DISEASES OF EXTERNAL

EAR
ANATOMY
• AURICLE OR PINNA
• EXTERNAL ACOUSTIC CANAL
• TYMPANIC MEMBRANE
AURICLE OR PINNA
• Entire pinna except its lobule is made up of a single piece of yellow
elastic cartilage covered on both sides by skin.
• Cartilage is deficient between tragus and crus of helix, and this area is
called incisura terminalis. An incision through this area is used for
endaural approach in surgery of external auditory canal and mastoid.
• Source of several graft materials (skin, cartilage, perichondrium, fat)
for reconstructive surgery of the middle ear, correction of depressed
nasal bridge and repair of defects of nasal ala.
DISEASES OF PINNA
• CONGENITAL DISORDERS
• TRAUMA TO THE AURICLE
• INFLAMMATORY DISORDERS
• TUMORS
CONGENITAL DISORDERS
• MICROTIA
Major developmental anomaly characterized by small pinna, can be unilateral or
bilateral. E.g.: peanut ear.
• ANOTIA
Complete absence of pinna and lobule, external auditory canal shows a small opening or is
completely absent, usually a part of first arch syndrome. Causes conductive hearing loss.
• MACROTIA
Excessively large pinna. Otoplasty is performed to reduce the size. Normal
auricular axis length in males is 62-66mm and in females is 58-62mm.
• BAT EAR (PROMINENT/PROTUDING EAR)
Concha is large, poorly developed antihelix and scapha. Can be corrected any
time after 6 years.
• CUP EAR/LOP EAR
Hypoplasia of upper third of the auricle so the upper portion of helix is cupped.
Cockleshell ear or Snail shell ear.
• PREAURICULAR SINUS
Sinus is an epithelial track due to incomplete fusion of tubercles. It
gets repeatedly infected causing purulent discharge, abscess may form.
Complete surgical excision of the sinus tract.
TRAUMA TO THE AURICLE
• HEMATOMA OF THE AURICLE
Collection of blood between auricular cartilage and its perichondrium.
Results from blunt trauma (boxing, wrestling). Cauliflower/boxer’s Ear.
Complication is infection leading to perichondritis.
Treatment
1- aspiration of hematoma and pressure packing of auricle
2- incision and drainage
3- prophylactic antibiotics to prevent infections
• LACERATIONS
• Deep cut or tear in the pinna.
• Repaired as early as possible.
• Skin is closed by non-absorbable sutures.
• Prophylactic antibiotics.
• KELOID OF AURICLE
Follows trauma or piercing of ear. Usual sites are lobule and helix.
Treatment is surgical excision with postoperative radiation (600-800 rad
in 4 divided doses) or local steroid injection to prevent reoccurrence.
INFLAMMATORY DISORDERS
PERICHONDRITIS
ETIOLOGY
Results from infection secondary to trauma, lacerations, hematoma, surgical
incisions or extension of infection from diffuse otitis externa or a furuncle.
COMMON PATHOGENS
Pseudomonas and mixed flora
SYMPTOMS
Initially red, hot, painful, stiff pinna.
Later abscess formation and necrosis of cartilage.
TREATMENT
Early stages, systemic antibiotics and local application of 4% aluminum
acetate compresses.
After abscess formation, incision and drainage, C&S of pus, removal of dead
• RELAPSING POLYCHONDRITIS
Rare autoimmune disorder involving ear cartilage. Septal, laryngeal,
tracheal, costal cartilage may be involved. Entire pinna except the
lobule becomes inflamed and tender and external acoustic canal
becomes stenotic.
TREATMENT is high doses of systemic steroids.
TUMORS
• BENIGN TUMOR
• MALIGNANT TUMORS
 BENIGN Lesion
• SABACEOUS CYST
Common site is post auricular sulcus or below and behind the ear lobule.
TREATMENT is total surgical excision.
• DERMOID CYST
Presents as a rounded mass over the upper part of mastoid behind pinna.
• HAEMANGIOMA
Congenital tumor often seen in childhood.
