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External canal

External canal. 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

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External canal

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  1. External canal ا د مسعد السيسي

  2. 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

  3. Treatment • Unilateral : postpone after puberty • Bilateral: HA fitting at 1 year • operation at one side (at 2-5 years) , the other after puberty

  4. 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

  5. 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 Traumatic: FBجسم غريب في الاذن

  6. 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

  7. FB • So donn’t wash if: • The FB is vegetable • The FB is disc battery Treatment: Animate FB: Kill by alcohol or oil  remove by ear wash or instruments Inanimate FB: - Non vegetable: remove by ear wash or instruments BUT PLEASE DO NOT WASH IF 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

  8. Inflammatory conditions ofthe external auditory canal • Bacterial: 1- Diffuse OE 2- Localised OE: frunculosis دمل 3- Malignant OE( Necrotizing OE) • Viral( bullous- Herpes) • Fungal: (Otomycosis) • Non infective ( allergic OE, Seborrhoic OE)

  9. Inflammatory: BacterialDiffuse 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

  10. Because the skin is tightly adherent to the underlying perichondrium & periostium Symptoms: Earache: • Severe Why? • Increase on moving the jaw Why? Deafness when edema is severe  obstruct the canal Signs 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 Because the external canal Lies immediately behind Temporomandibular joint

  11. Inflammatory: BacterialFrunculosis 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

  12. 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 )

  13. 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:

  14. Inflammatory: BacterialMalignant otitis externa (Necrotizing otitis externa) Def: invasive potentially fatal of the external canal which extends to the base of the skull Incidence: elderly uncontrolled diabetic patient Organism: pseudomonas aeuruginosa Symptoms: Ear discharge and severe earache which does not respond to analgesics Signs External examination: 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 علامة هامة جدا لهذا المرض Scanty, sanginous and purulent otorrhea Necrotizing external otitis should be suspected when patients with diabetes mellitus (or another condition that compromises the immune system) complain of persistent external otitis that causes severe pain, especially at night

  15. 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 with diabetes mellitus who had severe nocturnal otalgia for two months. This patient was referred because of facial nerve paralysis that developed despite oral treatment with ofloxacin (Floxin). The CT scan shows bony destruction of the right temporal bone. Note the missing posterior wall of the external auditory canal (short arrow). Mastoid air cells are secondarily involved and are opacified (long arrow) compared with the well-aerated left side. . Gallium citrate Ga 67 scintigraphy in a 74-year-old male patient with diabetes mellitus and left-sided temporal bone osteitis. This patient was referred because of persistent otalgia and otorrhea after a prolonged course of systemic oral antibiotics. As a result of ongoing infection, the left temporal bone shows enhanced uptake of 67Ga (arrow).

  16. 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

  17. 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 Inflammatory:Viral:Herpes Zoster Oticus

  18. 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 مثل قطعة صغيرة مبللة من ورق جرائد 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 Fungal:Otomycosis

  19. Neoplasm: BenignExostosis 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

  20. Incidence Rare More common in elderly males CP: Otological: Deep seated earache Bloody stained otorrhea Fleshy friable mass in the external canal Progressive hearing loss, initially CD then SNHL Neurological: paralysis of VII& last 4 cranial nerves Cervical: - Enlarged preauricular, postauricular and upper deep cervical LN Neoplasm: MalignantSquamous cell carcinoma

  21. 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 prosthesis انظر الشريحة القادمة لتري نموذج لمريض تم اجراء هذه الجراحة له Chest X ray Bone scan Abdominal ultrasound CT scan Of brain

  22. From; http://www.caritas.ab.ca/ther_new/respcare/hbo/case5.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.

  23. 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 WAX Accumulation

  24. What is WAX?ماهو الصملاخ؟ • 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

  25. Symptoms: Hearing loss and tinnitus when the wax obstructs the canal تحدث كثيرا بعد الاستحمام أو نزول البحر حيث ينتفخ الصملاخ 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

  26. 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

  27. 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

  28. Treatment Conservative: Antibiotic Avoid : • Nose blowing • Ear wash • Entry of water into the ear بوضع قطعة شاش عليها فازلين في الأذن عند غسل الرأس أو الاستحمام • Ear drops Surgical: • Myringoplasty لو لم يحدث التئام بعد ثلاثة اشهر

  29. تذكر - 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

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