UNIT: ENT NOTES.

prepared by :Weldon Korir.

Anatomy and physiology of the ear

The ear consists of three parts: - the External ear, middle ear and inner ear
Anatomy of the External Ear
The external (outer) ear help to collect and introduce sound waves from the environment to the
tympanic membrane
The Auricle (Pinna):
• Comma-shaped structure attached to the head by ligaments and muscles.
• Composed of fibro-elastic cartilage.
• Skin closely attached to the perichondrium.
Function:
• Collect sound waves from the environment and direct them to the ear drum through the
external ear meatus canal (EAM).
Blood Supply:
External carotid, temporal and auricular arteries
• Venous drainage: external jugular veins.
 Nerve Supply:
• Motor: Facial nerve.
• Sensory: Auricular-temporal nerve.
• Facial nerve supplies the concha.
The External Auditory Canal (External Auditory Meatus (EAM)):
• Extends from the base of the concha to the tympanic membrane.
• The EAM length is 24mm in adults.
 Outer two thirds is cartilaginous, with skin containing hair, sebaceous and ceruminous
glands.
Medial part is bony and continuous with the walls of the middle ear.

Shape: The EAM is Lazy S shape.

•Nerve supply to EAM

•By the auriculotemporal nerve and the vagus nerve.
 NOTE:
• EAM skin grows like fingernails, self-cleansing. Discourage inserting
cotton buds to clean or remove wax, disrupting the physiological
process
Middle ear:
Function to transmit sounds energy from the EAC to the cochlea. The
middle ear cleft consists from the following structures:
• Tympanic membrane
• Middle ear cavity
• Eustachian tube
• Mastoid air cells
Tympanic membrane:
Consist from three layers:
Outer: squamous epithelium (skin) without hairs or glands
Middle: fibrous layer
Inner: mucosal layer
Color: pearly grey
Shape: slightly oval divided into 4 quadrants:
 Light reflex: located in the antroinferior quadrant.
Middle ear cavity:
Biconcave box like space contain the following structures:
Ossicles: malleus, incus, stapes.
Nerves: facial nerve and chorda tympani.
Muscles: stapidus and tensor tympani.
Blood supply: branches from both external and internal carotid
arteries
Venous drainage: to pterygoid plexuses
Lymphatic drainage: to retropharyngeal and upper deep cervical
lymph nodes
Sensory innervation: branches from cranial nerves: V, IX, X
It has six walls:
Lateral: made by tympanic membrane
Medial: promontory of the cochlea with 2 opening: oval and round
windows
Anterior: contain Eustachian tube orifice allow air to pass freely
between the nasopharynx and middle-ear cavities
Posterior: contain antrum to mastoid air cells
Superior: bonny roof separates middle ear cavity from the meninges
and brain
Inferior: bonny plate cover the jugular vein bulb
Eustachian Tube: Anatomy and Functions
• Anatomy:
• Length: 3.6 cm tube connecting middle ear cavity to nasopharynx.
• Lining: Stratified squamous epithelium (respiratory epithelium).
• Structure:
• Lateral 1/3: Bony.
• Medial 2/3: Cartilaginous.
• Function:
• Aeration of the middle ear.
• Vascular Supply:
• Blood Supply: Ascending pharyngeal and middle meningeal arteries.
• Drainage:
• Venous Drainage: To pharyngeal plexuses.
• Lymphatic Drainage: To retropharyngeal lymph node.
Mastoid Air Cells: Anatomy and Boundaries
• Anatomy:
• Description: Air-filled, honeycomb-like space within the petrous part of the
temporal bone.
• Boundaries:
• Roof: Middle cranial fossa.
• Medially: Posterior semicircular canal of the inner ear and posterior cranial
fossa.
• Laterally: Skin behind auricle.
• Floor: Jugular bulb, digastric muscle, sternocleidomastoid muscle.
• Anteriorly: Middle ear cavity, external auditory canal, and facial nerve.
• Posteriorly: Sigmoid sinus
Inner Ear: Anatomy and Functions
• Anatomy:
• Description: Inner ear responsible for hearing and balance functions.
• Composition: Membranous labyrinth surrounded by bony labyrinth (maze-like tunnels).
• Labyrinth Fluids:
• Endolymph: Intracellular fluid within membranous labyrinth, similar in structure to
blood ultra-filtrate.
• Perilymph: Extracellular fluid surrounding the membranous labyrinth, similar in
structure to cerebrospinal fluid (CSF).
• Blood Supply:
• Blood Supply: Labyrinthine artery, a branch from the anterior inferior cerebellar artery.
• Components of Membranous Labyrinth:
• Cochlea: Responsible for hearing.
• Sacule: Involved in balance.
• Utricle: Involved in balance.
• 3 Semicircular Canals: Also involved in balance.
Vestibulocochlear Nerve: Functions and Importance
• Overview:
• Vestibulocochlear Nerve: Eighth cranial nerve.
• Function: Transmits sound and balance information from the inner ear to the
brain.
 Examination of the Ear (Pinna, Auricle, external ear)
1. Pull adult pinna upwards and backwards and use Bull’s eye lamb to examine the external
auditory canal and view tympanic membrane. However, for children pull pinna downwards
and backwards
2. The pinna is examined for congenital anomalies, position, size, shape, color, consistency
and tenderness.
3. The mastoid process is examined for signs of inflammation (behind the ear)
4.The External auditory canal (EAM): for discharge, pain sensation on chewing and whether
pressing on the tragus results to discomfort or tenderness

