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Congenital

Atresia

Etiology

: failure of canalization of the external auditiry canal It may be associated with anomalies of the auricle, middle ear or rarely inner ear

CP :

Unilateral or bilateral The external canal is absent or appears as a blind pit

Investigations

Radiological evaluation: To assess the middle and inner ear

Audiological evaluation

: Conductive deafness

Treatment

•

• Unilateral • Bilateral

:

postpone after puberty

:

HA fitting at 1 year operation at one side (at 2-5 years) , the other after puberty

Traumatic

:

Laceration

Self inflicted

grip : by ear bud hair

Iatrogenic

: ear wash or instrumentation

Clinically:

Earache, mild bloody otorrhea

Treatment:

Antibiotics Avoid entry of water in the ear canal

Traumatic : FB نذلاا يف بيرغ مسج

Type of patient:

Commonly children Mentally retaded adult

Type of FB

:

Animate FB :

Flies, larvae, fleas mosquito,,

Inanimate FB

:

Non vegitable

: bead, button, disc battery

Vegetable:

bean and pea

FB Symptoms

- History - Hearing loss if the FB obstructs the canal - Severe irritation and noise in the ear with animate FB

Signs:

The FB can be seen by otoscopy

FB

Treatment:

Animate FB:

Kill by alcohol or oil  instruments

Inanimate FB :

Non vegetable: remove by ear wash or remove by ear wash or instruments BUT PLEASE DO NOT WASH IF THE FB IS DISC BATTERY

-

Vegetable: Remove by instruments and avoid ear wash because it may swell by water and become more impacted General anesthesia may be needed in impacted FB and uncooperative children

Complications:

Injury of the external canal or drum by the FB or during removal

So donn’t wash if : -The FB is vegetable -The FB is disc battery

Inflammatory conditions of the external auditory canal

•

Bacterial:

1- Diffuse OE 2- Localised OE

: frunculosis لمد

3- Malignant OE

( Necrotizing OE) • • •

Viral

( bullous- Herpes)

Funga

l:

(Otomycosis) Non infective

( allergic OE, Seborrhoic OE)

Inflammatory : Bacterial Diffuse otitis externa

Definition: Diffuse inflammation of the skin lining of the extenal auditory canal Pridisposing factors : - Skin laceration: Self inflicted Iatrogenic:-

Ear wash or instruments

- Skin maceration: Hot humid atmosphere Swimmer ear Discharge of chronic suppurative Otitis media

Symptoms : Earache:

- Severe

Why?

- Increase on moving the jaw

Why?

Because the skin is tightly adherent to the underlying perichondrium & periostium Deafness when edema is severe



obstruct the canal Signs External exam: Tenderness on moving the auricle or pressure on the tragus Tender pre and postauricular LN Otoscopic exam : Redness, edema, tenderness of the skin of the external canal Scanty discharge, serous or purulent Because the external canal Lies immediately behind Temporomandibular joint

• • •

TREATMENT METICULOUS CLEANING PACK WITH ANTIBIOTIC CULTURE

Inflammatory : Bacterial Frunculosis

Definition Localized suppurative inflammation of a hair follicle in the skin of the external auditory canal Organism Staph aureus PP factors: - scratching of ear canal - DM

Symptoms: Earache:

-

Severe Why?

-

Increase on moving the jaw Why?

Deafness when edema is severe



obstruct the canal Signs: External : Tenderness on moving the auricle or pressure on the tragus Tender pre and postauricular LN Otoscopic : It is difficult to examine the external canal By Otoscope because there is localised area of tenderness in the skin of the outer Part of the external canal No or scanty purulent otorrhea ( never mucoid as there is no mucous glands )

Investigations : Blood glucose level especially in :

- Recurrent cases - Bilateral cases

DD acute mastoiditis Treatment Antibiotics Analgesic Aural toilet: removal of ear discharge Aural pack: by gauze strip soaked in glycrine icthyol:

Inflammatory : Bacterial

Malignant otitis externa (Necrotizing otitis externa)

Def: to the base of the skull Incidence : elderly uncontrolled diabetic patient Organism : pseudomonas aeuruginosa Symptoms: to analgesics Signs External examination : Tenderness on pulling the URICLE OR PRESSURE ON THE TRAGUS TENDER PRE AND PSTAURICULAR ln Necrotizing external otitis should be suspected when patients with diabetes mellitus (or another condition that compromises the immune system) complain of persistent external otitis that causes severe pain, especially at night Otoscopic examination : Granulations at the floor of the external canal at the attachment of bony and cartilagenous part ضرملا اذهل ادج ةماه ةملاع هذهو Scanty, sanginous and purulent otorrhea

• -

Investigations: Blood glucose level CT scan of the temporal bone& skull base Radio-isotop scan ( Gallium &Tecnetium) to assess severity & prognosis Biopsy Culture &sensitivity

•

. Gallium citrate Ga 67 scintigraphy in a 74 year-old male patient with diabetes mellitus and left-sided temporal bone osteitis. This patient was referred because of persistent otalgia and otorrhea after a prolonged course of systemic oral antibiotics. As a result of ongoing infection, the left temporal bone shows enhanced uptake of 67Ga (arrow).

compared with the well-aerated left side.

