OTOLARYNGOLOGY

Professor: Vion Guzman, MD, DPBO-HNS

Trans by: Agraviador, Anapen,
Angeles
TOPIC: DISEASES OF THE EAR - PART 1
Anatomical Relations
OUTLINE
● Anteriorly: temporomandibular joint
I. ANATOMY OF THE EAR ● Anterior and inferior to cartilaginous ear canal:
II. EXAMINATION OF THE EAR parotid gland
III. NONINFLAMMATORY DISEASE AND INJURY ● Posteriorly: mastoid
A. DEFORMITIES AND MALFORMATIONS ● Superiorly: temporalis muscle and squamous part
B. CERUMEN IMPACTION of the temporal bone
C. FOREIGN BODIES
D. AURICULAR HEMATOMA AND SEROMA
E. SHARP AURICULAR INJURY AND AVULSION
F. BURN AND FROSTBITE
IV. RECONSTRUCTIVE SURGERY
V. DIFFERENTIAL DIAGNOSIS OF INFLAMMATORY
CHANGES
VI. INFLAMMATORY DISEASE OF EXTERNAL EAR
A. ECZEMA AND DERMATITIS OF THE AURICLE
B. PERICHONDRITIS OF THE AURICLE
C. AURICULAR CELLULITIS
D. HERPES ZOSTER OTICUS
E. DIFFUSE OTITIS EXTERNA AND ECZEMA
F. CIRCUMSCRIBED OTITIS EXTERNA
G. NECROTIZING OTITIS EXTERNA
H. BULLOUS OTITIS EXTERNA
I. OTOMYCOSIS Figure 2. Auditory External Canal

J. RECURRENT POLYCHONDRITIS
II. EXAMINATION OF EXTERNAL EAR
K. WINKLER DISEASE
● History and inspection
L. GOUTY TOPHI
○ Otalgia, aural fullness, hearing loss, aural
M. LYMPHADENOSIS CUTIS BENIGNA discharge/otorrhea
N. SPECIFIC OTITIS EXTERNA ○ Inspection of the auricle, its surroundings
VII. REFERENCES and openings
VIII. APPENDIX ● Palpation
○ Tragal tenderness - inflammation of the
I. ANATOMY OF THE EAR cartilaginous portion of the ear canal
Innervation: ● Otoscopy
● Majority: great auricular nerve (from the cervical ○ Inspection of the internal ear canal and
plexus) and auricotemporal nerve (from the third tympanic membrane
division of the trigeminal) ○ Contaminants are removed by suction
● Portion of concha and ear canal with a small instrument or by irrigation
○ Auricular branch of the vagus nerve
(induce cough when stimulated - vagal
irritation)
○ Auricular branches of the facial nerve
(somatosensory portion)

Figure 1. Normal Auricle Figure 3. Examination of External Ear

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 III. NONINFLAMMATORY DISEASE AND INJURIES 5. CONGENITAL AURICULAR FISTULA

A. DEFORMITIES AND MALFORMATIONS

1. PROMINENT EARS
● Normal angle between auricle and head = 20-30°
● Increased due to a deep concha or lack of
development of the antihelix
● Treatment: surgical correction

Figure 7. Congenital Auricular Fistula

6. MALFORMATION OF THE AURICLE

Grade I dysplasia (minor anomalies)
Grade II dysplasia (mild microtia)
Grade III dysplasia (microtia and anotia)

Figure 4. Prominent Ears

2. EXOSTOSES
● True osteomas
● develops from ossification centers appear as pale,
rounded bony prominences
3. HYPEROTOSIS
● oppositional growth of bony ear canal
● induced by periosteal irritation (frequent contact
with cold water)
● Complication: recurrent otitis externa, conductive Figure 8. Malformation of the Auricle
hearing loss
● Tx: surgical removal 7. STENOSIS AND ATRESIA OF THE EAR CANAL