Note: Use of Autoscope is discouraged due to cross infection of diseases from one patient to
the other
• Assignment
1.Describe physiology of hearing?[ 10mks]
2. Describe the mechanism of hearing?[10mks]
NB; To be collected strictly after 2weeks.
 Diseases of the External Ear/Pinna/Auricle
Congenital anomalies:
· Anotia: Absent auricle
· Microtia: Small deformed auricle.
· Macrotia: Abnormally enlarged auricle.
· Accessory auricle: Small-elevation formed of skin and cartilage in
front of the auricle.
•Treatment: Surgical excision.
Protruding (Bat) ears:
 The commonest anomaly
Cause: Antihelix was under-developed.
Treatment: Otoplasty at the age of 5 years before school admission
Pre-auricular sinus:
A pin point depression in the skin just in front of the auricle.
Presents with a chronic painless discharge and not responding to treatment.
Treatment: Excision if recurrent infections occur.
 Hematoma of the auricle
 This is an accumulation of blood between the auricular cartilage and
the perichondrium
Causes:
Blunt trauma, commonly in boxers (boxer's ear).
May occur spontaneous in elderly and secondary to hemorrhagic
blood diseases.
Clinical picture:
 The auricle is painful, swollen, bluish and cystic.
Perichondritis
This is inflammation of the auricular perichondrium.
Causes:
Pyogenic bacteria, infected hematoma, trauma, furunculosis of the external
auditory canal, post- operative infection, or animal bite, post-irradiation.
Clinical picture:
• Cartilage necrosis leads to fibrosis and auricular deformity called
"cauliflower ear".
• Treatment: Intravenous antibiotics, incision and drainage with removal of
necrosed cartilage
FOREIN BODY (F.B.) LODGED IN EAM
•Incidence; Most commonly in children and mentally retarded persons.
TYPES OF F.B[LODGED IN EAM]
1. Inanimate foreign bodies:
 Non-vegetable foreign body as pieces of papers, beads or buttons.
 Vegetable foreign body as beans and peas, they swell with water.
2. Animate foreign bodies as flies, mosquitoes, myasis (larvae) or fleas
Clinical picture:
May be asymptomatic if small F.B..
Hearing loss, if the foreign body occludes the external ear meatus
Animate foreign body causes severe irritation, and noise in the ear e.g
Insects such as cockroaches
Child crying a lot hiding or holding specific ear
F.B .Complications:
•Produced by the foreign body or during unskilled attempts on its
removal:
•1. Injury of the external canal, tympanic membrane or ossicles.
•2. Otitis externa or otitis media.
Treatment:
Take note that the ear is very sensitive and therefore requires skill to extract
the foreign bodies.
1. Blunt Hooks can remove most foreign bodies and should be used to remove
impacted or large vegetable foreign body.
2. Ear Syringing: Most recommend as first choice in most foreign bodies
removal .If impacted refer to the specialist E.N.T expert to remove.
3. Insects should be killed by alcohol or oil before syringing
4. It is necessary in cases of impacted foreign body and un-cooperative patients
as children to remove under anesthesia
Otitis Externa: (situated at EAM region)
This is inflammation of external auditory canal.
Types
1- Diffuse Otitis Externa:
The whole skin of the external auditory canal is inflamed
Causes:-
Streptococci, Staphylococci, Pseudomonas aeruginosa, proteus.
Predisposing factors:-
1. Skin laceration:
2. Excessive sweating, and frequent bathing with water entry, or chronic
suppurative otitis media.
3. Diabetic patients.

