EAR DISCHARGE 1

Dr. Vilog

OUTLINE
The shape of the auricle is defined by the elastic
• Anatomy of External Ear cartilaginous plate. The perichondrium of the elastic cartilage
• Otitis Externa forms a unit with the lateral dermis of the auricle. There is no
• Otitis Media actual subcutaneous tissue in the region. It is attached directly
to the head by muscles and ligaments. The lobule has no
cartilage. The fibro-elastic cartilage continues to the ear canal.
ANATOMY OF THE EXTERNAL EAR
Therefore, cutaneous changes (swelling, erythema) on the
perichondrium and cartilage leads to severe pain, poor
absorption, cartilage destruction, permanent damage of the
auricle.
Cauliflower ear – punching someone results in a
hematoma and gets worse for the anatomical reason that there
is no actual subcutaneous tissue in that region.

THE EXTERNAL AUDITORY CANAL

Figure 1. Anatomy of the Ear

The auricle and external auditory canal form an

anatomical and functional unit. The lateral cartilaginous
structures of the external ear are continuous with the medial
bony structures, cartilaginous bone. Medial boundary of the
external ear is the tympanic membrane.
The auricle and the cartilaginous portion of the
external auditory canal form a unit, both anatomically and
pathologically. Infections can spread from the external to the
middle ear and vice versa.
THE AURICLE
Figure 3. The External Auditory Canal
• 2.5-3cm from the external meatus until the tympanic
membrane
• Outer 1/3 is cartilaginous (which has hair follicles,
sebaceous and ceruminous glands)
o Earwax is produced here
• Middle 2/3 / isthmus / junction is bony wherein the skin is
very adherent to the periosteum and devoid of any special
structure seen in the outer area
• Lined by keratinized stratified squamous epithelium cell

The lateral 2/3 of the external auditory canal consists

of fibrocartilaginous framework that is angled downward and
forward relative to the bony medial 1/3. There is longer
fibrocartilaginous and shorter bony part. This is why at
otoscopy, mobile cartilaginous part of the ear is pulled upward
and backward (favorite question daw). **
The bony portion of the ear canal is formed by the
tympanic part of the temporal bone. The skin at the region of the
ear canal is very thin, and overlies the periosteum, which is why
Figure 2. Anatomy of the Auricle. it is very pain-sensitive and can influence the course of the
disease and can lead to a worse acute otitis externa.
• Fibro-elastic cartilage continuous with ear canal The bony ear canal grows less than the cartilaginous
• Attached to head by muscle and ligaments ear canal as we grow older. The cartilaginous part is shorter than
the bony part in infants, but both parts are of approximately
• Lobule has no cartilage
equal length around the ages of 5-6. ** Favorite question: How
long/short is the ear canal? 1 inch/ 2.5 cm.

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DR. VILOG
 TYMPANIC MEMBRANE EUSTACHIAN TUBE
• Consists of bony part (lateral third) and a cartilaginous part
(medial two-thirds). At their junction is the narrowest part,
called the isthmus.
• Muscle involved: tensor tympani muscle
• Function:
o Ventilates the tympanic cavity and air cells
o Equalizes pressure differences between the tympanic
cavity and the atmosphere
o Drains the middle ear spaces when opened
o Creates a barrier to ascending infection
Figure 4. The Tympanic Membrane