1- capillary haemangioma
2- cavernous haemangioma
 MALIGNANT TUMORS
SQUAMOUS CELL CARCINOMA
• Presents as a painless nodule or an ulcer
• Common in fair complexion people and males with sun exposure
TREATMENT
• Small lesions with no nodal metastasis are excised
• Larger lesions with regional nodal metastasis require complete su
surgical excision with neck dissection and post operative
radiotherapy.
• BASAL CELL CARCINOMA
Presents as a nodule with central crust, removal of which leads in
bleeding. Ulcer has raised or beaded edge. Lesion often extends
superficially over skin but sometimes may penetrate deeper involving
cartilage and bone. Common sites are helix and tragus. Lymph node
metastasis is uncommon.
TREATMENT
small superficial lesions are irradiated/ Excised.
lesions involving cartilage require surgical excision.
EXTERNAL ACOUSTIC CANAL
• Extends from the bottom of concha to tympanic membrane.
• 24mm in length in adults, 10mm in infants.
1- Outer cartilaginous part
8 mm in length. Skin is thick and contains ceruminous glands,
sebaceous glands and hair follicles.
2- Inner bony part
Inner 16mm, skin lining is thin with no ceruminous glands and hair
follicles. Isthmus is the narrowest point present 6mm lateral to
tympanic membrane.
DISEASES OF EXTERNAL ACOUSTIC
CANAL
• CONGENITAL DISORDERS
• TRAUMA
• INFLAMMATION
• TUMORS
• MISCELLANEOUS CONDITIONS
CONGENITAL DISORDERS
• ATRESIA OF EXTERNAL CANAL
• First branchial cleft anomaly
• Incidence 0.8 to 1.6/ 10000 live births.
• Outer meatus is obliterated with fibrous tissue or bone.
• Associated with Treacher collins and Goldenhar syndrome.
 Investigation
• Care clinical examination
• Audiometric assessment
• CT SCAN Temporal bone
TREATMENT
• BAHA (Bone anchored hearing aid)
• Meatoplasty
• Cosmetic correction with prosthesis
COLLAURAL FISTULA

• Abnormality of first branchial cleft. Fistula has two openings: one

situated in the neck just below and behind the angle of mandible,
other in the external canal or middle ear. Fistula tract traverses
through the parotid in close relation to facial nerve.
• TREATMENT
• Excision of fistula tract.
TRAUMA TO THE EAR CANAL
• MINOR LACERATIONS OF THE CANAL
Usually result from Q-tip injuries, or unskilled instrumentation by
the physician. Heal with squeal.
• MAJOR LACERATIONS OF THE CANAL
Result from gunshot wounds, automobile accidents or fights. Angle
of mandible may force through the anterior canal wall. Treatment aim
is to maintain a skin lined canal of adequate diameter. Stenosis is
common complication.
INFLAMMATION OF EAR CANAL (OTITIS
EXTERNA)
On etiological basis it is divided in to two groups:
• INFECTIVE GROUP
1- BACTERIAL
LOCALIZED OTITIS EXTERNA/FRUNCLE
DIFFUSE OTITIS EXTERNA
MALIGNANT OTITIS EXTERNA
2- VIRAL
HERPER ZOSTER OTICUS
OTITIS EXTERNA HEMORRHAGICA
3- FUNGAL
OTOMYCOSIS
• REACTIVE GROUP
1- ECZEMATOUS OTITIS EXTERNA
2- SEBORRHOEIC OTITIS EXTERNA
• FURUNCLE (LOCALIZED ACUTE OTITIS EXTERNA)
Staphylococcal infection of the hair follicle. Seen only in outer
cartilaginous part. Usually single, may be multiple.
CLINICAL FEATURES:
Severe pain, tenderness.
Furuncle of posterior meatal wall causes edema
over mastoid and obliteration of reteroauricular
groove.
Periauricular lymph nodes are enlarged and tender.
TREATMENT:
Early cases, systemic antibiotics, analgesics and local heat.
After abscess formation, incision and drainage.
• DIFFUSE OTITIS EXTERNA
Diffuse inflammation of meatal skin which may spread to involve the
pinna and epidermal layer of the tympanic membrane.