Clinical picture:
Pain in the ear which worsens on the jaw movement while chewing.
A patient complains of hearing loss if edema has occluded the external
ear canal
Autoscopy : Reveals:
1.Scanty purulent ear discharge.
2.Skin of the external ear meatus (EAM) is red, oozing, tender, and
swollen with narrow a lumen.
3.Evidence of tenderness on tragus and auricle on pressure application
4.There is history of lymphadenitis.
5.The tympanic membrane is not affected if it can be seen.
Treatment:
1 Prevention of the predisposing factors.
2. I.V antibiotics and analgesics.
3. Suction or dry mopping.
4. Packing the canal with a gauze strip soaked with antibiotic, and
corticosteroids.
 Furunclosis
The condition presents as a localized infection of a hair follicle or glands
of the outer external auditory meatus.
Causative
 Staphylococcus aureus.
• Predisposing Factors:
1. Trauma such as scratching the canal
2. Diabetes mellitus leads to recurrent attacks.
Clinical picture:
Pain on chewing, on touching or moving the auricle.
Deafness only if the furuncle has occluded the EAM
Tenderness on moving the auricle or pressing the tragus
Otoscope reveals:
Purulent & scanty discharge in EAM
Tympanic membrane: Is intact if visible.

Investigations:
 Blood sugar: especially in bilateral and recurrent attacks.
Treatment:
 I.V antibiotics (anti-staphylococcal) and analgesics.
 Aural toilet i.e. repeated removal of the ear discharge by suction or
dry mopping.
 Pack canal with a gauze strip soaked with glycerin ichthyol 10% to
decrease edema) or antibiotic drops.
 Surgical incision: only when pointing occurs (very rare).
Necrotizing Otitis Externa (Malignant Otitis External)
Overview:
Potentially fatal disease due to destruction of the External Auditory Meatus
(EAM), including the skull.
• Incidence:
Rare occurrence, typically observed in the elderly with uncontrolled diabetes.
• Causative Agent:
Pseudomonas aeruginosa.
• Pathogenesis:
Production of enzymes by Pseudomonas aeruginosa.
• Enzymes cause necrotizing vasculitis, leading to tissue necrosis.
Diabetic micro-angiopathy of blood vessels.
• Contributes to tissue necrosis.
Clinical Picture:
• Patient complaints:
• Severe stabbing ear pain.
• Otoscope examination reveals:
Scanty purulent ear discharge.
Granulation tissue in the floor of the external canal.
• Investigations:
Culture and Sensitivity Tests:
• Conducted on the ear discharge.
CT Scans:
• Specifically of the temporal bone.
• Highlights skull base destruction.
Biopsy:
• Purpose: To exclude malignancy.
Complications and Treatment
Complications:
Osteomyelitis:
• Involvement of temporal bone and skull base.
Nerve Involvement:
• Facial nerve
• Glossopharyngeal nerve
• Vagus nerve
• Accessory nerve
Treatment:
Diabetes Management:
• Emphasize control of diabetes.
Antibiotic Therapy:
• Massive and combined I.V antibiotic therapy for 6 weeks.
• Antibiotics: e.g., quinolones and aminoglycosides (anti-