• Layers of the tympanic membrane In clinical practice, we say that the eustachian tube
o C – circular layer connects the nose and ears and is responsible for the popping
o Fi – intermediate fibrous layer (lamina 2ropria) sound.
o M – inner mucous membrane
o Mu – tensor tympani muscle ADULT VERSUS INFANT EUSTACHIAN TUBE
o CB – compact bone • Infants
o Ca – cartilage o Shorter & horizontally oriented
• Length of the tympanic membrane from the roof to the o Poor function of TVP (tensor veli palatine) – not yet
floor is 1cm/10mm developed
• Thickness is 0.8cm/8mm o Prone to reflux from NP (nasopharynx)
§ Breastfeeding while in a supine position
The tympanic membrane (ear drum) is a thin fibrous • Adults
membrane separating the external auditory canal from the cavity o Longer & angulated 45 degrees
of the middle ear. With the exception of a small triangular area o Drains better
superiorly, the pars flaccida, the membrane is tense (pars tensa),
being firmly attached to the surrounding bone by a
Infants are more prone to have otitis media because of
fibrocartilaginous ring. The handle of the malleus is attached to
the anatomy of the eustachian tube. It can be prevented through:
the center of the membrane, the chain of ossicles pulling the
• Breastfeeding because of an increased immunologic
membrane slightly inwards. The tympanic membrane is made up
response
of three layers: an external cuticular layer, a middle intermediate
• Don’t feed baby lying flat.
fibrous layer and an inner mucous layer. The cuticular layer (C)
consists of thin hairless skin, the epidermis being only about 10
cells thick and the basal layer being flat and devoid of the usual OTORRHEA
epidermal ridges. The thin dermis contains plump fibroblasts and
PATHOGENESIS
a fine vascular network. The intermediate fibrous layer Fi consists
of an outer layer of fibers radiating from the center of the
membrane towards the circumference and an inner layer of fibers Bacterial infection &
disposed circumferentially at the periphery. These fibers contain Canal skin inflammation:
a large amount of type II and type III collagen and a small amount irritation or
of type I collagen, representing a distinct composition especially • Diffuse (transudate)
trauma
adapted for the function of the tympanic membrane. The inner • Cirumscribed (pus)
mucous layer (M) represents a continuation of the modified
respiratory-type mucous membrane lining the middle ear cavity,
ACUTE OTITIS EXTERNA
but in this situation, it is merely a single layer of cuboidal cells
devoid of cilia and goblet cells. The underlying lamina propria is • 90%: Bacterial (most common)
thin with a blood supply separate from that of the dermis of the o Pseudomonas
cuticular layer. (From 2019 but not read) A similar modified o Staphylococcus epidermidis
respiratory-type mucosa invests the ossicles, small muscles and o Staphylococcus aureus
nerves exposed to the middle ear cavity. The ossicles consist of • 2% to 10%: Fungus / Other
compact bone CB formed by endochondral ossification, which o Aspergillus
accounts for the cartilage Ca seen in this specimen. o Candida
• Other causes:
MIDDLE EAR o Herpes zoster virus (HSV) (Ramsay Hunt)
o Erysipelas (beta-hemolytic strep)
Composed of the tympanic membrane, temporal system of o Furuncle (S. aureus)
the temporal bone (air cells), and eustachian tube. These 3 play • Treatment: Gentle cleaning
an important part in any middle ear problem. What is the problem
of the middle ear? Sound, because of the ossicles.

