external ear

Disease of External Ear

Auricle

• Elastic cartilage• Perichondrium, Subcut, Skin• 피하 지방층이 없고 혈관도 단층만으로 되어 있어서 Fro

stbite 에 잘 걸린다 .

Landmarks of Auricle

• Tragus (Tragal cartilage)• Concha : Cavum conchae, Cymba conchae• Incisurae Santorini

• Anterior incisura• Endaural incision

Preauricular fistula

Embryology

Auricle - 6 Hillock fusion

Fusion defect = Preauricular fistula

Microtia , Congenital aural atresia

Grade I II III

Auricle fusion defect

• R fusion defect• L preauricual fistula

BAHA

• Bone Anchoring Hearing Aid

BAHA Before vs After

Cauliflower deformity

• Wrestler

External OtitisOtalgia

Common Clinical Presentation

• Otalgia / Otorrhea(<<scanty discharge) with Normal TM• Usually without or minimal HL complaint• Gross dx • Pain on speculum insertion• If normal TM on P/E

• Referred otalgia? R-H syndrome?

Sensory Innervation of EAC – Otalgia vs Referred otalgia

• 1) Tympanic branch of Glossopharyngeal nerve (Jacobson's nerve) • 예 ) Tonsillitis 시 otalgia, Glossopharyngeal neuralgia

• 2) Auriculotemporal branch of V3 - • 예 ) dental origin 의 otalgia

• 3)Auricular branch of Vagus n. (Arnold's nerve) • 예 )EAC 만질 때 coughing reflex

• 4) Facial nerve • 예 )Herpes zoster 시 otalgia

• 5) C2,3

Quiz

• 외이도의 신경지배를 보여주는 그림이다 . 연결이 옳은 것은 ?• 가 . A-CN V2 B-CN VII• 나 . A-CN VII B-CN V2• 다 . A-CN VII B-CN V3• 라 . A-CN V3 B-CN V2• 마 . A-CN V3 B-CN VII

Otalgia – Referred otalgia (Neuralgia)

• F/20• C.C Otalgia• TM – WNL

• Referred Otalgia ?• Herpes Otalgia ?

Ramsay-Hunt syndrome and Otalgia

• = Herpes Zoster Oticus• FNP worst prognosis

• CN7 - Facial nerve paralysis• CN8 – Hearing loss, Vertigo • Skin vesicle

• without FNP or Skin vesicle• Otalgia may be only symptom

RH syndrome with vesicle

• 차달례 10807728

Ramsay Hunt Syndrome

• 10542425 임희 O F/65• 2004.6.15 OPD L) Otalgia

• L ear vesicle• HL(-), FNP(-)

• 2004.6.22 OPD L) FNP HB Grade 2-3

• 2004.6.23 – 6.28 Admission• IAC MR - WNL

EAC Quiz

• 성인 외이도에 대한 설명 중 틀리는 것은 ?

• 길이는 3.5cm 이고 2/3 은 골부이다 . • 이경검사시 이개를 후상방으로 당긴다 . • 공명강으로서 작용한다 .• Otofuruncle 은 골부에 생긴다 . • 외이도를 건드리면 기침이 난다 .

Otoscopy with Aural Speculum

• 이경의 목적 - Cartilage EAC를 확대• 가능한 한 가장 큰 것 • 단 이경이 Bony EAC 닿으면 pain 있으므로 Cartilage

EAC 까지만 • Auricle traction

• S – shaped EAC• Superior + Posterior• 단 4 세 이하 : Inferior + Posterior

Anatomy of External ear• Lateral 1/3 Cartilage, Medial 2/3 Bone• Bony EAC :

• Skin - thin, devoid of glands, directly adherent to periosteum• Periosteum – heavily innervated by CN5, 7,10, GAN• Severe otalgia even in mild inflammatory reaction

• Cartiliginous EAC: • Skin – thick, ceruminal glands(apocrine, exocrine) and hair follicles• Cerumen – secretions from glands, hydrophobic, acidic, lysozyme

External Auditory Canal (EAC)

• Anteroinferior direction• Horizontal section: S- shaped

• 먼저 Ant , 다음 Post, 다시 Ant• Coronal section:

• 먼저 Sup, 다시 inf• Cf. Auricle traction

EAC Fig by Earmold

• L from behind• EAC cross section• Axial section of the deep external ear canal. The skin and sparse connective tissue lie directly on the bony walls of the deep canal.

