NON-INFLAMMATORY DISEASES AND INJURIES OF THE EXTERNAL EAR

Description
Prominent Ears

Cerumen Impaction

aka Protruding Ear

Increased angle in protruding ear Normal: 2030
Normal congenital variant
No functional consequences
Cerumen:
Produced by ceruminous and sebaceous glands
in the skin of the ear canal
Forms a protective film
Protective function of cerumen:
Acts as a vehicle fir the removal of epithelial
debris and contaminants away from the
tympanic membrane
Provides lubrication and prevents dessication
of the epidermis with its associated fissuring
Fatty acids, lysozyme, and immunoglobulin
components are believed to be inhibitory or
bactericidal

Foreign Bodies in the Ear Canal

Etiology/Pathogenesis

Signs and Symptoms

Deep concha
Lack of development of the
antihelix

Excessive cerumen secretion

Disturbance of the normal selfcleansing mechanism
Cleaning using Q tips, aging,
decreases sebaceous secretion;
not advised
There is a general tendency for
cerumen to be drier in older
individuals because of physiologic
atrophy of apocrine glands with
subsequent lessening of the sweat
component of the cerumen

Treatment
Surgery: concha is reduced and antihelix is
constructed done usually at school age under
general anesthesia

Pressure sensation in the ear

Hearing loss
Vertigo
Tinnitus

Otoscopic findings:
Obstruction of the ear by a
yellowish-brown to black material

Removal with a small instrument (hook,

currette) or by aural irrigation using a blunt
cannula
Give cerumenolytic (wax softener) for 1 week
to soften cerumen prior to removal
IRRIGATION:
body temperature water is administered in a
postero-superior direction to allow the water to
pass between the cerumen mass and the
posterior wall of the canal. After
several irrigations the patient still complains of
blockage, suction is occasionally employed.
Do not hit the tympanic membrane to avoid
perforation

Self cleansing of the ear canal: epithelial

migration from the tympanic membrane
towards the external meatus

Avoid irrigation if a tympanic membrane

perforation may exist

The migration of the stratum corneum

contribute to the formation of the cerumen

Prophylaxis:
Avoid improper cleaning of the ear canal

The pH of the combined ingredients is around 6,

an additional factor that acts to prevent infection
Children: small play objects (beads, pellets,
erasers)

The most effective method to clean the ear canal

by the patient is not clean it

Adults: noise-reducing ear plugs, objects used for

manipulations in the ear canal like cotton, insect
Cockroach: most common foreign bodies in the
ear canal in adults

Complications:
Middle and inner ear damage
secondary to tympanic membrane
perforation
Secondary otitis externa

Removal of foreign body

1. Do not remove insect right away. Drown it first
with baby
oil and when it is paralyzed, remove it with
forceps.
2. Do not use forceps when removing round
objects because it will only make them slide
deeper. Irrigate instead using IV cannula
3. Contraindication for irrigation: tympanic

membrane perforation, temporal bone fracture,

ear surgery

Auricular Hematoma/ Auricular

Seroma

A collection of blood of serous fluid between the

perichondrium and auricular cartilage
This condition is most frequently seen in
wrestlers and boxers

Injuries to the External Auditory Canal

Usually there is history of trauma

Blunt trauma (e.g. from contact

sport)

Skin and attached perichondrium

separate from the auricular
cartilage

If injury remains close, hematoma

or seroma formation

Foreign bodies
Harmful manipulations

Signs and symptoms:

Pain
PE findings:
Swelling and fluctuation of the skin
over the lateral auricular cartilage
Complications:
Perichondritis secondary to
aspiration which can lead to
infection
Cauliflower ear
Sign and Symptoms:
Tender meatal skin
Bleeding from the ear canal

4. Button Battery do not use ear drops prior to

removal
because its electrical charges reacts with that of
the fluid,
causing severe alkali burn
Surgical Evacuation; aspiration / incision &
drainage of collected blood under sterile
conditions
Contoured dressing: cottonball impregnated
with oil so as not to have another
hematoma/seroma

Reapproximation of detached epithelium

Packing of the ear with Gelfoam if there is
bleeding

Otoscopic findings:
Epithelial injury
Bleeding Hemorrhagic bulla
Crusted blood

Traumatic Tympanic Membrane

Perforation

Probing of ear canal with a Q-tip

Forceful syringing of the ear for cerumen of
foreign
bodies
Forceful change of air pressure in the ear canal
(e.g. Blast injury, blow to the head)