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DR. VILOG
 DIFFUSE OTITIS EXTERNA OTOMYCOSIS
• “Swimmer’s ear” • Common in tropics, heat and humidity ideal for growth of
• Other signs and symptoms: fungus
o Pain – first manifestation; acute, some mild • Recurrent, long term treatment
o Tenderness-touch • Causes:
o Chewing o Use of contaminated ear cleaning devices
o Scanty discharge § Cerumen harbors saprophytic fungi
o In diabetics and the immunocompromised
Happens because of the development of a warm and o Overuse of topical antibiotics/steroids
moist environment. • Etiologic agents
Mainly, the patient will tell you it’s itchy. Conductive o Aspergillus niger (black)
type of hearing loss maybe experienced because of obstruction
o Aspergillus flavus (whitish cottony)
caused by crusting and swelling.
o Candida albicans (yellowish)
• Signs and symptoms:
• Diagnose through otoscopy
o Itchiness
o There is eczema: canal skin appears dry and cracked,
o Diffuse swelling of canal (after 3-5 days)
skin is thickened and with desquamation
o Mycelia/spores seen of otoscopy with cerumen
• Etiology
o Discharge /otalgia if with bacterial infection
o Pseudomonas
o Decreased hearing – conductive type because it is
o Proteus
already clogged.
o Staphylococcus
• Treatment
o Streptococcus
o Meticulous and gentle cleaning of canal
o Gram negative (rare)
o Topical antifungal drops
• Treatment:
§ Dexamethasone, Fluticasone.
o Gentle cleaning
§ Clotrimazole – most common and most effective
§ H2O2
§ Do not use if there is perforation
§ Suction
o Keep ear dry – boric acid powder
o Analgesics/antipyretics
o Oral Antibiotics OTITIS MEDIA
o Ear wick + topical antibiotic drops + steroid
TYPES:
§ Pseudomonas & Staphylococcus: neomycin +
• Non-suppurative
polymyxin B + steroid (Dexamethasone,
o No infection
Fluticasone)
o Aerotitis – barotrauma
FURUNCULOSIS o Serous otitis media or Otitis Media with Effusion
o Acute / chronic
• There is a bacterial infection in the cartilaginous portion of
o Allergic rhinitis
the ear canal.
• Suppurative
• Circumscribed otitis externa
o Bacterial in nature
• Confined in the outer 1/3 because there are hair follicles
o Acute suppurative
• Other signs and symptoms:
o Acute necrotizing
o Pain, tenderness- touch, chewing
o Chronic suppurative
o Purulent discharge - if ruptured
o Tuberculous
• Etiology
o Staphylococcus aureus CENTRAL PATHOPHYSIOLOGIC PROCESS OF EUSTACHIAN
• Treatment TUBE DYSFUNCTION
o Gentle cleaning
o Analgesics/antipyretics Eustachian Tube Dysfunction
o Oral Antibiotics
§ Cloxacillin – every 6 hrs
§ Amoxicillin – every 8 hrs Edema and
Impaired middle
inflammation of
§ Sultamicillin the mucosa
ear ventilation
o Incision & drainage
§ Puncture with a sterile needle
§ Done when it will not resolve for 2 days when using Negative pressure
antibiotics. in the middle ear

