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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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slide1

External canal

ا د مسعد السيسي

congenital
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

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

traumatic fb
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
slide6

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

slide7

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

inflammatory conditions of the external auditory canal
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)

inflammatory bacterial diffuse otitis externa
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

slide10

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

slide11

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

slide12
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 )

slide13
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:

inflammatory bacterial malignant otitis externa necrotizing otitis externa
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

slide15
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).

slide16
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
inflammatory viral herpes zoster oticus
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
fungal otomycosis
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
neoplasm benign exostosis
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

neoplasm malignant squamous cell carcinoma
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
slide21
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

slide22
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.
slide23
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

what is wax
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
slide25
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
rupture of the tympanic membrane
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

slide27
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
slide28
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
slide29

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