Complications:
Secondary infection
Cyst formation or stenosis of ear
canal secondary to
scarring
Sudden pain
Bleeding
Tinnitus
Hearing loss

Cautery of edges with silver nitrate or

trichloroacetic acid
Paper patch to act as scaffold for healing
Myringoplasty: may be needed if there is poor
healing or for larger perforations
Optional: otic drops
Most linear tears heal spontaneously

DESCRIPTION
ECZEMA AND DERMATITIS OF THE AURICLE

INFLAMMATORY DISEASES OF THE EXTERNAL EAR

ETIOLOGY/PATHOGENESIS

An inflammatory condition of the

auricle confined to the
dermis
Differentiation between a primary
dermatosis and
infection may be difficult (for
example: seborrheic dermatitis vs.
Skin reaction to neomycin)

PERICHONDRITIS OF THE AURICLE

An acute inflammation of the skin and

perichondrium that also involves the
auricular cartilage

Jewelry items
Soaps and Cosmetics
Listening aids
Thermal injury

Staphylococcus
Pseudomonas

Severe pain of rapid onset

Feeling of tension
Effaced auricular contours, earlobe is spared
Swelling of the concha with marked tenderness
Painful and enlarged regional LNs
Fever

Complication:
Cartilage destruction with permanent auricular
deformity (cauliflower ear)

Changes are localized (do not spread

beyond auricular cartilage)

AURICULAR CELLULITIS

Itching
Burning with little pain
Skin is erythematous and may be dry and scaly
or moist and weeping
Contours of the auricle remain unchanged
Complications:
Pyoderma
Perichondritis
Cellulitis

Develops when trauma or

inflammation causes an
effusion of serum or pus between the
layer of the perichondrium and the
cartilage of the external ear

Caused by a bacterial infection

stemming from a small injury in the
conchal cavity or auricle
An acute streptococcal infection of the
subcutaneous tissue involving the
auricle and its surroundings

SIGNS AND SYMPTOMS

Streptococci gain access to the auricle

through small injuries in the concha
or external meatus

Redness, swelling and warmth of the auricle and

its surroundings
Earlobe and adjacent facial skin are involved
Malaise with fever and otalgia
DDx:
Dermatitis - no fever and systemic effects
Perichondritis - surrounding tissues and earlobe
are NOT involved
Zoster oticus - concomitant involvement of CN VII

TREATMENT
Eliminate the causes
Antibiotics if with bacterial
superinfection
When a considerable portion of
the auricle is involved and the
lesion seems to be spreading, wet
dressing using a solution such as
Burows may be advisable for 3448 hours, at which time
fluorinated steroid ointment and
solution are employed
Systemic antibiotics against Staph
and Pseudomonas
Incision and drainage of pus
Cleansing of the auricle and ear
canal
Application of antiseptic or
antibiotic-containing
ointment
NSAIDs

High-dose regimen of penicillin,

preferably by IV administration
NSAIDs
Cleansing the auricle and ear
canal

HERPES ZOSTER OTICUS

RAMSAY HUNT SYNDROME

The onset of facial paralysis, when
accompanied by otalgia and a
herpetic eruption involving portions
of the external ear is caused by a
viral infection involving the
geniculate ganglion

DIFFUSE OTITIS EXTERNA AND ECZEMA OF

THE EAR CANAL

An inflammatory condition of the

external auditory canal
involving the canal skin (eczema,
dermatitis due to mechanical injury,
toxicity, or allergy) acute bacterial
infection of the skin
Also known as swimmers ear
Occurs during hot, humid weather

Caused by reactivation of the

dormant varicella zoster
virus in ganglion cells
Involves CNs VII &/or VIII
(occasionally IX & X)
Vesicular skin involvement may be
limited to the specific area of the
external ear canal innervated by a
small sensory branch of the CN,
extend to the auricle or have faded
by the time the patient is seen

Gm (-) predominantly Pseudomonas

and less often Staphylococcus albus,
E. coli, and Enterobacter aerogenes
Anaerobes

Ear pain or burning on one side in the absence of

PE findings vesicles erupt hearing loss,
vestibular complaints, facial nerve palsy
Other combinations of symptoms may exist
owing to progressive involvement of vestibular
and acoustic fibers of the eighth cranial nerve

