EXTERNAL EAR DISEASES😊

EXTERNAL EAR DISEASES

Congenital Abnormalities of Pinna

• Anotia
• Absence of the ear pinna.

• Microtia
• The size of the ear pinna is small.

• Correction/Reconstruction
• Rib cartilage is needed as a graft.
• Rib cartilage develops by 5-7 years of age.
• Correction of microtia/anotia is done at 5-7 years.
• Another reason to wait until 5-7 years:
• To allow complete development of the normal pinna.
• To take its impression for symmetric reconstruction.

Pre auricular sinus

• Occurs from incomplete fusion of Hillocks of His.

• Development of Pinna:
• Develops from the mesoderm of the first and second arches.
• These form 6 projections, known as Hillocks of His.
• These 6 projections fuse to form the ear pinna.

• In preauricular sinus, fusion is incomplete.
• If infected:
• Recurrent purulent discharge is observed.
• A swelling (the sac) is also seen.
• To track the sac:
• Methylene blue can be injected.
• The preauricular sinus can then be excised.

Chondrodermatitis Nodularis Helicis

• Painful, benign inflammatory condition of the helix (ear).

• Presents as a small tender nodule with central crust or ulcer.

Congenital Stapes Anomalies (with Normal Eardrum)

• Incus + Stapes anomalies > isolated stapes anomalies > anomalies in all 3 ossicles.

• Among stapes anomalies (descending order of frequency):
• Stapes footplate fixation only >
• Mobile stapes footplate + other anomalies >
• Stapes footplate fixation + other anomalies >
• Isolated stapes defect

• Clinical clue:
• Nonprogressive conductive hearing loss
• Normal eardrum
• No history of trauma or infection → suggests congenital ossicular malformation

Acquired abnormalities

Hematoma auris

• Accumulation of blood after trauma.

• Located between the cartilage and the overlying perichondrium.

• Also known as a boxer's ear or wrestler's ear.

• Must be drained.

• If not drained, it can become infected, involving cartilage.

• This leads to necrosis and a deformity called cauliflower ear.

Perichondritis

• Involve cartilaginous part of pinna

• Sparing of the lobule is seen.
• The lobule only contains fat.

• Redness, inflammation, and pain

• A/w relapsing polychondritis.
• Involves laryngeal, nasal, and costal cartilages.

Keloid

• Abnormal proliferation of the epithelium during healing.

• Usually occurs at the site of an incision or trauma.

• There is a high chance of recurrence after excision.

Stain for Differentiating Keloid/Hypertrophic Scar (and muscle/collagen):

• Masson Trichrome Stain.
• Red: Muscle.
• Blue: Collagen.

Feature	Keloid	Hypertrophic Scar
M/c site	Sternum, shoulder region	Extensor surface
Predisposition	Racial (dark-skinned people)	More common in children
Growth	More aggressive, Grows beyond scar boundary	Remains within scar boundaries
Progression	Does not subside	Subsides with time & pressure
Mx	Intralesional triamcinolone	Silicone pads/gel
Microscopically	Haphazard collagen bundles	Thin, orderly collagen fibers

To prevent recurrence:

• Intralesional steroids +

• Intramarginal excision +

• f/b Radiation therapy

Acquired abnormalities of external auditory canal

Wax

• A dark pile of sebaceous secretions.

• Most common cause of conductive hearing loss in adults.

Furunculosis

• Infection of the hair follicles.

• Swelling with hair follicles is seen in the ear.

• Causative organism is Staphylococcus.

• Presents with pain that ↑↑ on chewing/jaw movements.

• Treatment:
• Antibiotics.
• Ichthammol glycerin packs.
• Topical antibiotics.

Diffuse otitis externa

• Also known as telephonist ear, swimmer's ear, or Singapore ear.

• Diffuse inflammation of the external ear.

• Causative organism is Pseudomonas.

• Mode of infection: Contaminated water.
• Normally →EAC → acidic.
• Water or humidity → alkaline → bacterial growth.

• Presents with pain that increases on chewing/jaw movements.

Treatment:

• Antibiotics.

• Ichthammol glycerin packs.

• Topical antibiotics.

Malignant otitis externa

• It is a locally invasive, aggressive infection.

