external and middle ear disease for g ps

A Practical Guide to Diseases of the Ear

Simon LloydConsultant ENT Surgeon

Manchester Royal Infirmary

Otitis externa Acute otitis media Chronic otitis media without cholesteatoma

Chronic otitis media with cholesteatoma

Otitis media with effusion

Severe Otalgia 

Otalgia for a few days Otorrhoea intermittently or for more than 3 months

Otorrhoea intermittently or for more than 3 months

Hearing loss

Mild otorrhoea Fever Possibly conductive hearing loss

Probably conductive hearing loss

Speech delay

Occasionally conductive hearing loss

Otorrhoea once otalgia resolves

    Usually a child

History of swimming/holiday

Conductive hearing loss     May have adenoidal symptoms

Often a child      

Differentiating Types of Otitis

Acute Otalgia with normal TM

Otitis externa

• Inflammation of ear canal skin

• Aetiology:– Bacterial – Staph. aureus, Pseudomonas, Proteus– Fungal – Aspergillus niger, Candida albicans– Viral – Herpes simplex,Herpes zoster– Reactive – Eczema, Psoriasis

• Predisposing factors:– Bathing, humidity– Trauma– Canal stenosis– Eczema

Symptoms & Signs - Bacterial

• Otalgia - severe• Purulent otorrhoea• Deafness• Inflammation of

ear canal +/- pinna

Treatment

• Swab for sensitivities

• Aural toilet• Splinting of ear

canal (Pope wick)• Topical antibiotics

eg. Sofradex, Gentasone

• Keep dry

Malignant Otitis Externa

• Osteomylitis of temporal bone• Immunocompromised patients eg. Diabetes• Usually pseudomonas• Extremely painful• May be associated with cranial nerve palsy

• Have a high index of suspicion• Treat aggressively with IV antibiotics for at

least 6 weeks

Symptoms & Signs - Fungal

• Itching• Mild otalgia• Fullness• Greyish white

debris +/- fungal spores

Treatment

• Aural toilet• Topical antifungal agents eg.

Canestan

Furunculosis

• Staph. infection of hair follicle causing abscess formation

• Severe otalgia• Requires I&D

Ramsey Hunt Syndrome

• Herpes zoster• Geniculate ganglion of

facial nerve• Vesicular rash of pinna

and ear canal (+/- mouth and tongue)

• Facial nerve palsy• Painful• Vertigo• Treatment

– Analgesia– Antivirals eg. Acyclovir– Protect the eye

First Branchial Cleft AnomaliesPre-auricular sinus

First Branchial Cleft AnomaliesPre-auricular sinus

First Branchial Cleft AnomaliesPre-auricular sinus

First Branchial Cleft AnomaliesAccessory Auricle

Benign Skin Pathology

Benign Skin Pathology

Gouty Tophi

Benign Skin Pathology

Seborrhoeic KeratosisGouty

Tophi

Benign Skin Pathology

Seborrhoeic KeratosisGouty

Tophi

Solar keratosis

Benign Skin Pathology

Benign Skin Pathology

Chondrodermatitis helicis nodularis chronica

Benign Skin Pathology

Chondrodermatitis helicis nodularis chronica

Darwin’s tubercle

Benign Skin Pathology

Chondrodermatitis helicis nodularis chronica

Keloid ScarringDarwin’s tubercle

Malignant Skin Pathology of The Pinna

Malignant Skin Pathology of The Pinna

Basal Cell Carcinoma

Malignant Skin Pathology of The Pinna

Basal Cell Carcinoma

Squamous Cell Carcinoma

Middle Ear

• Otitis media– Acute– Chronic otitis media +/- cholesteatoma– Otitis media with effusion– Complications

• Tympanic membrane perforation• Hearing loss– Conductive

Acute Otitis Media

• Definition– Inflammation of the middle ear cleft

• Demographics– Mostly children (age 3-7)

• Aetiology– Viral (majority)– Bacterial (1y or 2y) - Strep. Pneumoniae, H. influenzae,

Bramhamella catarrhalis)• Risk Factors

– Poor sanitation/ hygiene and parental smoking– Exposure to other children– Eustachian Tube Dysfunction– ? allergy

Natural HistoryInfection via ET tube (Fever)

Mucosal oedema

Hyperaemia of tympanic membrane & purulent middle

effusion

Bulging tympanic membrane (Pain)

Pressure necrosis of tympanic membrane resulting in

perforation

Mucopurulent discharge

Acute Otitis Media

Acute Otitis Media

• Treatment– Expectant– Paracetamol/NSAIDS– Oral amoxycillin– +/- myringotomy

• Complications– Acute

• Mastoiditis• Facial palsy• Labyrinthitis• Meningitis• Intracranial abscess• Lateral sinus thrombosis

- Long term• Tympanosclerosis

• Tympanic membrane perforation

• Ossicular damage

Acute Mastoiditis

• History of acute otitis media

• Infection spreads to mastoid

• Post-auricular abscess

• Treatment– Grommet– Cortical mastoidectomy

Mastoiditis Treatment

Intracerebral Abscess

Ring enhancement with contract enhanced CT

Lateral Sinus Thrombosis

Filling defect on MRA

Tympanic Membrane Perforation

• Causes– Trauma– Otitis media– Iatrogenic eg. Grommets

• Symptoms– None– Recurrent otorrhoea– Hearing loss

Tympanic Membrane Perforation

• Treatment– None–Myringoplasty–+/- ossiculoplasty

Graft is placed under perforation to allow epithelium to regrow

Myringoplasty

Chronic Otitis Media

• Without cholesteatoma

– Tympanic membrane perforation

– Chronic middle ear infection– May resolve with topical or

oral antibiotics– If no resolution –

myringoplasty +/- cortical mastoidectomy

• Otorrohoea for more than 3 months• May occur with or without cholesteatoma

Chronic Otitis Media• With cholesteatoma• Eustachian tube dysfunction results in tympanic membrane

retraction (attic)• Accumulation of keratin in retraction pocket• Gradual enlargement and adjacent bony destruction• Complications as for AOM above

Cholesteatoma

Chronic Otitis Media with Cholesteatoma

Chronic Otitis Media with Cholesteatoma

• Treatment is surgical

• Aims of surgery

− Remove all disease

− Dry ear

− +/- Restore hearing

• Types of operation– Modified radical mastoidectomy

– Canal wall up mastoidectomy

Chronic Otitis Media with Cholesteatoma

Post-auricular incision Mastoid air cells drilled away

Posterior ear canal removed to leave mastoid cavity

Inner Ear

Sudden Hearing Loss

• Normal TM with sudden hearing loss• Aetiology unknown

• Viral• Vascular

• Rarely acoustic neuroma, perilymph leak• May be unsteady or vertiginous

Cochlea Drug Delivery

Sudden Hearing LossManagement

• Refer urgently

• Treatment options• Oral steroid• Antiviral• No evidence for efficacy

• Carbogen• No evidence for efficacy

• Intratympanic steroid• Reasonable evidence for efficacy

Hyperostosis

• Exostosis– Multiple bony swellings

in deep canal– Cold water– Asymptomatic

– No treatment unless large

• Osteoma– Single benign bony

tumour outer bony meatus

– No treatment unless large

Perichondritis

• Inflammation of perichondrium

• Aetiology:– Ear piercing– Laceration– Surgery– CT disease

• Treatment:– Antibiotics– I & D (if abscess)

• Sequelae: – Cauliflower ear