Systemic therapy with Acyclovir

Corticosteroids
Local Antiseptics on lesions
Treatment is mainly symptomatic

PE findings:
Herpetiform vesicles on the meatus and concha
and occasionally on the pinna
Lymphadenitis
Facial nerve palsy
Complications:
Secondary bacterial infection (Staphylococci or
pseudomonas
Zoster meningoencephalitis
Neuralgia
Itching
Pain (severe)
Crusting
Purulent discharge
Conductive hearing loss
Presence of tender regional adenopathy
Tragal tenderness

Meticulous, repeated cleansing

and drying of the ear canal

Antiseptic, antibiotic drops

Due to the degree of the canal

wall edema, a wick may be required
to bring medication into contact
with most of the canal.

The stroma overlying the bone of the inner third of

the canalvis very thin, allowing minimal room for
swelling. Thus, the subjective discomfort the patient
experiences is often out of proportion to the extent
of the disease visualized
Absence of acute infection:
o Dry, cracked and scaly canal skin
o Thickened skin with sites of desquamation

Presence of acute infection:

o Diffuse swelling of the canal skin with discharge
or crusting

Only severe cases should systemic

drugs be considered

CIRCUMSCRIBED OTITIS EXTERNA

Confined to the fibrocartilaginous

portion of the external auditory
meatus (furuncle)
Circumscribed lesion caused by an
acute bacterial infection of the
cartilaginous portion of the ear canal

NECROTIZING OTITIS EXTERNA

OTOMYCOSIS

Malignant otitis externa

Exclusively in older patients with DM
Common in warm climates
A severe infection involving the
temporal bone and soft
tissue of the ear
Patients with otitis externa (OE) for
more than 2 weeks
should be evaluated for NOE

Common in tropical countries

Due to cleaning ear with
contaminated implements
Common DM and
immunocompromised patients
May occur in conditions when the
normal flora is affected, such
overuse of certain topical antibiotics
particularly with steroid combination

Pathogenesis:
Local mechanical trauma and
contamination of the ear canal

Obstruction of the hair follicles or

glandular ducts

Staphylococcal infection of the

pilosebaceous units (usually
aureus or albus)

Simple OE

Infection with Pseudomoas

aeruginosa

Ulceration and osteitis on the floor of

the ear canal

Spread to the middle ear, skull base,

retromandibular fossa
and parotid compartment

Aspergillus (niger and flavus)

Candida albicans
Pityrosporum

Very painful, tender swelling

Mild hearing loss secondary to swelling
Otorrhea
Afebrile

PE findings:
Tragal tenderness
Pronounced swelling of the ear canal with debris
In severe cases, surrounding cellulitis may extend
beyond this area
Eventually, abscess formation occurs and a
point may form, at which time drainage can be
establishes by needle
Insiduous, persistent OE that does not heal
Moderate pain which may become severe
Fetid aural discharge

Treatment depends on the

furuncle size and surrounding
reaction
Meticulous cleaning of the ear
canal
Antibiotic and steroid-containing
drops
NSAIDs
Systemic antibiotics
Heat

Local debridement and cleaning

of the ear canal
High doses of antibiotic effective
against P. aeruginosa x 6 weeks
(systemic antibiotics is the 1st line
of therapy; patient is usually
admitted)
Close monitoring and control of
DM

Severe itching
(with manipulation, can lead to trauma and
eventually secondary bacterial infection)
Ear fullness

Surgical resection of the affected

bone in unresponsive
cases
Thorough cleaning and drying the
ear canal
Local antimycotics
Systemic antimycotic therapy in
immunocompromised
patients

Keloids

Very common benign tumor

Massive overgrowth of reparative (scar) tissue
Rare complications of earring use
Occur more commonly in African-American
Treatment:
Surgical excision followed by repeated steroid injections
Appraise patient that keloid may grow back

TUMORS OF EXTERNAL EAR

Basal Cell Carcinoma

Squamous Cell Carcinoma

A common skin CA
Caused by chronic exposure to sunlight

Usually occurs in older men on the posterior or

superior portion of the pinna

Treatment:
Complete excision with histologic control of margins (of about 1 cm)
Primary goal: remove the tumor
Secondary goal: reconstruction

Treatment:
Complete excision with histologic control of
margins, may require auricular resection
Primary goal: remove the tumor
Secondary goal: reconstruction