www.manchester-

ent.co.uk

A Practical Guide to Diseases

of the Ear

Simon Lloyd

Consultant ENT Surgeon

Manchester Royal Infirmary

www.manchester-

ent.co.uk

External Ear

• Otitisexterna

• Ramsey Hunt syndrome

• Foreign bodies

• Exostoses

• Lesions of the pinna

www.manchester-

ent.co.uk

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

www.manchester-

ent.co.uk

Symptoms &Signs - Bacterial

• Otalgia - severe

• Purulent otorrhoea

• Deafness

• Inflammation of ear canal +/-pinna

www.manchester-

ent.co.uk

Treatment

• Swab for sensitivities

• Aural toilet

• Splinting of ear canal

(Pope wick)

• Topical antibiotics eg.

Sofradex, Gentasone

• Keep dry

www.manchester-

ent.co.uk

Malignant OtitisExterna

• 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

www.manchester-

ent.co.uk

Symptoms & Signs - Fungal

• Itching

• Mild otalgia

• Fullness

• Greyish white debris

+/- fungal spores

www.manchester-

ent.co.uk

Treatment

• Aural toilet

• Topical antifungal agents eg. Canestan

www.manchester-

ent.co.uk

Furunculosis

• Staph. infection of

hair follicle causing

abscess formation

• Severe otalgia

• Requires I&D

www.manchester-

ent.co.uk

Ramsey Hunt Syndrome

• Herpes zoster

• Geniculate ganglion of facial nerve

• Vesicular rash of pinnaand ear canal (+/- mouth and tongue)

• Facial nerve palsy

• Painful

• Vertigo

• Treatment– Analgesia

– Antiviralseg. Acyclovir

– Protect the eye

www.manchester-

ent.co.uk

Perichondritis

• Inflammation of perichondrium

• Aetiology:– Ear piercing

– Laceration

– Surgery

– CT disease

• Treatment:– Antibiotics

– I & D (if abscess)

• Sequelae: – Cauliflower ear

www.manchester-

ent.co.uk

Foreign body in ear

www.manchester-

ent.co.uk

Hyperostosis

• Exostosis

– Multiple bony swellings in

deep canal

– Cold water

– Asymptomatic

– No treatmentunless large

• Osteoma

– Single benign bony

tumour outer bony

meatus

– No treatment unless

large

www.manchester-

ent.co.uk

First Branchial Cleft Anomalies

Pre-auricular sinus

www.manchester-

ent.co.uk

First Branchial Cleft Anomalies

Accessory Auricle

www.manchester-

ent.co.uk

Benign Skin Pathology

SeborrhoeicKeratosisGouty Tophi

Solar keratosis

www.manchester-

ent.co.uk

Benign Skin Pathology

Chondrodermatitishelici

snodularischronica

Keloid ScarringDarwin’s tubercle

www.manchester-

ent.co.uk

Malignant Skin Pathology of The

Pinna

Basal Cell Carcinoma

Squamous Cell Carcinoma

www.manchester-

ent.co.uk

Middle Ear

• Otitis media

– Acute

– Chronic otitis media +/- cholesteatoma

– Otitis media with effusion

– Complications

• Tympanic membrane perforation

• Hearing loss

– Conductive

www.manchester-

ent.co.uk

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, Bramhamellacatarrhalis)

• Risk Factors– Poor sanitation/ hygiene and parental smoking

– Exposure to other children

– Eustachian Tube Dysfunction

– ? allergy

www.manchester-

ent.co.uk

Natural History

Infection 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

www.manchester-

ent.co.uk

Acute Otitis Media

www.manchester-

ent.co.uk

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

www.manchester-

ent.co.uk

Acute Mastoiditis

• History of acute otitis

media

• Infection spreads to

mastoid

• Post-auricular abscess

• Treatment

– Grommet

– Cortical mastoidectomy

www.manchester-

ent.co.uk

Intracerebral Abscess

Ring

enhancement

with contract

enhanced CT

www.manchester-

ent.co.uk

Lateral Sinus Thrombosis

Filling defect

on MRA

www.manchester-

ent.co.uk Tympanic Membrane

Perforation• Causes

– Trauma

– Otitis media

– Iatrogenic eg. Grommets

• Symptoms

– None

– Recurrent otorrhoea

– Hearing loss

www.manchester-

ent.co.uk Tympanic Membrane

Perforation

• Treatment

– None

– Myringoplasty

– +/- ossiculoplasty

Graft is placed under perforation to allow epithelium to regrow

Myringoplasty

www.manchester-

ent.co.uk

Ossiculoplasty

www.manchester-

ent.co.uk

Chronic OtitisMedia

• 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

www.manchester-

ent.co.uk

Chronic Otitis Media

• With cholesteatoma

• Eustacian 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

www.manchester-

ent.co.uk

Cholesteatoma

www.manchester-

ent.co.uk

Chronic Otitis Media with

Cholesteatoma

www.manchester-

ent.co.uk

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

www.manchester-

ent.co.uk

Chronic OtitisMedia with

Cholesteatoma

Post-auricular incision Mastoid air cells drilled away

Posterior ear canal removed to leave

mastoid cavity

www.manchester-

ent.co.uk

Conductive Hearing Loss

• External ear– Wax

– Foreign bodies

– Otitisexterna

• Middle ear– Middle ear effusion

– Tympanic membrane perforation

– Ossicular damage/fixation

– Otosclerosis

www.manchester-

ent.co.uk

Inner Ear

www.manchester-

ent.co.uk

Sensorineural Hearing Loss

Cause Examples

Hereditary Pendreds syn.,Alports syn., NF2, Pagets

Infection Ramsey Hunt syn., Syphilis, meningitis

Ischaemia CVA, Sickle cell disease

Inflammation Autoimmune disease eg. Rh. Arthritis

Neoplastic Vestibular Schwannoma

Trauma Head injury, ototoxicity

Degenerative Presbycusis

Others Menieres syn., noise induced

www.manchester-

ent.co.uk

Sudden Hearing Loss

• Normal TM with sudden hearing loss

• Aetiology unknown• Viral

• Vascular

• Rarely acoustic neuroma, perilymph leak

• May be unsteady or vertiginous

www.manchester-

ent.co.uk

Sudden Hearing Loss

Management

• Refer urgently

• Treatment options

• Oral steroid

• Antiviral• No evidence for efficacy

• Carbogen• No evidence for efficacy

• Intratympanic steroid• Weak evidence for efficacy