External Ear Trauma

Essentials of Diagnosis

 History of auricular trauma.

 Edematous, fluctuant, and ecchymotic
pinna with loss of normal cartilaginous
landmarks.
 Early diagnosis and treatment necessary to
minimize cosmetic deformity
Treatment
 Cleaning
 Closing
 Pressure dressing
 Cartilage penetrating antibiotics
Injury of the tympanic membrane
 symptoms ： pain, tinnitus, deafness, vertigo
 Signs: the drum is perforated in the pars tensa
 Treatment:
do not put in drops or syringe, or interfere
Keep the nose from the obstruction
Otitis Externa
Essentials of Diagnosis

 Otalgia, otorrhea, pruritus, hearing loss,

history of water exposure.
 Tender pinna and canal; canal erythema,
edema, and purulent debris.
 Culture for refractory cases
Treatment
 Analgesia
 otic drop
antiseptic, acidifying, or antibiotic (or any
combination of these) should be used .
Ofloxacin and ciprofloxacin are single-agent
antibiotics with an excellent spectrum of coverage
for pathogens encountered in otitis externa.
 steroids help to reduce edema and otalgia.
 Systemic antibiotics are indicated for infections
that spread beyond the EAC.
Acute suppurative otitis media
 An infection of the mucous membrane of
middle ear
 The most common infectious way is the
Eustachian tube
 Before the onset of symptoms of AOM, the patient
frequently has symptoms of an upper respiratory tract
infection. Older children usually complain of earache,
whereas infants become irritable and pull at the
affected ear. A high fever is often present and may be
associated with systemic symptoms of infection, such
as anorexia, vomiting, and diarrhea. Otoscopy
classically shows a thickened hyperemic tympanic
membrane, which is immobile on pneumatic otoscopy.
 Further progression of the infective process may lead to
the spontaneous rupture of the tympanic membrane,
resulting in otorrhea. If this occurs, the otalgia and
fever often subside. At this stage, it is often not
possible to visualize the tympanic membrane because
of the discharge in the ear canal
Diagonosis
 Otalgia.
 Pyrexia,fever.
 Thickened, bulging, hyperemic tympanic
membrane.
 Hearing loss.
 Otorrhea.
Differential Diagnosis
 Otitis externa, furuncle of external acoustic meatus
 Myringitis bullosa
 also presents with otalgia and otorrhea and may be the primary
diagnosis, or it may be secondary to the infected discharge from the
middle ear.
 If otalgia is the primary complaint, then referred pain should be
considered, particularly when otoscopy reveals a normal tympanic
membrane.
 The common sites of origin of referred otalgia are the teeth and
temperomandibular joints. In adults, malignant neoplasms of the
pharynx and larynx may present with otalgia as the only symptom.
 In neonates and infants with a high fever and systemic upset, the
possibility of meningitis should be considered.
 Myringitis bullosa
Treatment
 Nonsurgical Measures
 Watchful Waiting
nonsevere illness (mild otalgia and fever < 39 °C)
because AOM symptoms improve in most within 1–3 days.
not recommended for children < 2 years old if AOM
is certain.
 Antibiotic Therapy
 Adjunctive Therapy
analgesics and antipyretics.
 Surgical Measures
Myringotomy (drainage of pus from the middle ear space
Chronic suppurative otitis media
Definition
 A long period of time infection of a part or whole of the
mucous membrane of the middle ear
 The lesions invasive the middle ear mucosa, periosteum
or deep bone
 the tympanic cavity and mastoid process and eustachian
tube can be influenced
 Chronic or recurrent otorrhea or both.
 Tympanic membrane perforation
 Hearing loss
 Persons who have had ear disease in early childhood
 Intracranial Complications happens
Etiology
 Acute otitis media Delayed healing in 6-8
weeks
 Chronic inflammation of the nose and
pharynx
 Bacteria infection: Bacillus strain,
Pseudomonas aeruginosa, Staphylococcus
aureus, mixed infection. Anaerobic bacteria
infection.
The pathological changes:
 Middle ear mucosa is red , edematous and velvety
when disease is active;
 The discharge is definitely mucoid or
mucopurulent intermittent and appears mostly at
time of upper respiratory tract infection or on
accidental entry of water into the ear ;
 The perforation is in the central part of pars tensa
and its size and position varies. Sometimes the
perforation is marginal with the part of bony
destruction.
 Symptoms
 Discharge : scanty, thick and yellowish, foetid
with the bony necrosis
 Hearing loss is conductive.
 Tinnitus
Examination
 Perforation, hearing examination,CT scan
 (1) (2) (3) (4)