• • -

Complications: Osteomyelitis of the temporal bone &skull base Facial nerve paralysis stylomastoid foramen at the Last 4 cranial nerves paralysis the jagular foramen at

-

Treatment: Medical: Control of diabetes Antibiotics; - Gentamycin (be aware of possibility of ototoxicity)

-

- Quinolones 3 rd generation cephalosporins Local antibiotic ear drops Analgesics Aural toilet Surgical: Removal of granulations and debridement of necrotic tissue up to mastoidectomy

Inflammatory : Viral :

Herpes Zoster Oticus

Etiology:

Herpes zoster virus

Clinically:

- Pain in and around the ear - Vesicles on the auricle and external canal - Ramsay-Hunt syndrome :

Vesicles+ facial nerve palsy+SNHL& Vertigo TTT:

- Antiviral - Corticosteroid if there is affection of VII nerve f VIII nerve

Fungal

:Otomycosis

-

Fungal infection of the skin of the exernal canal Etiology: organism: Aspirigillus Niger Candida albicans

• • •

Symptoms: Itching is usually the only symptom Pain if there is secondary infection Deafness if the external canal is obstructed

-

Signs: The external canal contains whitish mass withblack spotslike wet newspaper دئارج قرو نم ةللبم ةريغص ةعطق لثم

-

TTT : Aural toilet : removal of the fungal mass by suction or ear wash Antifunga fungicidal l: nystatin, or or salicylic acid (2%) as a keratolytic in alcohol as

Neoplasm

: Benign Exostosis

Incidence The commonest tumor of the external canal More common in swimmers Symptoms: Usually asymptomatic Hearing loss if the external canal is obstructed by large exostosis or wax Signs: Bilateral smooth bony swelling TTT: - If obstructing the canal



excision

Neoplasm

: Malignant Squamous cell carcinoma

• • -

Incidence

Rare More common in elderly males

CP:

-

Otological:

Deep seated earache Bloody stained otorrhea Fleshy friable mass in the external canal Progressive hearing loss, initially CD then SNHL

Neurological:

paralysis of VII& last 4 cranial nerves

Cervical

: - Enlarged preauricular, postauricular and upper deep cervical LN

-

Investigations:

CT scan

and

MRI

to assess tumor extension and lymph nodes involvement

Biopsy Metastatic work up

Treatment:

Surgical resection of the temporal bone + postoperative radiotherapy + Radical neck dissection prosthesis

يرتل ةمداقلا ةحيرشلا رظنا هل ةحارجلا هذه ءارجا مت ضيرمل جذومن Chest X ray Abdominal ultrasound Bone scan CT scan Of brain

• From; http://www.caritas.ab.ca/ther_new/respcare/hbo/case5 .html

•

This 68 year old man was diagnosed with squamous cell carcinoma of the left external auditory miatus. The temporal bone resection resulted in loss of the left ear. Following the resection, the patient was treated with therapeutic radiation

•

Craniofacial oseointegrated implants were used to retain an auricular prosthesis

•

A close-up view of the auricular prosthesis retained on the craniofacial osseointegrated implants

.

WAX Accumulation

Def: Abnormal accumulation of wax

-

in the external auditory canal Etiology:

• Failure of the natural cleaning as a result of :

Narrow external canal Attempts of the patient to clean his ear



push the wax medially TMJ dysfunction

What is WAX?

؟خلامصلا وهام

•

Wax is a mixture of secretions of ceruminous sebaceous glands with desquamated and skin cells

•

It is expelled outside the canal in the form of flakes BY movement of the TMJ during talking and eating

•

Function Protects the skin by : Acidic reaction Lyzozyme activity

Symptoms:

Hearing loss and tinnitus when the wax obstructs the canal خفتني ثيح رحبلا لوزن وأ مامحتسلاا دعب اريثك ثدحت ءاملاب خلامصلا

Signs:

brownish mass in the exernal canal

-

Treatment: Remval by: Ear wash : if the wax is hard it should be softened by glycrine bicarbonate before ear wash Instruments

Rupture of the Tympanic membrane

-

Incidence

: uncommon why?

The drum is protected by the tortuous course of the external canal

Etiology

:

Indirect Trauma

: Hand slap (the commonest) Explosion Otitic barotrauma

Direct Trauma:

-FB -Self inflicted - Iatrogenic ( ear wash or instruments) - Longitudinal temporal bone fracture

-

Symptoms: History of trauma Earache at the time of rupture

-

No or mild bloody otorrhea Air comes from the ear on nose blowing

-

Hearing loss Signs: Central perforation( in the pars tensa) Any size Any shape Ragged edges Surrounded by blood clots

Treatment Conservative:

Antibiotic

Avoid :

- Nose blowing - Ear wash - Entry of water into the ear يف نيلزاف اهيلع شاش ةعطق عضوب مامحتسلاا وأ سأرلا لسغ دنع نذلأا - Ear drops -

Surgical:

Myringoplasty ثدحي مل ول رهشا ةثلاث دعب مائتلا

-

- Elderly diabetic patient presents with persistent otitis externa inspite of proper treatment



suspect Malignant Otitis Externa (Necrotizing OE)

-

- It is normal to have some wax in the middle ear Wax causes deafness when it obstructs the external canal You should check for blood sugar in: Recurrent or bilateral frunculosis In eldrly patient with persistent otitis externa