external and middle ear disease for g ps
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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