pseudomonas).
Aural Toilet:
• Repeated removal of ear discharge by suction.
Antibiotic Ear Drops:
• Utilize prescribed antibiotic ear drops.
Surgical Treatment:
• Removal of granulations and debridement of necrotic tissues.
 Otomycosis[fungal otitis externa]
Introduction
Otomycosis: Fungal infection of the outer ear.
Incidence not precisely known, more common in hot climates and
aquatic sports enthusiasts.
Approximately 1 in 8 otitis externa cases are fungal in origin.
Causative agent;
90% of fungal infections involve Aspergillus spp[blacks]., rest are
Candida spp[white].
Prevalence and Factors
Prevalence: About 10% of patients with otitis externa symptoms.
Higher occurrence in hot climates, especially tropical and subtropical
regions.
Incidence peaks during summer months (American study).
Predisposing Factors
Absence of cerumen in the ear.
High humidity and increased temperature.
Local trauma from cotton swabs or hearing aid usage.
Cerumen (pH 4-5) suppresses bacterial and fungal growth.
Aquatic sports like swimming and surfing increase risk.
Repeated water exposure removes cerumen and dries the auditory
canal.
History of invasive ear procedures.
Eczema as a predisposing factor.
pathophysiology of otomycosis.
• Fungal Invasion
Entry: Fungal spores enter the external auditory canal, often due to a breach in the
skin or mucous membrane.
Factors aiding invasion: Increased humidity, warm temperatures, trauma, or
absence of cerumen.
• Fungal Growth and Colonization
Adherence and growth: Fungal spores adhere to the ear canal's epithelial lining
and start to grow, forming colonies.
Hyphal growth: Fungal hyphae penetrate the epithelial tissue, causing tissue
damage and inflammation.
• Inflammatory Response
Host reaction: The body responds to fungal invasion with an inflammatory
response.
Symptoms: Itching, redness, swelling, pain, and discharge are typical
inflammatory symptoms.
pathophysiology of otomycosis cont’
• Immune System Involvement
Immune response: The immune system attempts to combat the fungal
infection by mobilizing immune cells, including neutrophils and
lymphocytes.
Immune regulation: Fungal antigens trigger immune responses that
can either aid in fungal clearance or contribute to prolonged
inflammation.
NB:
 Recap of key points regarding the pathophysiology of otomycosis.
Emphasis on the fungal invasion, inflammatory response, tissue
damage, immune involvement, and potential complications.
Clinical picture:
Patient complains of itching ear with greyish white discharge.
Ear pain due to secondary infection.
Hearing loss, if the fungal mass has occluded the external auditory
canal
Complications
Spread of infection: In severe cases, otomycosis can spread to
surrounding structures, leading to secondary complications like
tympanic membrane perforation or mastoiditis.
Chronic cases: Chronic otomycosis may result in persistent
inflammation, scarring, and hearing impairment.

