‫ا د مسعد السيسي‬

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 : postpone after puberty

• Bilateral : HA fitting at 1 year
• operation at one side (at 2-5 years) , the other
after puberty
 Traumatic: Laceration

Self inflicted : by ear bud hair grip

Iatrogenic: ear wash or
instrumentation
Clinically:
Earache, mild bloody otorrhea
Treatment:
Antibiotics
Avoid entry of water in the ear
canal
 Traumatic: FB‫جسم غريبف يا الذن‬

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  remove by ear wash or
instruments
Inanimate FB:
- Non vegetable: remove by ear wash or So donn’t wash if:
instruments BUT PLEASE DO NOT WASH
IF THE FB IS DISC BATTERY -The FB is vegetable
-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
 Inflammatory conditions of
the external auditory canal
• Bacterial:
1- Diffuse OE
2- Localised OE: frunculosis‫دمل‬
3- Malignant OE ( Necrotizing OE)
• Viral ( bullous- Herpes)
• Fungal: (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: Because the skin is tightly
- Severe Why? adherent to the underlying
- Increase on moving the jaw Why? perichondrium & periostium
Deafness when edema is severe  Because the external canal
obstruct the canal Lies immediately behind
Signs Temporomandibular joint
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

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:
Necrotizing external otitis should be
invasive potentially fatal of the external canal which
extends to the base of the skull suspected when patients with
Incidence: elderly uncontrolled diabetic patient diabetes mellitus (or another
Organism: pseudomonas aeuruginosa
condition that compromises the
Symptoms:
Ear discharge and severe earache which does not respondimmune system) complain of
to analgesics persistent external otitis that causes
Signs
External examination:
severe pain, especially at night
Tenderness on pulling the URICLE OR PRESSURE
ON THE TRAGUS
TENDER PRE AND PSTAURICULAR ln

Otoscopic examination:
Granulations at the floor of the external canal at the
attachment of bony and cartilagenous part
‫وهذه عالمة هامة جدا لهذا المرض‬
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
• Axial computed tomographic (CT) scan in a 65-year-old
. male patient
Gallium citratewith
Ga diabetes mellitus
67 scintigraphy in who had severe
a 74-year-old
nocturnal otalgia for two months. This patient was
male patient with diabetes mellitus and left-sided
referred because of facial nerve paralysis that developed
temporal
despite bone osteitis. This
oral treatment withpatient was referred
ofloxacin (Floxin).because
The CT
ofscan
persistent otalgia and otorrhea after a prolonged
shows bony destruction of the right temporal bone.
course
Note thesystemic
of missingoral antibiotics.
posterior wall As a result
of the of auditory
external
ongoing infection,
canal (short the left
arrow). temporal
Mastoid bone are
air cells shows
secondarily
involveduptake
enhanced and are opacified
of 67Ga (long arrow) compared with
(arrow).
the well-aerated left side.
• Complications:
• Osteomyelitis of the temporal bone
&skull base
- Facial nerve paralysis at the
stylomastoid foramen
- Last 4 cranial nerves paralysis at
the jagular foramen

- Treatment:
- Medical:
- Control of diabetes
- Antibiotics;
- Gentamycin (be aware of possibility
of ototoxicity)
- Quinolones
- 3rd 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 ‫ئد‬N‫را‬N‫غيرة مبللة منورقج‬NN‫ة ص‬N‫طع‬NN‫مثل ق‬

TTT:
- Aural toilet: removal of the fungal mass
by suction or ear wash
- Antifungal: nystatin, or or salicylic acid
(2%) as a keratolytic in alcohol as
fungicidal
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
Incidence
-- Rare
Rare
-- More
Morecommon
commonininelderly
elderlymales
males
•• CP:
CP:
Otological:
Otological:
-- Deep
Deepseated
seatedearache
earache
-- Bloody
Bloodystained
stainedotorrhea
otorrhea
-- Fleshy
Fleshyfriable
friablemass
massininthe
theexternal
externalcanal
canal
-- Progressive
Progressivehearing
hearingloss,
loss,initially
initiallyCD
CDthen
then
SNHL
SNHL
Neurological:
Neurological:
paralysisof
paralysis ofVII&
VII&last
last44cranial
cranialnerves
nerves
Cervical:
Cervical:
--Enlarged
Enlargedpreauricular,
preauricular,postauricular
postauricularand
and
upperdeep
upper deepcervical
cervicalLN
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
prosthesis‫تري‬NN‫لقادمة ل‬NN‫لشريحة ا‬NN‫نظر ا‬N‫ا‬
N‫ه‬N‫حة ل‬N‫لجرا‬NN‫ ا‬N‫جراء هذه‬N‫ ا‬N‫م‬NN‫مريضت‬NN‫موذج ل‬NN‫ن‬

Chest X ray Abdominal Bone scan CT scan

ultrasound Of brain
• From;
http://www.caritas.ab.ca/ther_new/respcare/hbo/case
5.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
What is WAX?
WAX?
‫ماهو اا للصمالخ؟‬
‫صمالخ؟‬ ‫ماهو‬
• Wax is a mixture of secretions of ceruminous and
sebaceous glands with desquamated 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
‫تحدث كثيرا بعد االستحمام أو نزول البحر حيث ينتفخ‬
‫الصمالخ بالماء‬

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
‫ب وضع ق طع ة ش اشعليها ف ازلين‬
‫ف يا ألذنعند غسلا لرأسأو ا الستحمام‬
- Ear drops
Surgical:
- Myringoplasty ‫ل و ل م ي حدث‬
‫ا لتئام ب ع د ث الثة اشهر‬
- 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