ulceration and osteitis on the floor of
of therapy; patient is usually
Patients with otitis externa (OE) for the ear canal
admitted)
more than 2 weeks
should be evaluated for NOE Spread to the middle ear, skull base, Close monitoring and control of
retromandibular fossa DM
and parotid compartment
Surgical resection of the affected
bone in unresponsive
cases
OTOMYCOSIS Common in tropical countries Aspergillus (niger and flavus) Severe itching Thorough cleaning and drying the
Due to cleaning ear with Candida albicans (with manipulation, can lead to trauma and ear canal
contaminated implements Pityrosporum eventually secondary bacterial infection) Local antimycotics
Common DM and Ear fullness Systemic antimycotic therapy in
immunocompromised patients immunocompromised
May occur in conditions when the patients
normal flora is affected, such
overuse of certain topical antibiotics
particularly with steroid combination
TUMORS OF EXTERNAL EAR
Keloids Basal Cell Carcinoma Squamous Cell Carcinoma
Very common benign tumor A common skin CA Usually occurs in older men on the posterior or
Massive overgrowth of reparative (scar) tissue Caused by chronic exposure to sunlight superior portion of the pinna
Rare complications of earring use
Occur more commonly in African-American
Treatment: Treatment: Treatment:
Surgical excision followed by repeated steroid injections Complete excision with histologic control of margins (of about 1 cm) Complete excision with histologic control of
Appraise patient that keloid may grow back Primary goal: remove the tumor margins, may require auricular resection
Secondary goal: reconstruction Primary goal: remove the tumor
Secondary goal: reconstruction