• Presence of red granulation tissue.

• R/F
• Uncontrolled diabetes
• Immunosuppressed.

• Caused by Pseudomonas infection

• Symptoms:
• Excruciating pain that increases on chewing/jaw movements.

• Can involve bones:
• Base of the skull and facial nerve can be involved.
• Later, lower cranial nerves (9th, 10th, 11th) are involved

The external auditory canal of a 75-year-old diabetic patient has granulation tissue, which is causing acute ear pain and face nerve involvement. What is the most likely diagnosis?

1. Malignant otitis externa

2. Nasopharyngeal carcinoma

3. Acute suppurative otitis media

4. Chronic suppurative otitis media

Diagnosis:

• Culture:
• Positive.

• Tc99 scan:
• Tc99 dye is taken up by osteoclasts and osteoblasts.
• Infection initially leads to osteoclast activity and bone resorption.
• Osteoclasts take up the dye, visualizing infected areas.
• Used for early diagnosis.
• Osteoblastic activity continues after infection subsides
• due to remodelling.
• Cannot specify the endpoint of therapy.

• Gallium 67 scan:
• Gallium is taken up by neutrophils.
• Scan will be negative after treatment.
• Specifies the endpoint of therapy.

• MRI:
• When intracranial complication is suspected.

• CT:
• Done to identify any bony erosion.

Treatment:

• Antipseudomonal antibiotics:
• Piperacillin (Penicillin)
• Tazobactam (Monobactam)
• Ciprofloxacin (FQs)

• Debridement of dead tissue.

Otomycosis

• Fungal infection of the EAC.

• Cause: Aspergillus Niger > Candida > Aspergillus fumigatus.

• Can occur in immunocompromised or immunocompetent patients.

• Most common symptom is itching.

• Appearance: Wet newspaper-like.

• Treatment:
• Aural toileting
• Topical antifungals
• If persisting: Systemic antifungals

Foreign body in the ear

• Presents with unilateral foul-smelling discharge.

Method of removal:

• Inorganic (beads/pellets):
• Foreign body probe/hook.

• Graspable/non-living:
• Crocodile forceps.

• Living insect:
• Anesthetize with oil or local anesthetic drops (4% xylocaine).
• This makes it hypoxic and paralyzes it.
• Remove with probe/hook/forceps.

• Organic & button batteries:
• Never do syringing as it may swell or leak.

Keratosis obturans

• In ciliary motility disorder → cilia normally push dead epithelium out.

• In this disorder, epithelium gets trapped layer by layer.

• Forms a plug of dead desquamated mass.

• Has an onion skin lamellar arrangement.

• Overlying bone gets widened; ballooning is seen.

• Rarely, 7th nerve palsy can occur.

Treatment:

• Remove mass after giving keratolytics to soften it.

Herpes zoster oticus / Ramsay hunt syndrome

• Involves reactivation of herpes zoster virus.

• Virus remains latent in
• Geniculate ganglion, CN 7

• Presents with
• Vesicles in facial nerve distribution (EAM)
• LMN type of facial palsy.
• SNHL due to 8th nerve involvement.
• Otalgia
• Loss of taste in anterior 2/3 tongue

Treatment:

• Antiviral therapy: Acyclovir, Valacyclovir.

• Topical agents and lotions for vesicles.

• Steroids (+/-).

Facial nerve palsy is seen in

• Malignant otitis externa

• Ramsay Hunt syndrome

• Keratosis obturans

• Bell’s Palsy

• MRK facial N palsy

---

NOTE: Referred Otalgia

Lesion Site	Nerve involved in referred pain
Oral lesions /dental caries	5th nerve (V3)
Oropharyngeal lesions / Tonsil	9th nerve (Glossopharyngeal)
Hypopharyngeal & Laryngeal lesions	10th nerve (Vagus)

---

Bell’s palsy

• Idiopathic facial nerve palsy.

• Seen in pregnancy, diabetics.

• Associated with EBV and HSV.

• Clinical features:
• Deviation of angle of mouth.
• Loss of nasolabial fold.
• Sagging of eyebrow.
• Hyperacusis

Traumatic perforation of tympanic membrane

• Cause: Trauma such as a fall or slap.