(1) Pars tensa front-inferior part perforation means

the pharygotympanic infection;
(1) pars tensa large perforation the corrosion of the handle of the malleus;
(2) boundary perforation;
(3) pars flaccida perforation.
Differential Diagnosis

 chronic myringitis
 Carcinoma of middle ear
 Tuberculous otitis:
The discharge is thinner
Treatment
 Nonsurgical Measures
Aural Toilet
Aural toilet is important for the successful treatment of
CSOM, particularly when topical medication is used.
Clearing the discharge from the external auditory canal
allows the topical agent to reach the middle ear in an
adequate concentration.
Topical Antibiotics
The recent availability of topical ofloxacin preparations
may prove to be as effective as topical aminoglycosides
without the ototoxic potential.
0.3% ofloxacin, 0.2-0.5% chloromycetin solution
4% boric acid alcohol
almost all eardrops should be given as four drops, four times daily

General bacterial culture

Treatment
Surgical Measures
 Tympanoplasty
 Tympanoplasty and mastoidectomy
Cholesteatoma
Cholesteatoma
 Epidermoid tumor of the middle ear, not a true neoplas
 Chronic otitis media with cholesteatoma
 Congenital cholesteatoma
 Acquired Cholesteatoma
Primary acquired cholesteatoma (no history of otitis media)
Secondary acquired cholesteatoma(history of otitis media)
Pathogenesis
 retraction pocked theory
Pathogenesis
retraction pocked theory :
The eustachian tube dysfunction

negative pressure of the middle ear for long time

Pocket retraction formation
Epithelial shedding and accumulation

Cholesteatoma formation (Primary

acquired cholesteatoma)
Pathogenesis
Epithelial migration theory:
marginal perforation of tympanic membrane

The epithelium of the canal and the membrane m

to the middle ear

Epithelial shedding and accumulation

Cholesteatoma formation (Secondary acquired

cholesteatoma)
Epithelial migration theory ：
Pathogenesis
 Squamous metaplasia
Middle ear mucosa epithelial cells stimulated
by inflammation become keratinizing squamous
epithelial metaplasia, secondary cholesteatoma
 Basal cell proliferation theory
The proliferation of cells on the pars flaccida
enter into the subcutaneous tissue, forming
primary cholesteatoma
Pathology
a bag like cystic structure
The inner wall of the capsule is keratinizing
stratified squamouse epithelium
the content : the crystal of cholesterol, desquamated
tissue debris, keratin and bacteria are embedded.
bony destruction may cause an enormous cavity
invading the internal ear and middle ear and
posterior cranial fossae, thus opening up pathways
for the spread of infection to the meninges and
brain.
。
symptoms
 Discharge : foul smelling, bloody stained
discharge
Primary cholesteatoma usually no
purulent ear
 Severe hearing loss
 Earache: facial paralysis and vertigo appear
Examination
 Otoscope
 hearing examination
 CT scan
 The membrane is not clear, the surface with the
dirty things, the facial nerve has been broke.
 Coronal CT scan of the left temporal bone, showing pars
flaccida cholesteatoma. The white arrow points to
cholesteatoma. The black arrow points to eroded scutum.
Differential Diagnosis
 Carcinoma of middle ear
 Tuberculous otitis:
The discharge is thinner
 Chronic suppurative otitis media
A 63-year-old man
complained of a 2-month
history of chronic discharge
from his left ear. He was a
habitual user of cotton
swabs, and he cleaned his
ears daily. In addition to the
otorrhea, he occasionally
noticed blood on the swabs.

Examination revealed the

presence of a friable polyp
on the floor of the ear canal
(figure). The tympanic
membrane was intact. The
512-Hz tuning fork test
showed lateralization to the
left ear, and air conduction
was greater than bone
conduction in both ears.
The differential diagnosis included an inflammatory polyp or
a malignant growth. The patient was initially started on
ototopical antibiotic/steroid drops three times daily and
asked to return in 7 to 10 days. At the return visit, the
condition of the mass was unchanged. A biopsy was
performed in the office and submitted for pathology. In
addition, high-resolution computed tomography (CT) of the
temporal bone was ordered. The biopsy analysis identified a
squamous cell carcinoma. CT detected no bony erosion.