ETIOLOGY
Commonly seen in hot humid climate and in swimmers.
1- Trauma to meatal skin
2- Invasion of pathogenic organisms
PATHOGENIC ORGANISMS
S. aureus, E. coli, Bacillus proteus, Pseudomonas infection is often
mixed.
CLINICAL FEATURES
1- Acute phase,
Hot burning sensation in ear, pain, aggravated by movements.
Thin serous discharge which later becomes thick purulent.
Swollen, red meatal lining.
In severe cases regional lymph nodes are enlarged and tender.
Causes conductive hearing loss.
TREATMENT
Ear toilet (dry mopping, suction clearance, irrigation and canal with normal
saline)
Medicated wicks (antibiotic steroid preparations)
Broad spectrum systemic antibiotics (in case of cellulitis and acute tender
lymphadenitis)
Analgesics
2- Chronic phase,
Irritation and severe desire to itch.
Scanty discharge, dries up to form crusts.
Thick swollen meatal skin shows scaling and fissuring, and rarely
becomes hypertrophic leading to MEATAL STENOSIS (CHRONIC
STENOTIC OTITIS EXTERNA)
TREATMENT
Gauze wicks soaked in 10% ichthammol glycerin to reduce swelling and
perform ear toilet.
Topical steroid cream for itch.
• MALIGNANT (NECROTIZING) OTITIS EXTERNA
An inflammatory condition caused by pseudomonas infection in usually in
the elderly diabetics, or in those on immunosuppressive drugs.
CLINICAL FEATURES
Excruciating pain
Granulation tissue in ear canal at cartilaginous-bony junction
COMPLICATIONS
Facial paralysis
Multiple cranial nerve palsies as infection can spread to jugular foramen and
base of skull
TREATMENT
Control of diabetes
Ear toilet
Antibiotic treatment (for 6-8weeks) with gentamycin, third generation
cephalosporin e.g. ceftriaxone, and quinolones e.g. ciprofloxacin, ofloxacin,
levofloxacin.
• OTOMYCOSIS
Fungal infection of ear canal
PATHOGENS
Candida albicans, Aspergillus niger, A. fumigatus.
CLINICAL FEATURES
Intense itch, discomfort and pain in the ear.
Watery discharge with musty odor.
Ear blockage, conductive hearing loss.
Red edematous meatal skin.
On otoscopic examination,
Black filamentous growth = A. niger
Pale blue or green = A. fumigatus
Creamy white = C. albicans
TREATMENT
Ear toilet
Broad spectrum antifungal (nystatin, clotrimazole)
Ear must be kept dry
Antibiotics and steroid in case of associated bacterial infections
• OTITIS EXTERNA HEMORRHAGICA
It is characterized by hemorrhagic bullae on tympanic membrane
and deep meatus. Viral in origin, seen in influenza epidemics.
CLINICAL FEATURES
Severe pain
Blood stained discharge when bullae rupture
TREATMENT
Analgesics for pain
Antibiotics for secondary bacterial infection
• HERPES ZOSTER OTICUS
Characterized by formation of vesicles on tympanic membrane,
meatal skin, concha, and post auricular groove. VII and VIII
cranial nerves may be involved.
• ECZEMATOUS OTITIS EXTERNA
It is the result of hypersensitivity to infective organisms or
ear drops such as chloromycetin or neomycin. Characterized
by intense irritation, vesicle formation, oozing and crusting
in the canal.
TREATMENT
withdrawal of topical ear drops and application of steroid
cream.
• SEBORRHOEIC OTITIS EXTERNA
Associated with seborroheic dermatitis of scalp. Characterized by
presence of greasy yellow scales in the external canal, over the lobule and
post auricular sulcus. Itch is the main complaint.
TREATMENT
Ear toilet
Application of cream containing salicylic acid and sulfur
Attention to the scalp for seborrhea.
• NEURODERMATITIS
Psychological factor leading to intense, compulsive scratching. Bacterial
otitis externa may fellow because of infection of raw area after scratching.