• A flap can be seen at the perforation area.

• Approximation of the flap is attempted.

• Wait for 4-6 weeks as it usually heals spontaneously.

• If it does not heal, myringoplasty should be performed.

Myringoplasty

• Closure of pars tensa perforation

• Prevent recurrent infections

• Contraindications
• Active middle ear discharge
• Uncontrolled nasal allergy
• Otitis externa
• Squamous epithelium ingrowth into middle ear
• May need excision or tympanomastoidectomy
• Opposite ear dead
• Or not suitable for hearing aid
• Age < 3 years

One liners

• The fungus most commonly causing otomycosis is Aspergillus niger.

• Keratosis obturans is characterized by an onion ring appearance.

• A chalky white tympanic membrane is seen in tympanosclerosis.

MIDDLE EAR DISEASES

ASOM (Acute Suppurative Otitis Media)

• Cause: Streptococcus pneumoniae.

• Predisposing factors:
• URTI.
• Diseases affecting the nose/nasopharynx.
• Eustachian tube dysfunction → middle ear effusion and infection.

• Common in children
• ET dysfunction is more frequent.
• ET is shorter, straighter, and horizontal in children.

• Stages:
• Tubal occlusion.
• Pre-suppuration.
• Suppuration.
• Resolution.

Symptoms:

• Pain

• Conductive hearing loss.

• High grade Fever.

Signs:

• Stage of tubal occlusion:
• Mild pain and hearing loss.
• Retracted tympanic membrane with:
• Prominent malleolar fold.
• Foreshortened hand of malleus.
• Distorted cone of light.

• Stage of pre-suppuration:
• Cart-wheel appearance:
• Blood vessels radiating from periphery to centre.
• High-grade fever.

• Stage of suppuration:
• Bulging tympanic membrane:
• Loss of all landmarks.
• Pulsatile otorrhea.
• Light house sign: When pus reflects light.

• Stage of resolution:
• Perforation of TM,
• mostly in the anteroinferior quadrant.
• Resolves spontaneously.
• Symptoms subside.

• Diagnosis: Based on history and examination.

Treatment:

• Medical therapy:
• Antibiotics for at least 8-10 days.
• Nasal/oral/topical decongestants.
• Anti-inflammatory drugs.
• Analgesics.

• Myringotomy:
• A curvilinear incision in the postero-inferior quadrant.
• Done here as the cone of light is in the anteroinferior quadrant.

• Indications of myringotomy:
• Pain + bulging TM.
• ASOM not responding to antibiotics.
• Persistent effusion beyond 12 weeks.
• ASOM and facial palsy.

SOM (Secretory Otitis Media)

• Also known as
• non-suppurative otitis media,
• otitis media with effusion,
• glue ear.

• Effusion is sterile, unlike ASOM
• no bacterial etiology

• Cause: ET dysfunction.

Predisposing conditions:

• Nasal cause: URTI.

• Nasopharyngeal cause:
• Adenoid hypertrophy (MC cause of B/L SOM in children).
• U/L SOM in juvenile age group: JNA.
• U/L SOM in older age group: Nasopharyngeal carcinoma.
• Cleft Palate
• Eustachian tube has two openers:
• Tensor veli palatini and levator veli palatani.
• In ET pathologies → weak → affect middle ear ventilation.
• Palatal infection.

Signs:

• Age: Younger age group.

• Symptoms: Conductive hearing loss.

• Tympanic membrane:
• Thick/thin/dull/lusterless.

• Absent light reflex.

• Retracted tympanic membrane with decreased mobility.

• Presence of air-fluid level with air bubbles.

Diagnosis:

• Tuning fork tests:
• Rinne's test: Negative.
• Weber's test: Lateralized to the affected side.
• Absolute bone conduction test: No role.

• Audiometry:
• Shows conductive hearing loss.

• Tympanometry (IOC):
• 'B' type of graph
• suggesting fluid in the middle ear.

Treatment:

• Initially, wait and watch for up to 12 weeks.

• If no resolution, Myringotomy with grommet insertion.
• A grommet is a ventilating tube between the EAC and middle ear.
• In SOM, myringotomy → anteroinferior quadrant.
• Incision is radial.

• Treat the underlying cause.