• The most important thing to consider in otitis media is

Eustachian tube dysfunction
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DR. VILOG
PATHOPHYSIOLOGY
• Impaired ventilation of the middle ear
o Stenosis due to inflammatory mucosal swelling (upper
respiratory tract infection-most common)
o Negative pressure due to rapid rise of ambient air
pressure (aircraft landing)
o Extrinsic obstruction (tumor)
o Deficient active opening of the tube by the tensor veli
palatini muscle
o Congenital or acquired bony stenosis of stricture during
scarring
EUSTACHIAN TUBE DYSFUNCTION IN OTITIS MEDIA
• Functional obstruction
o Collapse of tube
o Inability to open
§ As in cleft palate, craniofacial deformity, Pierre-
Robin, Downs, Crouzons
• There’s a floppy tube = poor tensor veli palatini function
• Mechanical obstruction
o Intrinsic (inflammation)
§ URTI, allergy
o Extrinsic (tumor or adenoids)
§ Adenoids – usually, because it’s the nearest
• Abnormal patency
o Patulous - always open
§ Loss of weight
o Leads to “reflux” otitis media because it is too wide and
too open, leading to ascending infection.
Figure 5. Functional obstruction.
STAGES OF ACUTE OTITIS MEDIA
Stages of Acute Otitis Media by history usually happens in
chronological order.
• Natural History
1. Stage of Hyperemia/Retraction
§ Generalized hyperemia of the muco-periosteum
§ Mild earache, ear fullness, and fever
§ Otoscopy: erythematous & retracted eardrum
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DR. VILOG
Figure 6. Stage of hyperemia and retraction. Otoscopic finding reveals
erythematous and retracted eardrum.
2. Stage of Exudation
§ Outpouring of fluid from dilated permeable
capillaries
§ Aggravated symptoms especially severe pain &
fever because of increased bacterial load.
§ Otoscopy: erythematous & markedly retracted
eardrum
Figure 7. Stage of exudation. Otoscopic finding reveals erythematous
and markedly retracted eardrums.
NOTE: When this is left untreated, stage of
suppuration/perforation follows.
3. Stage of Suppuration/Perforation
§ Eardrum ruptures → middle ear discharge
§ Relief of pain & fever
§ Worsening of hearing loss
Figure 8. Stage of suppuration or perforation.
NOTE: At this time, patient usually does not seek consult
because there is already relief of pain and fever. Pain is caused
by increased pressure; when it is disregarded and becomes
painless it means that the eardrum already ruptures and
eventually middle ear discharge.
4. Stage of Coalescence and Mastoiditis
§ Recurrence of pain, mastoid tenderness & fever
(milder degree)
§ Mickey mouse ear
ü “Mickey Mouse Sign”
§ (+) mastoid tenderness & sagging of
posterosuperior wall
§ It usually happens at the back (postauricular
abscess-like).
4
 RISK FACTORS
1. Host Related
§ Very young age
§ Presence of allergy
ü Allergic rhinitis
§ Immunodeficiency
§ Craniofacial abnormalities
ü Cleft palate
§ Genetic predisposition
2. Environmental
§ Upper respiratory infection
§ Daycare attendance
Figure 8. Stage if coalescence and mastoiditis. ü “nagkakahawaan”
§ More siblings
5. Stage of Complication
§ Tobacco smoke exposure
§ Due to severe immunocompromised state
ü Worst in secondhand smokers
§ Spread of infection beyond the middle ear
§ Bottle feeding
§ Pathways for spread:
§ Pacifier use
ü Bone erosion
§ Persistence of middle ear disease
ü Thrombophlebitis
3. Anatomic
ü Preformed opening
§ Eustachian tube defect
ü Surgical opening
§ Cleft palate
ü Hematogenous spread
6. Stage of Resolution
§ May occur at any stage of the disease

SUMMARY: Figure 9 & 10.

Figure 11. Otitis media can be attributed to different risk factors

such as infection, impaired immunology, allergy, environmental
factors, and most specially, eustachian tube dysfunction.
DIAGNOSIS
• CLINICAL HISTORY is POORLY PREDICITIVE of AOM
(Acute otitis media) especially in YOUNGER CHILDREN
A. Normal tympanic membrane o Abrupt onset of otalgia/ear tugging
B. Tympanic membrane with mild bulging o Irritability in an infant/toddler
C. Tympanic membrane with moderate bulging o Otorrhea and fever → Non-specific and are also
D. Tympanic membrane with severe bulging found in patients with URTI
• PNEUMATIC OTOSCOPY: FOR CONFIRMATION
o Middle Ear Effusion
§ Fullness/bulging of tympanic membrane
§ Reduced or absent mobility
ü Because there is already effusion/discharge
in the middle ear
§ Opacification and cloudiness of the tympanic
membrane
o Middle Ear Inflammation
NOTE: At a younger age, if the perforation is that small (see left § Distinct erythema of tympanic membrane
image) it can usually heal or closes if it does not have any active § Must differentiate from pink erythematous
infection. Years after, otosclerosis can happen (right image). flushed evoked by crying or high fever

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DR. VILOG
 • AUDIOMETRY & TYMPANOMETRY o These risk factors probably favor the development of
o Tympanometry provides an objective assessment of CSOM by:
tympanic membrane mobility, eustachian tube § Weakening the immunological defenses
function, and middle ear function by measuring the § Increasing the inoculum
amount of sound energy reflected back when a § Encouraging early infection
small probe is placed in the ear canal.
SAFE VERSUS DANGEROUS EAR

