L R: E C D: Iteratur Eading AR Anal Isease

LITERATUR READING :
EAR CANAL DISEASE
Supervisor :
Dr. Shinta Fitri Boesoirie., dr., M. Kes., Sp.THT-KL(K)
Presentan :
dr. Tita Puspitasari
Dept of Otorhinolaryngology – HNS

Hasan Sadikin General Hospital
Bandung
2017
ANATOMY AND PHYSIOLOGY
 The EAC is derived from the first ectodermal branchial

groove between the mandibular (I) and hyoid (II) arches.
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 The process of canalization is complete by about week
12 of gestation.
 The outer 40% of the canal in its anterior and inferior
aspect is cartilaginous contains a thin layer of
subcutaneous tissue between the skin and cartilage.
 The inner 60% is osseous, is formed primarily by the
tympanic ring, and contains very scant soft tissue
between the skin, periosteum, and bone.
Linstrom J. Christophere, Lucente E. Frank. Disease ofExternal Ear. Bailey BJ & Johnson JT. Head and Neck Surgery-
Otolaryngoloy. Philadelphia: Lippincot Williams and Wilkins; 2014 : 2333-2357
OTITIS EXTERNA
 Otitis extema is a spectrum of infection of the EAC
 Classification : Acute, subacute, or chronic.
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 Acute otitis extema (AOE)/swimmer's ear : bacterial
infection of the canal caused by a break in the normal
skin, cerumen protective barrier in the milieu of elevated
humidity and temperature.
 In patients in whom the disease does not resolve after
treatment → a subacute/chronic → eczema, ranging
from mild drying and scaling of the canal skin to
complete obliteration by chronically infected
hypertrophic skin.
ETIOLOGY
 The usual pathogens responsible for AOE are
Pseudomonas aeruginosa, Proteus mirabilis,
staphylococci, streptococci, and various gram-negative
bacilli.
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THE CLINICAL COURSE
 preinflammatory; acute inflammatory, which can be
mild, moderate, or severe; and chronic inflammatory.
DIFFERENSIAL DIAGNOSIS
 Necrotizing EO, bullous EO, granular EO,
perichondritis, chondritis, relapsing polychondritis,
furunculosis, and carbunculosis, as well as many
dermatoses, such as psoriasis and seborrheic dermatitis.
ACUTE MILD DIFFUS EO
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MODERATELY SEVERE DIFUSE EXTERNAL
OTITIS
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The EAC Is more edematous than in the acute stage, approaching
obliteration of the lumen, with a more profuse exudate.
MEDICAL TREATMENT
 The four fundamental principles in the treatment of EO
cleaning, judicious use of appropriate antibiotics,
treatment of associated inflammation and pain, and
recommendations.
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SURGICAL MANAGEMENT HYPERTROPHIC
CHRONIC EO
 When such local measures are insufficient to eradicate
infection and reestablish the lumen of the canal.
 A generous amount of conchal cartilage is removed to effect a
wide meatoplasty.
 The bony canal is enlarged with a drill.
 The canal is resurfaced with a split-thickness skin graft that is

temporarily held in place with stents or packing.
EMERGENCIES EO
 Unresolving pain, despite local care, Cranial neuropathy
with external otitis, Consider necrotizing external otitis
DIAGNOSIS NECROTlZING EXTERNAL OTITIS
 History : Persistent otalgia, Persistent purulent otorrhea,
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granulations, DM, advanced age, immunocompromised
 Physical examination : Granulations,Purulent discharge,
cranial neuropathy, cranial nerve VII
 Culture : Pseudomonas sp, Pseudomonas aeruginosa.
SKULL BASE OSTEOMYELITIS (SBO)

 Meltzer and Kellemen : a case of progressive
Pseudomonas osteomyelitis of the temporal bone and
skull base.
FURUNCULOSIS AND CARBUNCULOSIS
 Gram-positive infections, usually staphylococcal, of the
hair follicles.
 Small well-cirrumscribed pustule → a furuncle or merge
→ a carbuncle.
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 Junction of the concha and canal skin.
 Treatment : any accumulated infectious material must be

removed.
 Topical and oral antibiotics.
 Relieve obstruction of the canal, incision drainage under

local anesthesia.
INFECTIOUS ECZEMATOID DERMATITIS
 Drainage of contaminated or purulent material from

the middle ear into the floor of the external ear and
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adjacent infra-auricular skin →
infection/autosensitization phenomenon → crusted
plaques.
 Treatment : control of the underlying middle ear
infection.
 Supportive treatment : Removal of acumulated
debris, antibiotic cream or ointment.
OTOMYCOSIS
 Otomycosis is a fungal infection of the skin of the
external canal.
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 All fungi have three basic growth requirements:
moisture. warmth, and darlmess.
 Pruritus, white, black, or dotted gray membrane.
 Treatment : Cleaning under a microscope, Clotrimazole