CSOM (Chronic Suppurative Otitis Media)

• Perforation always present

• Chronic Disease lasts > 12 weeks.

• Two types:
• Tubotympanic type/Mucosal type.
• Atticoantral type/Squamous type.

CSOM and its complications

• (1) Cerebellar lobe abscess.

• (2) Temporal lobe abscess.
• Peripheral enhancement of abscess is seen.

• (3) Sclerosis of mastoid bone

Brain abscess:

• Organism: Aerobic, anaerobic or mixed infection.

• Specifically temporal lobe
• MC abscess secondary to CSOM

• Infection breaks the tegmen and spreads to the middle cranial fossa.

• CF
• Headache, projectile vomiting +
• Foul smelling, blood stained ear discharge.

• MRI shows a space occupying lesion.
• Central hypodense area and enhancing ring on the outside.

• Treatment:
• Drainage of abscess, antibiotics, MRM.

A 40-year-old male presents with left ear discharge and mild ear pain for the past 7 years. There is no history of deafness. On examination, the tympanic membrane is intact and discharge is seen coming from the posterior superior wall. The left ear canal and tympanic membrane is normal. Which of the following is the most likely diagnosis?

1. Chronic suppurative otitis media

2. Chronic otitis externa

3. Keratosis obturans

4. Carcinoma of the external auditory canal
Ans
• 2 - Chronic otitis externa

Cholesteatoma

• Presence of stratified squamous epithelium in the middle ear.

• Epithelium
• EAC → Stratified squamous epithelium
• Middle ear → Cuboidal epithelium

Cause of erosion:

• Production of proteolytic enzymes
• collagenase, alkaline phosphatase, acid phosphatase

Types:

• Congenital:
• Entrapment of ectodermal cells
• in the middle ear during development.
• Levinson's criteria for congenital cholesteatoma:
• No prior ear disease/surgery.
• No symptoms
• Whitish mass behind an intact TM.
• No family history

• Acquired.
• Epithelial invasion.
• Metaplasia.
• Basal cell hyperplasia.
• Keratin flakes in attic or posterosuperior quadrant is the hallmark.

Symptoms:

• CHL (Conductive Hearing Loss).

• Mild ear discharge.

• Foul smell from ear.

Diagnosis:

• Keratin flakes on otoscopy.

• Examination under microscope.

• CT scan to determine disease extent.

• Audiological tests.

Treatment:

• Surgery: MRM (Modified Radical Mastoidectomy).

Cholesteatoma can spread:

• Via tegmen to the middle cranial fossa.

• Medially to the inner ear.

• Laterally to the EAC.

• Posteriorly to the mastoid.

Mastoidectomy

• Modified radical mastoidectomy:
• Also known as canal wall down surgery.
• Posterior canal wall and entire mastoid air cells are removed.
• Made into a single cavity.
• Indications
• Residual cholesteatoma
• Glomus tumour
• Carcinoma middle ear

• Simple Cortical mastoidectomy:
• Schwartz surgery/ Canal wall up surgery/intact canal wall mastoidectomy:
• As initial step to perform:
• Endolymphatic sac surgery
• Decompression of facial nerve
• Indications
• Acute coalescent or masked mastoiditis
• Acute otitis media with reservoir sign
• Schwartz Sign (10%):
• Flamingo-pink hue on the promontory
• Can be seen through an intact tympanic membrane.
• Seen in Otosclerosis
• Indicate active lesions
• All air cells are opened
• entire mastoid made into a single cavity
• Posterior canal wall is kept intact.

 

Tubercular otitis media

• Characterized by multiple tympanic perforations.

Buzz words (Middle Ear Diseases)

Complications of ASOM and CSOM

• Internal auditory canal is seen in petrous part of temporal bone

Acute mastoiditis

• Spread of middle ear infection to mastoid air cells.

• Organisms/symptoms are similar to middle ear infection (ascending infection).

• Symptoms are exaggerated with pain and redness beyond the ear.

• Pulsatile otorrhea (light house sign).

• Ironed out appearance of the mastoid
• first sign

• Positive reservoir sign:
• specific sign
• Immediate reappearance of discharge after mopping
• If it doesn't reappear, it indicates ASOM.