Figure 5. Exostosis and Hyperotosis

4. AURICULAR APPENDAGES

Figure 9. A. Normal mastoid growth B. No mastoid growth

Figure 6. Auricular Appendages

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 B. CERUMEN IMPACTION
● Cerumen is produced by cerumen and sebaceous
glands in the skin of the ear canal and forms
protective film
● Self-cleansing by epithelial migration from
tympanic membrane to the external meatus
● Impaction results from
○ disturbance of the normal self-cleansing
mechanism
○ from excessive cerumen secretion
Figure 12. Foreign Bodies
● Symptoms: pressure sensation, hearing loss, vertigo,
tinnitus D. AURICULAR HEMATOMA AND SEROMA
● Dx: obstruction of ear canal by a yellowish brown ● Collection of blood or serous fluid between
to black material perichondrium and auricular cartilage
● DDx: epithelial plug or crust from cholesteatoma, ● Cause: blunt trauma
tumors, foreign bodies, crusted blood ● Dx: swelling and fluctuation, exclude associated
● Complication: otitis externa injuries
● Tx: removal with a small instrument (hook, curette) ● DDx: Recurrent polychondritis → spontaneous
or by aural irrigation seroma
● Complications: secondary infection, perichondritis,
permanent deformity of cartilaginous framework →
“cauliflower” ear
● Tx: surgical evacuation of the hematoma or
seroma and reattachment of perichondrium to the
cartilage

Figure 10. Cerumen Impaction

C. FOREIGN BODIES Figure 13. Auricular Hematoma

● History is diagnostic and foreign body is easily E. SHARP AURICULAR INJURY AND AURICULAR AVULSION
identified at otoscopy
● Auricular avulsion can be
● Check for signs of associated injury
○ Partial - with an intact bridge of skin
● Complications: middle- and inner-ear damage,
○ Complete - part of the auricle is
secondary otitis externa
completely dettached
● Tx: removal with a small extraction hook, aural
● Check associated injuries
irrigation should NOT be used, insects can be killed
● Complications: soft tissue infection, perichondritis
with 10% lidocaine solution
● Tx: primary measures = Cover-Refer-Send-Cool