The patient underwent a lateral temporal bone resection,

which included resection of the external bony canal, the
tympanic membrane, the malleus, and the incus. The ear
canal was sutured closed.
Principal of Treatment

1.eliminate infection,
prevent cranial complication
2.acquired a dry ear
3.reconstruction the hearing ,
restore normal functioning to the middle ear
Surgical Measures
 mastoidectomy
 mastoidectomy ＋ Tympanoplasty
 modified radical mastoidectomy
Residual disease of chronic otitis
media
 Adhensive otitis media
 tympanosclerosis
Surgical Measures
Tympanoplasty
Ideally, surgery should be carried out when the infection
has been adequately treated and the middle ear mucosa is
healthy, since the chance of a successful outcome is increased.
In this situation, a tympanoplasty, with repair of the tympanic
membrane and ossicular chain (if required), is recommended.
modified radical mastoidectomy
Procedure End Result Advantages after Disadvantages
Surgery after Surgery

Tympanoplasty Ear canal with tympanic Low risk of otorrhea Risk of recurrent
(canal wall up) with membrane pars flaccida
mastoidectomy cholesteatoma

Atticotomy Ear canal with tympanic Intermediate risk of Risk of recurrent

membrane and defect into otorrhea pars flaccida
epitympanum cholesteatoma

Modified radical Mastoid cavity with Low chance of recurrent Significant risk
mastoidectomy tympanic membrane pars flaccida of otorrhea
(canal wall down) cholesteatoma

Radical Mastoid cavity without Low chance of recurrent Significant risk

mastoidectomy tympanic membrane pars flaccida and pars of otorrhea and
(canal wall down) tensa cholesteatoma poor hearing
Complication of middle ear infection
and mastoiditis
 Complication of middle ear infection and
mastoiditis are caused by extention of infection
from the mastoid to the contiguous structure.
 Causes
Types of middle ear infection
High virulence of organisms and resistance of
organisms to antibiotics.
Resistance of patient is poor. Chronic diseases
may be present, e.g. diabetes mellitus,
tuberculosis, AIDS, nephritis, leukaemia, etc.
1.Postauricular subperiosteal abscess
3.Bezold’s abscess (inside the diagastric)
9.Periosteum
Petrositis, labyrinthitis, facial paralysis
2.Extradural abscess
4.Sigmoid sinus peripheral abscess
5.Thrombophlebitis of sigmoid-sinus
6.Brain abscess
7.Cerebellar abscess
8.Endocrainium of temporal lobe
 The incidence of intracranial complications has
been considerably reduced since the introduction
of antibiotics. Despite this fact, once an
intracranial complication develops, it carries a
significant risk to life. Therefore, early recognition
and treatment are vital to improve the prognosis.
 It is not uncommon for more than one intracranial
complication to occur simultaneously. The most
common early symptoms of intracranial extension
of infection are persistent headache and fever.
Other features include lethargy, irritability, and
neck stiffness. A decreasing level of consciousness
and seizures are late signs associated with a poor
prognosis.
 Once suspicion of an intracranial infection is
raised, an MRI of the brain is the investigation of
choice, along with lumbar puncture if meningitis
is suspected. The causative organism depends on
whether the complication has developed as a
consequence of acute or chronic OM; the initial
antibiotic therapy should be prescribed
accordingly until the results of bacterial cultures
and sensitivity are available.
Meniere’s disease
 Meniere disease is characterized by remissions and
exacerbations, making it difficult to predict the future
behavior of the disease in any individual patient based
on the patient's own history, diagnostic evaluations, or
epidemiologic profiles. The initial manifestation may be
vertigo or hearing loss, but within 1 year of onset, the
typical syndrome—attacks of vertigo, tinnitus,
fluctuating hearing loss, and aural fullness—is present.
Longitudinal studies have shown that after 10–20 years,
the vertigo attacks subside in most patients and the
hearing loss stabilizes to a moderate to severe level (50
dB). Meniere disease is usually a unilateral disease, and
the risk of developing this disease in the contralateral
ear appears to be linear with time. Twenty-five to forty-
five percent of patients may develop disease in the
contralateral ear.
Meniere’s disease
 Caused by distension of the membranous
labyrinth with endolymph.
 Characterized by attacks of vertigo,
fluctuating hearing loss, tinnitus, and aural
fullness.
Diagnosis
 the diagnosis of Meniere disease is based on the
longitudinal course of the disease rather than on a
single attack.
 Otoscopy, eustachian tube inflation, tympanometry
are no abnormality.
 Audiometry
audiogram ： early time sensorineural loss of low
tones
later sensorineural loss of the whole
frequency
tympanometry ： normal
Diagnosis
OAE ： abnormal
ABR: hearing threshold is
elevated
 Glycerol test