Safe Ear Dangerous Ear

Figure 12. This is a normal, type A tympanogram result. The height of Tubo-tympanic Attico-antral
the tracing may vary but is normal when the peak falls within the 2 Marginal, attic, total
stacked rectangles. The AD tracing (upper) indicates an abnormally Central perforation
perforation
flexible tympanic membrane, and the AS tracing (lower) indicates an
Mucopurulent, non-foul, Purulent, foul, scanty
abnormally stiff tympanic membrane; the presence of a well-defined
peak, however, makes the likelihood of effusion low. profuse otorrhea otorrhea
Mucosa edematous with Large polyps and
small granulation granulation
Conductive hearing loss Mixed hearing loss
X-ray or CT scan: No X-ray or CT scan: With
cholesteatoma Cholesteatoma
Tx: Medical + surgery to Tx: Surgery for
preserve hearing complications
NOTE: The basic technique for otoscopy is not only direct-
TRANS NOTE: Bigger picture at the appendix. forward, you should also investigate the whole circumference
of the canal.
CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM)
• Persistent inflammation of the middle ear or mastoid cavity CHRONIC OTITIS MEDIA WITH CHOLESTEATOMA
• Presents with persistent or recurrent ear discharge
(otorrhea) over 3 months through a perforation of the
tympanic membrane.
• Synonyms:
o “Chronic otitis media (without effusion)”
o “Chronic mastoiditis”
o “Chronic tympanomastoiditis”
• Does not include:
o Chronic perforations of the eardrum that are dry
o Discharge only occasionally
o Have no signs of active infection
• Risk Factors:
o Inadequate antibiotic treatment Cholesteatoma
o Frequent upper respiratory tract infections • Keratinizing squamous epithelium in the bony spaces.
o Nasal disease • Bone is destroyed through inflammatory osteoclastic
§ Presence of nasal polyp or with rhinosinusitus process.
o Poor living conditions with poor access to medical care • Can erode bone
o Poor housing, hygiene and nutrition are associated with • Management: Otic solution
higher prevalence rates
o Bottle-feeding, passive exposure to smoking,
It is a bone eating, benign infection but has the potential to
attendance in congested centers (ex. day-care harm/damage vital structures. Skin (keratinizing epithelium) inside
facilities), and a family history of otitis media are some the middle ear is also present.
of the risk factors for otitis media.
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DR. VILOG
THEORIES OF CHOLESTEATOMA FORMATION: SURGICAL TREATMENT OF CHRONIC OTITIS MEDIA:
• Metaplasia theory – transformation of respiratory
epithelium into keratinizing squamous epithelium
• Loss of contact inhibition theory – because of the
perforation there is extension of the keratinizing
squamous mucosa within the middle ear
• Formation of retraction pouch theory – a sac filled with
keratin debris slowly expands as the keratin debris
accumulates
OTOGENIC COMPLICATION OF OTITIS:
• Mastoiditis
o There is inflammation of air cells in mastoid process
§ Mucous membranes of the air cells are affected
o There is a bigger or faster degree of erosion when IN SUMMARY:
complication reaches the mastoid OTITIS EXTERNA OTITIS MEDIA
o TRIAD: More severe pain Less severe pain
§ Prominent auricle with retroauricular swelling Tenderness No tenderness
§ Tenderness Fever usually absent Usually present
§ Abscess No history of URTI Usually with URTI
• Intracranial complications (+) ear cleaning history (-) ear cleaning history
o Meningitis Hearing not impaired unless
Hearing impaired
o Intracranial abscesses canal totally obliterated
o Inflammatory thrombosis and otogenic sepsis May have evidence of
Mastoid X-ray normal
• Labyrinthitis mastoiditis
o Patient has vertigo
• Cranial nerve defects REFERENCES
o Most common cranial nerve palsy: Facial nerve 1. PPT
paralysis 2. 2019 trans
3. Recordings
TRANSCRIBERS
1. TRANS GROUP: 8A
2. SUBTRANSHEAD: Rose Lyn Vega

APPENDIX:

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DR. VILOG