Otoscopy
•Reveals:
A whitish mass with black spots appearing like a wet newspaper in the
external ear canal
Treatment:
Ear syringing
Anti-fungal ear drops and creams e.g. clotrimazole, nystatin or 2%
salicylic acid in alcohol or Rocacorten with vioform ear drops for 3
weeks.
Patient Education
• Hygiene and Prevention:
Emphasize proper ear hygiene, avoidance of trauma, and keeping ears dry,
especially for those participating in aquatic activities.
• Avoid Cotton Swabs:
Discourage the use of cotton swabs to prevent trauma to the ear canal.
Herpes Oster Oticus (Ramsey Hunt syndrome):
Definition: A viral infection affecting the facial nerve and inner ear
caused by the reactivation of the varicella-zoster virus (VZV).
Importance: Rare but significant neurological disorder with specific
clinical manifestations.
• Etiology and Pathogenesis
Varicella-zoster virus (VZV): A member of the herpesvirus family,
causing chickenpox during primary infection.
Reactivation: The virus reactivates from the dorsal root ganglia,
spreads along the sensory nerves, and affects the facial and
vestibulocochlear nerves.
Clinical Features
Vesicular rash: Typically involves the ear, external auditory canal, and
occasionally the oropharynx.
Otalgia (ear pain): Often precedes the rash and is a prominent early
symptom.
Facial weakness or paralysis: Due to facial nerve involvement.
Hearing loss, tinnitus, vertigo, and vestibular dysfunction: Arising
from inner ear involvement.
Diagnosis
Clinical evaluation: Detailed medical history and physical
examination, with emphasis on ear and facial examination.
Polymerase chain reaction (PCR): Testing for VZV DNA in vesicle
fluid, blood, or cerebrospinal fluid (CSF).
Imaging: Magnetic resonance imaging (MRI) to assess the extent of
nerve involvement.

Differential Diagnosis
Differentiating from Bell's palsy and other facial nerve disorders is essential
for accurate diagnosis and appropriate treatment.
• Treatment
Antiviral medication: Early initiation of antiviral drugs (e.g.,
acyclovir, valacyclovir) to reduce viral replication and severity of
symptoms.
Pain management: Analgesics to alleviate pain, often severe in
Ramsey Hunt syndrome.
Corticosteroids: Used to reduce inflammation and potentially prevent
complications.
• Prognosis
Prognosis varies: Recovery may be complete, but residual facial
weakness or hearing loss can persist.
Prompt treatment: Early diagnosis and initiation of treatment improve
outcomes.
• Complications
Secondary bacterial infections from skin lesions.
Persistent facial weakness.
Postherpetic neuralgia: Persistent pain in the affected area after the
rash resolves.

• Prevention and Vaccination

Varicella-zoster vaccine: Recommended for older adults to prevent
shingles and associated complications.
Importance of timely vaccination and its role in reducing the risk of
Ramsey Hunt syndrome.
•Tumours of the External auditory canal
Introduction to Tumors of the External Auditory Canal
Definition: Abnormal growth of cells or masses in the external auditory
canal, which connects the outer ear to the middle ear.
Importance: Rare but significant, potentially affecting hearing and
overall ear health.
• Classification of Tumors
1.Benign Tumors:
Exostoses, osteomas, papillomas, hemangiomas, and lipomas.
2.Malignant Tumors:
Squamous cell carcinoma, basal cell carcinoma, adenoid cystic carcinoma,
melanoma, and sarcomas.
• Common Benign Tumors
Exostoses and Osteomas:
Bony growths often associated with exposure to cold water (exostoses) or
trauma (osteomas).
Slow-growing, noncancerous, but can cause hearing loss and discomfort.
Papillomas:
Benign growths caused by human papillomavirus (HPV).
May obstruct the ear canal and lead to hearing loss.