TREATMENT
Psychotherapy
Antibiotics for secondary infection
Ear pack and bandage to prevent compulsive scratching
• PRIMARY CHOLESTETOMA OF EAR CANAL
Squamous epithelium of the external canal invades its bone.
Usually post traumatic or post surgical.
CLINICAL FEATURES
Pain
Purulent ear discharge
Granulations in the ear canal
TREATMENT
Removal of necrotic bone and cholestetoma and lining the defect with
fascia.
TUMORS OF THE EAR CANAL
• BENIGN
• MALIGNANT
 BENIGN TUMORS
• OSTEOMA
It arises from cancellous bone and presents as a single, smooth,
hard, pedunculated, tumor, often from the posterior wall of the
osseous meatus, near its outer end.
• Arise from tympano-sqamous or tympano- mastoid sutures
• Slow growing and frequently asymptomatic
TREATMENT
Surgical removal by fracturing through its bony pedicle or removal
with a drill.
• EXOSTOSES
Multiple, bilateral, smooth, sessile, bony swellings in the
deeper part of meatus near tympanic membrane, arising from
compact bone.
•Typical history of cold water exposure
•Periostitis following exposure leading to new bone formation
TREATMENT
Larger ones which impair hearing and cause retention
of wax are removed with high speed drill to restore normal sized meatus.
It lies in close association with facial nerve so use
of gouge and hammer should be
avoided.
MALIGNANT TUMORS
• SQUAMOUS CELL CARCINOMA
Seen in cases of long standing ear discharge.
CLINICAL FEATURES
Examination shows ulcerated area in meatus, bleeding polypoidal mass or granulations.
Severe earache
Blood staining of purulent or mucopurulent ear discharge
Regional lymph nodes metastasis
Facial nerve paralysis is common complication
TREATMENT
Wide surgical excision with post operative radiation.
• BASAL CELL CARCINOMA OR ADENOCARCINOMA
Clinical picture is similar to squamous cell carcinoma, diagnosis is
only made on biopsy.
TREATMENT
Wide surgical excision with post operative radiations.
• MALIGNANT CERUMINOMA
Twice as common as benign type.
• MALIGNANT MELANOMA
Rare
MISCELLANEOUS CONDITIONS
• IMPACTED EAR WAX
Wax is composed of secretions of sebaceous glands, ceruminous glands, hair,
desquamated epithelial debris and dirt.
ETIOLOGY
Excessive production of wax
Retention of wax (narrow, tortuous ear canal, obstructive lesion of ear canal e.g.
exostosis, osteoma)
SYMPTOMS
Blocked ear
Conductive hearing loss
Tinnitus and giddiness (when present against TM)
Reflex cough
Onset of above symptoms is sudden, when water enters the ear and wax swells up
Wax granuloma long standing wax may ulcerate the meatal skin and result in
granuloma formation
TREATMENT
1- Removal by syringing

2- Instrumental manipulation

3- Drops of 5% sodium bicarbonate in equal parts of glycerin and water,

or Hydrogen peroxide, liquid paraffin or olive oil instilled 2-3 times a
day for a few days to soften the wax. Paradichlorobenzene 2%
(ceruminolytic agent) can also be used.
• FOREIGN BODY OF EAR
NONLIVING
Piece of paper, sponge, grain seeds, piece of chalk, pencil lead, ball bearings. Often seen in
children.
METHODS OF REMOVING
Forceps (fine crocodile forceps for small, soft, irregular objects)
Syringing (for smooth, rounded objects, not advisable in perforated TM)
Suction
Microscopic removal (when earlier attempts have been made, general anesthesia and operative
microscope is used)
Post aural approach (impacted in deep meatus, medial to isthmus, or those pushed into middle
ear)
LIVING
Flying or crawling insect, bees, mosquitoes, cockroach, maggots. Intense irritation and pain is
felt.
METHODS OF REMOVAL
Kill the insect first with oil, chloroform water or spirit
Then follow the above methods
Maggots in ear cause severe pain and swelling around the ear with blood stained ear discharge
• KERATOSIS OBTURANS
Collection of pearly white mass of desquamated epithelial cells in the deep meatus. This by its
pressure effect causes bone absorption and widening of ear canal so much that the facial nerve may
be exposed and paralyzed.