cream.
 In refractory cases, gentian violet or metacresyl acetate
(Cresylate) is used topically
HERPES ZOSTER AND HERPES SIMPLEX
 Herpes zoster and herpes simplex are viruses that affect the
EAC.
 The patient initially experiences a period of burning, pain,. or
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localized headache, and vesicles usually appear within several
days.
 When vesicles coalesce and rupture. crusts are formed.
 Herpes zoster tends : unilaterally in a dermatomic, paresis or
paralysis (herpes zoster oticus or Ramsay Hunt syndrome).
 Treatment : topical application of a drying agent, such as
hydrogen peroxide for crusts, Bacitracin ointment, surgical
decompression of the facial nerve.
 Acyclovir, famciclovir, and valacyclovir : ameliorate herpetic
infections, especially herpes zoster oticus.
 Famcyclovir may reduce the duration of post herpetic
neuralgia.
RAMSAY HUNT SYNDROME
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DERMATOSES
 Allergic and irritant contact dermatoses may mimic diffuse external
otitis.
 Contact with any type of agent that can produce a cutaneous
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response.
 Irritants may be absolute, so noxious that a reaction occurs in
everyone exposed (e. g., strong adds or alkalis), or
 Relative, noxious to susceptible individuals, usually after repeated
exposures (e.g., various soaps, the plastic mold of a hearing aid).
 Allergic contact dermatitis : delayed hypersensitivity from
substances such as poison ivy, nickel compounds (earrings), and
rubber compounds (headphones). The
 Erythema, weeping, and vesiculation, itching.
 Treatment : removal of the causative agent and the use of topical
steroids and astringents, antibiotics are indicated for the treatment of
infection.
 Systemic steroids : severe cases.
THERMAL INJURY
 Thermal, ultracooling due to frostbite → first degree leading to

erythema, second degree (blistering), and third degree (full
thickness).
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 Suspect that the extent of the injury extends greater than that
apparent on inspection. This is especially true in electrical injuries.
 Cooling a thermal bum quickly with cold/ iced compresses
 Frostbite is rewarmed more slowly with warming compresses.
 Broad-spectrum antibiotic coverage against expected organisms
such as Pseudomonas sp.
 1% silver sulfadiazine creams.
 Surgical debridement should be delayed until the wound declares
itself and a line of demarcation between healthy and dead tissue
becomes apparent.
FRACTURES OF EAC
 The anatomic boundaries of the EAC make it susceptible to injuries
of the temporomandibular joint (e.g., a blow to the jaw) and of
fractures to the temporal bone, most commonly longitudinal
fractures.
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 Deformity of the canal, a flail piece of bone with or without an
accompanying laceration.
 Treatment is of the underlying cause: mandible has been fractured,
→ (IMF)
 Temporal bone fractures, even with CSF otorrhea, are ordinarily
observed with the patient placed in bed at about 45 degrees, the ear
should not be manipulated.
 Progressive facial nerve dysfunction : of injury is at the geniculate
ganglion, the
 nerve is followed clinically and electrically with serial ENOG and/or
needle EMG studies and may need to be decompressed.
CONCLUSION
 EAC : The outer 40% anterior and inferior aspect is

cartilaginous contains a thin layer of subcutaneous tissue
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between the skin and cartilage, the inner is osseous, is
formed primarily by the tympanic ring, and contains very
scant soft tissue between the skin, periosteum, and bone.
 Otitis externa presents as a spectrum of disease and may
be classified into preinflammatory, acute inflammatory,
and chronic inflammatory stages.
 Four principles form the basis of treatment for all stages
of infection of the external ear: cleaning, antibiotic
therapy, control of inflammation and pain, and
recommendations to prevent infection.
CONCLUSION
 Surgery is rarely indicated for infections of the external

canal but may be required to reverse the natural course of
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chronic disease.
 NEO must be treated aggressively with proper
radiographic imaging to map the extent of disease,
meticulous local care control of diabetes or
immunodeficiency (when possible), and antibiotics.
 Surgery is rarely required. Mortality remains significant
with cranial nerve involvement.
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THANK YOU

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LITERATUR READING :

EAR CANAL DISEASE

Dept of Otorhinolaryngology – HNS

 The EAC is derived from the first ectodermal branchial

 The canal is resurfaced with a split-thickness skin graft that is

SKULL BASE OSTEOMYELITIS (SBO)

 Treatment : any accumulated infectious material must be

 Relieve obstruction of the canal, incision drainage under

 Drainage of contaminated or purulent material from

 Treatment : Cleaning under a microscope, Clotrimazole

 Thermal, ultracooling due to frostbite → first degree leading to

 EAC : The outer 40% anterior and inferior aspect is

 Surgery is rarely indicated for infections of the external

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