 MRI
Treatment

 During the attack ： suit the remedy to the

case (dramamine) ， dehydration
 Diapause ： low salt diet, vasodilators,
antiallergic drugs
 Surgical treatment ： Endolymphatic Sac
Surgery, Vestibular Nerve Section,
Labyrinthectomy
Vertigo
 Dizziness indicates a disturbed sense
of relationship to space. It is a subjective
sensation that rises to the level of
consciousness, alarming the patient, who is
often unable to describe exactly what he or
she is feeling. The sensation may be one of
turning or whirling., or it may be a less
well-defined symptom of giddiness,
weakness, confusion, or unsteadiness.
 peripheral central

pattern paroxysmal attacks whirling or not

degree acutely uncertainly
Position relatively irrelevant
symptom hearing loss without otologic symptoms
consciousness normal disturbance
Nystagmus go round and round ， changefully in
direction
as the vertigo direction
Attacking time hours to days days to months

Vestibular
Function peripheral central
Hearing loss
Hearing loss
 It is the functional or organic disturbances of the
hearing passway that makes the hearing loss.
 hard of hearing ， deaf ， deaf-mute
 Between 30% and 35% of individuals over the age
of 65 have a hearing loss sufficient to require a
hearing aid. Forty percent of people over the age
of 75 have hearing loss.
 Preventing hearing loss and hearing rehabilitation
now are the intercross problem.
 Conductive cetral
 Sensorineural
 Combined neuropathic
Essentials of Diagnosis
 May affect patients of all ages.
 For patients who have unilateral hearing loss:
 Weber tuning fork test lateralizes to the unaffected
side.
 Rinne tuning fork test demonstrates air conduction
greater than bone conduction.
 Pure-tone thresholds result in equally diminished air
and bone conduction.
 Speech discrimination testing less than 90% correct.
Tuning fork
 Tuning fork is a simple metal two-pronged fork
with the tines formed from a U-shaped bar of
elastic material (usually steel). When set vibrating
with a blow from a mallet, and after waiting a
moment to allow some high overtones to die out,
a tuning fork resonates at a constant, specific
pitch. The pitch that a particular tuning fork
generates depends upon the length of the two
prongs, with two nodes near the bend of the U.
 Conductive Sensorineural
deafness deafness
Rinner test +, +- +
Weber test To the ear To the normal
concerned ear
Schwabach + -
test
Audiometry

 The audiogram is a graph that depicts

threshold as a function of frequency.
Threshold is defined as the softest intensity
level that a pure tone (single frequency) can
be detected 50% of the time.
 Conductive Hearing loss
dB
﹝
               

0 ﹝  ﹝ ﹝ ﹝
         
﹝    

               

20                
○
       
○        
○ ○ ○
40  
○            
○  

               

60                

               

80                

               

100
125 250 500 1K 2K 4K 8K
Hz
 Sensorineural Hearing loss
dB
0
20
○ ﹝○ ﹝○
40 ﹝○
﹝○ ﹝○ ﹝○
60

80

100
125 250 500 1K 2K 4K 8K Hz
 Combined Hearing loss
dB
0
20 ﹝
﹝
﹝
40 ﹝ ﹝ ﹝
○
○ ○
○
60 ○
○ ○

80

100
125 250 500 1K 2K 4K 8K Hz
 Tympanometry
1.4
type A ： normal 。
0.7 peak value at ±50dapa

0
-200 0 +200
1.4
type As ： peak value is normal
0.7
immitance<0.7
tympanosclerosis
0
-200 0 +200