ETIOLOGY
Normally epithelium from TM migrates to posterior meatal wall, failure of this migration due to wax
or foreign body may lead to collection of desquamated epithelial cells.
SYMPTOMS
Pain in ear
Ear discharge
Tinnitus
Conductive hearing loss
ON EXAMINATION
Pearly white mass
Removal of this mass shows widening of meatus
Ulceration
Granuloma formation
TREATMENT
Syringing
• ACQUIRED ATRESIA AND STENOSIS OF MEATUS
ETIOLOGY
1- Infections: chronic otitis externa
2- trauma: lacerations, fracture of tympanic plate, surgery on ear canal
3- burns: thermal or chemical
TREATMENT
Meatoplasty
Using a post aural incision, scar tissue and thickened meatal skin is
excised, bony meatus is enlarged and raw meatal bone is covered with
pedicled flaps from meatus or split skin grafts.
TYMPANIC MEMBRANE
• Shiny and pearly grey, concavity on its lateral surface, maximum at tip
of malleus, the umbo.
• Bright cone of light in the anteroinferior quadrant.
• Normal tympanic membrane is mobile.
DISEASES OF TYMPANIC MEMBRANE
• RETRACTED TYMPANIC MEMBRANE
• MYRINGITIS BULLOSA
• HERPES ZOSTER OTICUS
• MYRINGITIS GRANULOSA
• TRAUMATIC RUPTURE
• ATROPHIC TYMPANIC MEMBRANE
• RETRACTION POCKETS AND ATELECTASIS
• TYMPANOSCLEROSIS
• PERFORATIONS
• RETRACTED TYMPANIC MEMBRANE
It is the result of negative intratympanic pressure due to Eustachian
tube blockade.
Dull, lusterless
Cone of light is absent
Lateral process of malleus becomes more prominent
Anterior and posterior malleolar folds become sickle shaped
• MYRINGITIS BULLOSA
Painful condition characterized by formation of hemorrhagic blebs
on tympanic membrane and deep meatus.
Caused by a virus or Mycoplasma pneumonia
• HERPES ZOSTER OTICUS
Viral infection involving VII or VIII cranial nerve, more often
geniculate ganglion of VII nerve.
Characterized by presence of vesicles on TM, deep meatus, concha and
retro-auricular sulcus.
• MYRINGITIS GRANULOSA
Non-specific granulations on the outer surface of tympanic
membrane.
Associated with impacted wax, long standing foreign body, or external
ear infection.
• TRAUMATIC RUPTURE
Due to:
1- trauma (hairpin, match-stick, unskilled instrumentation)
2- sudden change in air pressure (a slap, sudden blast, valsalva)
3- pressure by fluid column (diving, water sports, syringing)
4- fracture of temporal bone
TREATMENT
Examination of middle ear
Edges of perforation are repositioned and splinted
• ATROPHIC TYMPANIC MEMBRANE
ETIOLOGY
Serous otitis media
Perforation
Leading to loss of fibrous middle layer
• RETRACTION POCKETS AND ATELECTASIS
Thin and atrophic tympanic membrane
Eustachian tube insufficiency
Entire or segments of TM may get retracted, these retraction pockets
may get plastered on the promontory and also wrap around the ossicles.
Deep retraction pocket may accumulate keratin, debris and form
a cholesteatoma.
• TYMPANOSCLEROSIS
Hyalinization and later calcification in the fibrous layer of TM, sometimes also involve
ligaments, joints of ossicles, muscle tendons and sub mucosal layer of middle ear cleft and
interferes with the conduction of sound.
Appears as chalky, white plaque.
Asymptomatic
Frequently seen in serous otitis media as a complication
ETIOLOGY
Long term otitis media (glue ear)
Atherosclerosis
increased fibroblast activity leads to collagen deposition, followed by
calcium phosphate deposition.
DIAGNOSIS
Audiometry
CT scan
TREATMENT
Hearing aids
• PERFORATIONS
Seen in
Chronic otitis media
Acute suppurative otitis media
May be central, attic or marginal
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