• Pinna pushed forward.

• Erythema and tenderness in the post-auricular region.

• Deepening of retro-auricular groove.

• Diagnosis:
• On X-ray: Hazy mastoid air cells, bone erosion.
• On CT: Diseased region appears Gray.

• Treatment:
• Cortical mastoidectomy + IV antibiotics.

Abscess in relation to mastoid

• Post auricular abscess (most common):
• Pus breaks outer cortex of mastoid.

• Zygomatic abscess.

Schullers view

• Citelli's abscess:
• Abscess into posterior belly of digastric muscle.
• Mnemonic: Telli → Belli

• Bezold's abscess:
• Pus tracks into sternocleidomastoid muscle.

• Luc's abscess:
• Pus extends into the external auditory meatus.
• Mnemonic: Look at EAC

Petrositis

• Inflammation of the petrous apex.

• Two cranial nerves at petrous apex:
• 6th cranial nerve: Causes lateral rectus palsy.
• 5th cranial nerve: Causes retro-orbital pain.

Triads

• Gradenigo's Syndrome:
• Petrous apicitis
1. Persistence of ear discharge (after cortical mastoidectomy)
2. Deep seated retro-orbital pain → D/t CN 5
3. Diplegia - Lateral rectus palsy due to CSOM → D/t CN 6
• Mnemonic: Pettennu (Petrositis) Granede (Gradenigo) 5,6 thavana itt → Kannilum cheviyilum kond → Eye pain + ↓ movement - case eduth(CSOM)

• Sampter's triad
• (Mnemonic: AAP): SAM → MAS → AS, AS, NAS
• AS - Asthma
• AS - Aspirin intolerance (& other NSAIDS that block COX1)
• NAS - Nasal polyp (Ethmoidal)

• Trotter's Triad
• Diagnostic of Nasopharyngeal Carcinoma
• NPC
• Temporoparietal neuralgia.
• Palatal paralysis.
• CN 10
• Tensor and Levator Veli Palatini involvement
• Unilateral conductive hearing loss.

---

• CSOM → Lateral sinus thrombophlebitis signs



• Hectic picket fence type
• Intermittent septic emboli enter bloodstream
• Fever + rigors
• Fever does not touch baseline
• Tobey-Ayre's test:
• Compression of IJV on healthy side raises CSF pressure.
• Mnemonic: Tobey has lot of pressure in his head
• Crowe-Beck test:
• Pressure on IJV on healthy side causes engorgement of retinal veins.
• Mnemonic: Crow with red eyes
• Griesinger sign
• Mastoid emissary veins cannot drain
• Edema and bluish discoloration of the mastoid
• Similar to battle sign
• Mnemonic: Blue color grease

---

• Grisel syndrome:
• Seen in Downs
• Non-traumatic inflammatory atlanto-axial subluxation
• Neck stiffness
• Torticollis
• Severe neck pain
• Due to paraspinal spasm from inflammation

Labyrinthitis

• Mnemonic: Toxic or Negative → Look to other side

• Inflammation of the labyrinth.

• Three types:
• Circumscribed
• Diffuse serous
• Diffuse suppurative

• Leads to SNHL, vertigo, tinnitus.

Lateral sinus thrombophlebitis

• Infection spreads from middle ear to mastoid sinus.

• Posterior border of mastoid has the sigmoid sinus.

• Infection results in thrombosis of the sigmoid sinus.

Intracranial Effects

• Impaired cranial venous drainage

• Leads to raised ICP
• papilledema
• Optic disc dilatation

Dural Venous Sinus Thrombosis CT/MRI

• Plain CT → Dense clot sign
• Thrombus appears white

• CECT → Delta sign or Empty delta sign.
• In superior sagittal sinus thrombosis
• Accumulation or pooling of blood
• Hemorrhagic infarct
• Triangle (delta) area shows filling defect

• MRI → No Flow Void

Arachnoiditis

• Empty thecal sac sign is seen.
• Normally, thecal sac has black nerve roots.

• Mnemonic:
• Empty thekkan → Aere (Arachnoid) theeykkum ini
• Empty delta sign → D for D → Dural venous sinus → sagittal sinus thrombosis

• In arachnoiditis, inflammation/fibrosis pulls nerve roots to periphery.
• No nerve roots visible in thecal sac.