Figure 11. Removal of Foreign Bodies

Figure 14. Sharp auricular injury and auricular avulsion

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 F. BURN AND FROSTBITE INJURY
● Damage confined to the skin
○ Grade I: localized erythema
○Grade II: blistering of the skin
● Damage involves the entire skin-cartilage unit
○ Grade III: deep tissue necrosis
● DDx: chemical and electrical injuries
● Complications: cartilage necrosis and permanent
deformity, perichondritis
● Tx: follows general principles of surgical wound
care for burns and frostbite
Figure 15. Burn and frostbite injury
IV. RECONSTRUCTIVE SURGERY OF THE AURICLE
SHAPE CORRECTIONS
● Prominent ears
PARTIAL RECONSTRUCTIONS
● Grade II dysplasia
● Auricle is reconstructed using available local
cartilage whenever possible
● Skin coverage is obtained with advancement flaps
TOTAL RECONSTRUCTION
● Congenital aplasia and severe anomalies (grade
III dysplasia)
EPITHESIS
● An external prosthesis may be considered as an
alternative to auricular reconstruction
Figure 16. Epithesis Prosthesis
V. DIFFERENTIAL DIAGNOSIS OF INFLAMMATORY CHANGES
IN EXTERNAL EAR
See Appendix
VI. INFLAMMATORY DISEASES OF THE EXTERNAL EAR
A. ECZEMA AND DERMATITIS OF THE AURICLE
● Confined to the dermis, cartilage and
perichondrium are NOT involved
● Cause: Immune/allergic, toxic or physical causes
● Symptoms: Itching, Occasional burning, Little pain,
Skin is erythematous, Dry and Scaly or Moist and
Weeping, Contours of auricle are unchanged
● Dx: Skin test
● Complications: Pyoderma, Perichondritis, Cellulitis
● Tx: Eliminate cause, Antibiotic for superinfection
Figure 17. Eczema and dermatitis of the auricle
B. PERICHONDRITIS OF THE AURICLE
● Acute inflammation of the the skin, perichondrium
and auricular cartilage
● Cause: Bacterial infection (staphylococci and
Pseudomonas spp.)
● Symptoms: Severe pain, Feeling of tension, Effaced
auricular contours, Swelling of concha with marked
tenderness, Blisters, Painful and Enlarged regional
lymph nodes, Fever
● Dx: Normal tympanic membrane, No hearing loss
unless with otitis externa, ↑ WBC, ↑ CRP, ↑ ESR
● Complications: Cartilage destruction with
permanent auricular deformity
● Tx: Systemic antibiotics
Figure 18. Perichondritis of the Auricle
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 C. AURICULAR CELLULITIS
● Acute streptococcal infection of the
subcutaneous tissue
● Bacteria gained access through small injuries in the
concha or external meatus
● Symptoms: Redness, Swelling and Warmth of
auricle and its surroundings
● Malaise, fever, otalgia
● Complications: Necrotizing fasciitis, GN, RF,
Rheumatic endocarditis
● Tx: Penicillin G, NSAIDs for pain
Figure. 19. Auricular Cellulitis
D. HERPES ZOSTER OTICUS
● AKA Ramsay Hunt syndrome caused by
reactivation of the dormant varicella-zoster virus in
ganglion cells
● Involves CN VII, VIII, IX, X
● Symptoms: Ear pain, Vesicular eruption, Hearing
loss, Vertigo, Facial nerve palsy
● Dx: Herpetiform vesicles, Lymphadenitis
● Complications: Secondary bacterial infection,
Zoster meningoencephalitis
● Tx: Acyclovir, Valacyclovir, Famciclovir, +
Corticosteroid if facial nerve palsy is present
Figure 20. Herpes Zoster Oticus
E. DIFFUSE OTITIS EXTERNA AND ECZEMA
● Inflammatory condition the canal skin → acute
bacterial infection
● Warm, moist climate promotes its development
(Swimmer's itch)
● Symptoms: Itching, pain, Crusting, Purulent
discharge, Conductive hearing loss
● Complications: Perichondritis, Cellulitis, Abscess
formation, Necrotizing otitis externa
● Tx: Cleansing and drying, Antiseptic, Antibiotic
drops
Figure 21. Diffuse Otitis Externa and Eczema
F. CIRCUMSCRIBED OTITIS EXTERNA
● AKA furuncle, acute bacterial infection of the
cartilaginous portion of ear canal
● Cause: obstruction of the hair follicles and
glandular ducts
→ Staphylococcal infection of the pilosebaceous
unit
● Symptoms: Very painful swelling, Mild hearing loss,
Otorrhea (rare)
● Dx: Tragal tenderness, Pronounced swelling with
debris, Conductive hearing loss, Bacteriologic
exam
● Complications: Perichondritis, Superinfection with
Pseudomonas → necrotizing OE
● Tx:
○ Ear canal meticulously cleaned and
treated with 70% alcohol for 1-2 days
○ Crust dissolved with antibiotic-containing
ointment strips
○ NSAIDs for pain
○ Systemic antibiotics for px with systemic
symptoms
Figure 22. Circumscribed otitis externa
G. NECROTIZING OTITIS EXTERNA
● AKA malignant otitis externa, in older patient with
diabetes mellitus
● Can involve the bone
● Symptoms: History of insidious OE that does not
heal
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● Dx: Signs of infection on surrounding tissues,
Otoscopy, Culture and sensitivity (P. aeruginosa),
CT scan
● Tx: Local debridement and cleansing, Antibiotic
against P. aeruginosa, DM be monitored
Figure 23. Necritizing otitis externa
H. BULLOUS OTITIS EXTERNA
● AKA Flu-related otitis hemorrhagic otitis externa
● Cause toxic capillary damage on epithelial layer
→ hemorrhagic epithelial bullae
● Symptoms: Severe otalgia, Bloody discharge,
Conductive and sensorineural hearing loss
● Dx: Serous or hemorrhagic bullae
● Tx: Antiviral therapy NOT available, Local
anesthetic ear drops, NSAIDs
Figure 24. Bullous otitis externa
I. OTOMYCOSIS
● Warm moist climate is conducive to fungal
infections
● Symptoms: Pain, Itching, Feeling of fullness
● Dx: White, yellow or black membrane lining the
swollen, Erythematous skin of the ear canal
● Tx: Thorough cleaning and drying, then local
antimycosis can be administered
Figure 25. Otomycosis
J. RECURRENT POLYCHONDRITIS
● Chronic autoimmune disease directed against
cartilage tissue
● AKA relapsing polychondritis, systemic
chondromalacia, chronic atrophic panchondritis
K. WINKLER DISEASE
● AKA chronic chondrodermatitis nodularis helicis
● Presence of a very painful epithelial nodule with
umbilicated center on the free border of the helix
or antihelix
L. GOUTY TOPHI
● Appear as small, pale, freely movable
subcutaneous nodules on the helical rim
M. LYMPHADENOSIS CUTIS BENIGNA
● Lymphadenosis represents cutaneous
manifestation of infection with Borrelia burgdorferi
N. SPECIFIC OTITIS EXTERNA
● Syphilis (mainly stage II), Mycobacterium
tuberculosis and atypical mycobacteria
VII. REFERENCES
● Doc Vion’s lecture and PPT
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III. APPENDIX

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