1.4
type Ad ：
0.7 immitance >1.4
ossicular discontinuity
0
-200 0 +200
 Tympanometry

type B ： no peak
otitis media 。

-200 0 +200

type C ： peak value less than –100dapa

disfunction of Eustachian tube

-200 0 +200
Causes of conductive hearing loss
 infection ： acute or chronic otitis
 Foreign body
 trauma ： tympanic perforation ， ossicular
discontinuity
 tumor ： external ear ,middle ear
 abnormality ： atresia in the external canal,
congenital stapes fixation
 others ： cholesteatoma 、 cerumen
hereditary hearing loss

 Michel abnormality （内耳完全未发

育）
Mondini abnormality （仅耳蜗底转发
育）
Large Vestibular Aquaduct Syndrome , 简
称 LVAS, 大前庭导水管综合症
 A case report
 A 10 year-old-girl ;
 She can not speak until 3-year-old, and her speech is
unclear.
 ABR test showed neural deafness at 6-year-old. Hearing
threshold is 60 dB.
 After wearing hearing aids, she can exchange with others
normally.
 3 months ago , because of getting cold , she felt hearing
level decreasing rapidly.
 Pure-tone thresholds to 100dB.
 CT scan : Large Vestibular Aquaduct Syndrome , LVAS
 It is hereditary hearing loss.
Nonhereditary acquired sensorineural
hearing loss
 Sudden sensorineural hearing loss
 Drug toxicity
 Noise-induced hearing loss
 Presbycusis
 Head trauma
 virus or bacteria induced hearing loss
 autoimmune inner ear disease
 Other disease relative to hearing loss
Sudden Sensorineural Hearing Loss
 First described in 1944 by DeKleyn
 Incidence: 5-20 per 100,000
 4,000 new cases/year in US
 Idiopathic
 Hearing loss in 3 contiguous frequencies o
at least 30 dB
• Some authors use at least 20 dB loss
Sudden Sensorineural Hearing Loss
 Onset of hearing loss occurs in less than 72
hours
 Recovery rate without treatment 32% - 79%
• Usually within 2 weeks of onset
• Only 36% with complete recovery
 No middle ear disease
 Otologic emergency
Sudden Sensorineural Hearing Loss
 Clinical Presentation
• Sudden onset hearing loss
• Less than 3 days
• Usually unilateral
• Left side possibly more common (55%)
• Bilateral 2%
• Median age 40-54
• Equal among males and females
• Awakening from sleep
• Hearing a “popping” prior to hearing loss
• Aural fullness
• Tinnitus
• Vertigo
Sudden Sensorineural Hearing Loss
 Differential Diagnosis
• Infectious
• Bacterial: meningitis, labyrinthitis, syphilis
• Viral: Mumps, CMV
• Inflammatory
• Autoimmune, Cogan syndrome, Lupus, MS
• Traumatic
• Temporal bone fracture, acoustic trauma, perilymph fistula
• Neoplastic
• CPA tumor, temporal bone metastasis
• Toxic
• Aminoglycosides, aspirin
• Vascular
• Thromboembolism, macroglobulinemia, sickle cell disease, cerebral
infarct, TIA
• Congenital
• Mondini malformation, enlarged vestibular aqueduct
Sudden Sensorineural Hearing Loss

 Theories
• Viral infection
• Temporal association of SSNHL with viral URI in 25% - 63%
• Serology confirming active viral infection
– HSV, VZV, CMV, influeza, parainfluenza, rubeola, mumps, rubella
– Immunoreactivity against virus
• Histopathology of human temporal bones
– Atrophy of organ of Corti, spiral ganglion, tectorial membrane
– Hair cell loss
– Unraveling of myelin
• Animal experiments confirm viral penetration of the inner ear
Sudden Sensorineural Hearing Loss
 Theories:
• Vascular injury
• Sudden onset suggesting infarction
– Perlman (1959) demonstrated loss of cochlear microphonic 60
seconds after occlusion of labyrinthine artery in guinea pig
– Buerger’s, macroglobulinemia, sickle cell, fat embolism
• Histopathologic changes in cochlea caused by vascular
occlusion in animal models
– In guinea pigs, labyrinthine vessel occlusion lead to loss of spiral
ganglion cells, mild to moderate damage to organ of Corti,
cochlear duct fibrosis
• Controversial
Sudden Sensorineural Hearing Loss