ICT ↑↑

ICT ↑↑ in children

• Copper beaten / silver beaten appearance

ICT ↑↑ in adults

• Empty sella sign

• Herniation of subarachnoid space into sella
• → Clinoid process erosion / dorsum sella erosion

• Leads to flattened pituitary gland against floor of sella

Treatment:

• Thrombolytics (based on thrombosis length).

• Excision.

Otosclerosis

• Oto: Ear

• Sclerosis: Excessive bone deposition.

• Affects the stapes footplate.

 

Aetiology:

• Hereditary: Autosomal dominant with incomplete penetrance.

• Sex: F>M (but male predominant in India).

• Age of onset: 20-40 years.

• Hormonal: Increases in pregnancy and during menopause.

Syndrome Associated with Otosclerosis:

• Paracusis willisii:
• Patient hears better in a noisy environment.

• Vander Hoeve Syndrome:
• Osteogenesis Imperfecta.
• Blue sclera.
• Otosclerosis.
• Pregnant() female on shorts (Schwartz sign) vandering (Vander) in Car (Carharts), Oto (Otosclerosis) van Van (Vander)- para (Paracusis willisii)vach - bcz avalde bone(Excessive bone deposition) poyi

Signs:

• Tympanic membrane is normal (90%).

• Tympanic membrane is mobile.

• Schwartz Sign (10%):
• Active lesions have a flamingo-pink hue on the promontory.
• Can be seen through an intact tympanic membrane.

NOTE: Schwartz Surgery vs Schwartz Sign

Stapedial Otosclerosis: Tests:

• Gelle’s test → Negative

• Carhart's notch:
• A notch in the bone conduction curve at 2000 Hz.
• Specific to otosclerosis.

• Rinne: Negative.

• Weber: Lateralized to the abnormal ear.

• Absolute bone conduction: Normal.

High-Resolution CT in Otosclerosis

• Stapedial otosclerosis → CT role is limited
• Uses:
• Atypical presentations
• Cochlear otosclerosis
• → shows hypodense lesions in otic capsule
• Sensitive and specific for active otosclerosis

• Halo/Double ring sign
• Due to Labyrinthine fistula
• Erosion of bony labyrinth by d/s
• Usually involves lateral semicircular canal

• Findings:
• Active disease → hypodense lesions
• Inactive disease → not effective (due to dense otic capsule)

Treatment:

Medical:

• Hearing aid.

• Mild cases → Observation and monitor

• Sodium fluoride:
• Given only to arrest an active focus
• MOA:
• Inhibits osteoclastic resorption and osteoblastic deposition,
• preventing progression.
• Cannot reverse the disease.
• Contraindication:
• Pregnancy, lactation, renal disease, rheumatoid arthritis, skeletal fluorosis.

Surgery:

1. Stapedotomy + prosthesis (treatment of choice).



• A hole is made on the footplate.
• A piston is anchored from the incus to the hole.
• The stapes remains intact.
• Steps:
• Incision in external ear canal.
• Elevation of skin → expose stapes area.
• Dislocate incudostapedial joint.
• Cut stapedial tendon.
• Remove stapes superstructure (anterior + posterior crus).
• Leave behind incus + stapes footplate.
• Create a hole in stapes footplate.
• Insert piston prosthesis into the hole.

2. Stapedectomy + prosthesis.
• Entire stapes is removed and replaced by a piston.
• Piston is Teflon.
• Anchored between incus and oval window.

3. Stapes mobilization.

4. Lempert's fenestration operation.

Tympanic Membrane Retractions

• TM retractions
• Pars flaccida (PF): Tos classification
• Pars tensa (PT): Sade classification

Sade classification (Pars tensa)

• Mnemonic: Tension → Sad

• Stage 1
• Retracted TM
• Not touching incus

• Stage 2
• Touches incus
• Incudostapedial joint

• Stage 3
• Atelectasis
• Touches promontory

• Stage 4
• Adhesive otitis media
• Adherent to promontory mucosa

Note

• Stage 3 and 4
• can be differentiated by siegalisation/pneumatic otoscopy

Features

Tos classification (Pars flaccida)