• Common Malignant Tumors

Squamous Cell Carcinoma:
Arises from the skin cells lining the external auditory canal.
Risk factors: Chronic inflammation, exposure to irritants, and sometimes
associated with HPV.
• Common Malignant Tumors cont’d
Basal Cell Carcinoma:
Originates in the basal cells of the skin in the external auditory canal.
Slow-growing but locally invasive.
Adenoid Cystic Carcinoma:
Uncommon cancer arising from the salivary glands in the external
auditory canal.
Typically slow-growing but can be aggressive.
Melanoma:
Rare but aggressive cancer that can occur in the external auditory
canal.
Arises from melanocytes, the pigment-producing cells.
Diagnosis
1.Clinical Evaluation:
Symptoms, medical history, and physical examination including otoscopy.
2.Biopsy:
Sampling of the tumor tissue for pathological analysis to confirm the type and
grade of the tumor.
Treatment
1.Surgical Excision:
Standard treatment to remove the tumor, aiming for complete resection.
2.Radiation Therapy:
Used in combination with surgery or as primary treatment for inoperable
tumors.
3.Chemotherapy:
Depending on the type and stage of the tumor.
• Prognosis and Survival Rates
1.Early Detection:
 Better prognosis when tumors are detected and treated in the early stages.
2.Survival Rates:
 Vary based on the type and stage of the tumor.

• Prevention and Education

1.Awareness:
 Promote awareness about risk factors and early symptoms.
2.Protection:
 Encourage ear protection in high-risk individuals, e.g., those exposed to irritants or cold
water.
Earwax (Cerumen)
Introduction to the self-cleansing mechanism of the ear and the accumulation
of wax in the external ear canal.
Earwax Composition and Formation
Earwax is a mixture of secretions from ceruminous and sebaceous glands.
Expulsion: Wax is pushed out in the form of flakes through epithelial
migration.
Functions of Earwax
Lubrication of the external ear canal.
Fungicidal and bactericidal properties.
Protection against dust
Causes of Wax Accumulation
Using cotton buds for ear cleaning.
Increased wax production.
Narrow external ear canal.
Clinical Presentation
Observation using an otoscope: Brownish soft mass occluding the external
auditory canal.
Patient Complaints: Unilateral or bilateral hearing loss and/or tinnitus,
especially after bathing.
Treatment Approach
Instill Otorex ear drops for 4 days, then syringe the affected ear.
Antibiotic ear drops for treatment
Syringing ContraindicationsTympanic membrane perforation.
Otitis externa.
Impacted or large vegetable foreign body.
A fistula between the middle and inner ears.
Syringing Technique
Use warm water at body temperature (37°C).
Patient positioning and precaution to avoid wetting clothes.
Gentle and cautious approach to prevent trauma, aiming for clear water flow.

Complications of Ear Syringing

Reflex: Cough or syncope due to vagus nerve stimulation.
Vertigo and nystagmus: Due to caloric stimulation of the inner ear.
Trauma: Rupture of tympanic membrane due to forcible jet of water.
Infections: Otitis externa, otomycosis, or otitis media due to non-sterile water
or equipment.
Rupture Tympanic Membrane
Causes
1.Direct Trauma:
Foreign body or during its removal
Self-inflicted trauma
Improper ear syringing
Temporal bone fracture
2.Indirect Trauma:
Secondary to rapid pressure changes:
Swimming
Flying high in aerospace
Commonest cause: Hand slap on the ear (Note: Never slap somebody on the
ear; it is a criminal offense)
Otitic barotrauma
Blast injury (e.g., extremely loud explosion)
Sudden fluid compression (e.g., jumping in a swimming pool)
Clinical Presentation
Patient complaints:
Severe pain (transient at the time of rupture)
Otoscopy findings:
Mild bloody ear discharge
Hearing loss and Tinnitus
Air escapes on nose blowing, producing a whistle sound
Ear drum perforation characteristics:
Antero-inferior quadrant
Irregular and hyperemic with blood clots
Slap-induced or self-inflicted
Tuning Fork Tests:
 Conductive hearing loss
Complications
Otitis media
Permanent ear drum perforation
Ossicular dislocation
Implantation cholesteatoma

Treatment
1.Conservative Treatment:
IV antibiotic therapy
Decongestant nasal drops
Avoid blowing the nose forcibly
Follow up for three months
2.Surgical Treatment (if perforation fails to heal):
Recommend Myringoplasty
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