 Theories:
• Intracochlear membrane rupture
• Loss of endocochlear potential due to mixing of
endolymph and perilymph
• Gussen (1981) histologic evidence
• Fallen out of favor
 Likely combination of viral cause and
vascular insult
Sudden Sensorineural Hearing Loss

 Challenges
• True incidence is not known
• Patients with spontaneous recovery usually do
not present to an otolaryngologist
• Patients may present beyond what is considered to be
therapeutic window
• Etiology still unclear
• Relative paucity of studies examining treatments
based on prospective, double-blind, randomized,
controlled trials
Sudden Sensorineural Hearing Loss

 Clinical Evaluation
• History
• Complete head and neck exam
• Pneumatotoscopsy to evaluate for fistula sign
• Audiogram including pure-tone audiometry (PTA),
speech reception threshold (SRT), and speech
discrimination scores (SDS)
• Tympanometry
• +/- Auditory brainstem response (ABR) and otoacoustic
emission (OAE)
• ENG if vestibular symptoms and/or signs are present
Sudden Sensorineural Hearing Loss

 Radiography
• MRI with gadolinium
• 0.8%-2% of patients with SSNHL have been
diagnosed with IAC/CPA tumors
• Non-contrasted CT of temporal bones in
younger patients
• Mondini malformation
• Enlarged vestibular aqueduct
Sudden Sensorineural Hearing Loss
 Laboratory Evaluation
• CBC with diff
• Polycythemia, leukemia, thrombocytosis
• Electrolytes
• Erythrocyte sedimentation rate (ESR)
• Nonspecific, autoimmune or inflammatory marker
• Antinuclear antibody or 68 kD antibody
• Rheumatoid factor (RF)
• FTA-Abs (Syphilis)
• Coagulation profile
• Thyroid function testing
• Lipid profile
Sudden Sensorineural Hearing Loss
 Treatment
• Systemic Steroids
• Historical perspective: Reduce inner ear inflammation
• Nonspecific
• Dependent on time to therapy
• Oral, IV
• Variable to poor response for profound SSNHL
• Cannot be used for all patients
– Diabetics, ulcers, TB, glaucoma
– Intratympanic steroids
Sudden Sensorineural Hearing Loss

• Antivirals
• Volume expanders
• Vasodilators
• Anticoagulants
• Carbogen inhalation
drug-induced hearing loss;
ototoxicity
 Aminoglycoside antibiotics
streptomycin, gentamicin, tobramycin, kanamycin
amikacin
 Salicylates
 Quinine and related antimalarials
 Diuretic:furosemide
 Antitumor: cisplatin
 CO poisoning, alcohol poisoning
noise-induced hearing loss
 Ten million Americans have noise-induced
hearing loss and 20 million are exposed to
hazardous noise in their employment.
 Noise-induced hearing loss can be prevented by
avoiding exposure to loud noise or by the regular
use of earplugs or fluid-filled muffs to attenuate
intense sound.
 Noise-induced hearing loss results from
recreational as well as occupational activities and
often begins in adolescence.
presbycusis ,age-associated
hearing loss
 is the most common cause of hearing loss in
adults.
 Initially, it is characterized by symmetric,
high-frequency hearing loss that eventually
progresses to involve all frequencies.
 More important, the hearing loss is
associated with a significant loss in clarity.
presbycusis ,age-associated
hearing loss

 hearing aid is the most helpful treatment.

Treatment
 Prevent early, treat early
 Operation
 Cochlear Implants
 Hearing aid
 Aural Rehabilitation
acouophone---HEARING AIDS

 A hearing aid is an aid to hearing that

makes sounds louder so they are more
accessible for a hearing impaired
person. Hearing aids must be
individually prescribed and selected to
suit each person's hearing loss.
 All hearing aids have 3 main parts.

1.A microphone, which picks up sound and

converts it into electrical signal

2.An amplifier, which increases the strength of

the signal

3.An earphone, which converts the amplified

signal back into sound (at the louder volume)
a Cochlear Implant

 A cochlear implant (Bionic Ear) is an

artificial hearing device, designed to
produce useful hearing sensations by
electrically stimulating nerves inside the
inner ear.
The internal component of the cochlear implant
SPrintTM speech processor

ESPritTM speech processor