Self protection mechanism of EAC

• Cerumen – 귀밥 , 귀지 , Earwax• Do not remove your cerumen. Why?

• Unique feature of EAC skin• continuous centrifugal growth & laterally• prob d/t migrating Keratinocytes in the parabasal cell layers

•

EAC FB with Itching, discomfort

• Impacted cerumen• Foreign body

• Inanimated FB : isthmus 안으로 집어넣지 않도록 유의• Animated FB: 올리브유 , Saline 등 사용

• Otomycosis

EAC infection with Otalgia

• Pain on • Auricle traction , Speculum insertion(Tragal cart)

• Otofuruncle• Hair follicle infection • Staphylococcus, Streptococcus

• Diffuse external otitis• Swimmer’s ear• Breakdown of natural skin protection – pH 6 (acid)• Pseudomonas

Otofuruncle

• Hair follicle infection• Staphylococcus, Streptococcus

Acute Diffuse External Otitis

• Acute external otitis (swimmer’s ear). The inflamed canal has narrowed

• to a slit as a result of edema. Note the absence of cerumen and the peau d’orange appearance of the canal.

(Acute) Diffuse External Otitis• Symptoms:

• pruritus, otalgia varying from sense of fullness to throbbing pain, hearing loss.• Signs:

• Edema and erythema of canal skin, tenderness of tragus, foul-smelling secretions, possible periauricular cellulitis.

• Treatment: • Clean EAC• Topical otic neosporin-polymyxin B (or colistin)-hydrocortisone for gram negative bacilli (mos

t commonly Pseudomonas aeruginosa) for 10 days;• impregnated wick for severe edema; • adequate analgesic.

Chronic (recurrent) otitis externa

• Preventive Measures for Recurrent Otitis Externa: • Ethyl alcohol drops (70%) • acetic acid - nonaqueous solutions (2%) after swimming or bat

hing. • Avoid self-instrumentation.

Chronic external otitis• The hallmarks are atrophy of the skin of the ear canal and stenosis due to chronic irritation. This patient abused cotton-tipped applicators; debris from the canal

with cotton fibers has been pushed medially against the tympanic membrane.

Necrotizing external otitis

• =Skull base osteomyelitis SBO• = Malignant external otitis NEO

• Chronic external otitis in DM patient

SBO• DM complication after Minimal EAC trauma• Symptoms & Signs:

• Progressive pain and drainage from the EAC. • Granulation tissue often present. • Pseudomonas aeruginosa invasion of soft tissue, cartilage and bone. • Occasional facial nerve palsy. • Lower CN palsy Resp arrest Fatal (Malignant EO)

• Treatment: • Radical surgical debridement with combination semi-synthetic penicillin and amino

glycoside for 4-6 weeks. Significant mortality in diabetics who acquire disease.

NEO• A nubbin of granulation tissue sits on the floor of the ear canal at the junction of the bony and cartilaginous portions.

EAC Cancer

• Suspect in chronic external otitis

Osteoma

Myringitis

• TM inflammation without MEE

• Bullous myringitis

• CGM (Chronic granular myringitis)

Bullous Myringitis

Chronic granular myringitis (CGM)• A tongue of granulation tissue can be seen by the umbo and extending to the posterior margin of the tympanic membrane.

Otomycosis

The End

EAC Fig Quiz 1

EAC Fig Quiz 2

Overview

Symptoms TM Audiometry

Disease of Middle ear perforation … Conductive

- External ear ? normal normalcf. pain on TM exam

- Inner ear (cochlea) normal Sensorineural

Aural Speculum

Endaural incision

Auricle cartilage for Rhinoplasty

• Anteriorly based skin/perichondrium flap is reflected anteriorly, exposing the conchal bowl. The optimal site for harvesting the graft is from the ascending portion, or "shoulder," of the conchal bowl, as demonstrated.