Ear and eye disorders

• Otitis media• Conjunctivitis

Otitis media Inflammation of the middle ear Common in children types

Acute suppurative otitis media Serous otitis media Chronic suppurative otitis media

Acute suppurative otitis media Etiology

Streptococcus pneumoniae Haemophilus influenzae

Acute suppurative otitis media Predisposing factors

Recurrent upper respiratory tract infection Tonsillitis Cleft palate

Route of infection Via eustachian tube Via external ear Haematogenous route (uncommon)

ASOM: Pathogenesis URTI- usually viral origin Edema of the nasopharyngeal end of ET ET blockage Negative pressure in the middle ear Promotes invasion of pyogenic organism Acute suppurative inflammation Tympanic membrane bulges outward and perforates Release of pus in the external ear Followed by resolution If persistence of infection spread of infection with various complications

ASOM: Complications Acute mastoiditis Facial paralysis Labyrinthitis Extradural abscess Meningitis Brain abscess

Acute suppurative otitis media: morphology Gross:

Edematous and congested middle ear mucosa Haemorrhage Middle ear cavity may be filled with pus

Microscopy: Neutrophilic infiltration in the mucosa Osteoclastic destruction of the mastoid bone Fibrosis

Serous otitis media Insidious onset Accumulation of non-purulent effusion in

the middle ear cleft

Chronic suppurative otitis media Chronic infection of the middle ear cleft Common in developing countries

Types of CSOM Tubotympanic- safe or benign type Atticoantral- unsafe or dangerous type

CSOM- tubotympanic type Involves anteroinferior part of middle ear

cleft Central perforation No risk of serious complications

CSOM- atticoantral type Involves posterosuperior part of middle ear

cleft (attic, antrum, posterior tympanum, mastoid

Attic perforation of tympanic membrane Associated with cholesteatoma Risk of serious complications

CSOM Etiology

Sequelae of acute otitis media Causative organisms

Gram negative bacilli proteus species pseudomaonas aeruginosa

CSOM- tubotympanic type: Morphology

Involvement of anteroinferior part of the middle ear cleft with central perforation of tympanic membrane

Aural polyp (granulation tissue) protuding out thru’ perforation

Loss of ossicular bone

CSOM- atticoantral type: morphology Involvement of posteriosuperior part of middle

ear with attic perforation of tympanic membrane

Osteitis Ossicular necrosis Cholesterol granulomas Cholesteatoma- stratified squamous epithelium

with underlying thin fibrous stroma and central keratin debris- tendency to erode bone and surrounding structures

Clinical features‘TT’typeEar discharge- mucoid or mucopurulent Hearing loss- conductive typeCentral Perforation‘AA’ typeEar discharge- foul smellyHearing loss- mostly conductive typeBleeding Attic perforation

Conjunctivitis Inflammation of conjunctiva

RED EYE

Types of Conjunctivitis Based on duration

Acute subacute Chronic

Conjunctivitis: etiology

Infectious causes Bacterial Viral Fungal Chlamydial parasites

Non-infectious Allergic Irritants Autoimmune Toxic Idiopathic

Bacterial conjunctivitis Causative agents:

Staphylococcus aureus (common) Haemophilius aegyptius H. influenzae

clinically manifest as acute purulent or mucopurulent conjunctivitis

Conjunctiva Hyperemia, edema (chemosis) mucopurulent or purulent discharge

Viral conjunctivitis Common causative agents

Adenoviruses Paramyxoviruses Herpes simplex

Watery clear or serous discharge

Trachoma Form of chronic conjunctivitis (>4wks

duration) caused by chlamydia trochomatis serotypes

A,B,C Endemic in many parts of the world Contagious in the acute stages Common in unhygienic and crowded

surroundings One of the leading cause of blindness

Trachoma

WHO classification (FISTO) Trachomatous Follicles – active disease Trachoma Intense- severe disease requiring

urgent treatment Trachomatous Scarring- old inactive disease Trachomatous Opacities- corneal opacities

with visual loss

Trachoma

Tumors of eye: classificationEye lid tumor- Basal cell carcinoma, Sebaceous carcinoma

Contd.Tumors of conjunctiva Benign: Squamous papilloma

Conjunctival nevi Malignant: Squamous cell carcinoma Melanoma

Tumors of uvea(choroid, iris, ciliary body) Benign-uveal nevi Malignant- melanoma

Tumors of retina Retinoblastoma Retinal lymphoma

Tumours of optic nerve Pilocytic astrocytoma Meningioma

Tumours of orbit: Mesenchymal tumoursBenign Lipoma Haemangioma Schwannoma Neurofibroma Osteoma Chondroma

Malignant tumours Angiosarcoma Chondrosarcoma Malignant nerve

sheath tumours

Tumours of lacrimal gland Pleomorphic adenoma

Retinoblastoma Commonest intraocular malignancy Children Hereditary sporadic

Retinoblastoma: morphology Gross:

exophytic or endophytic retinal growth Creamy whitish in colour with areas of

calcification and necrosis

Retinoblastoma : microscopy

Sheets of small round cells with scant cytoplasm and hyperchromatic nucleiFlexner-Wintersteiner rosettesNecrosis

Well differentiated retinoblastoma

metastasis Brain Bone marrow Prognosis poor

Skin

Macroscopic terms Macule- flat circumscribed, 0.5cm Papule- raised, 0.5cm Vesicle-raised, fluid filled, 0.5cm Pustule- pus filled raised lesion Nodule- raised, >0.5cm

Skin diseases Infections Dermatitis Tumors

Skin infections Bacterial Viral fungal

Bacterial infections Furuncle, boil, carbuncle Impetigo

Furuncle/boil/carbuncle Causative organism- staphyoloccoci Hairy areas- face, axilla Furuncle- Focal suppurative inflammation of

the hair follicle Boil - abscess point Carbuncle- Deep suppuration beneath the

subcutaneous fascia and superficial multiple sinuses

Boil and carbuncle

Impetigo Organisms:

Group A beta hemolytic streptococci Staphylococcus aureus

Common infection in children Site: Face, hands Gross examination- Erythematous macule to small

multiple pustules that ruptures and appears as honey coloured crusted lesion

Microscopic examination- subcorneal pustule

Viral infections Verrucae(warts) Cold sores(herpes simplex)

Verrucae (Wart) Caused by Human papilloma virus (HPV) Direct contact or autoinoculation Any age group Self limiting disease Verrucae vulgaris – common type – hands Flat to raised papules with rough surface Microscopy: Papillomatous hyperplasia

Herpes simplex virus infection Commonly known as Cold sores- mucocutaneous

junction Lip, nose Causative agent: HSV1 & HSV2 Acute primary infection- replication of viruses in the

epidermis-> vesicular eruptions Latent infection-Via sensory nerve spread to the sensory

ganglion and remain in dormant phase ( no replication) Recurrent infection- reactivation of latent viruses-

spread to the skin and mucous membrane from the affected ganglion

Superficial fungal infections Dermatophytes Candidiasis

Superficial dermatophytoses Limited to the stratum corneum Reservoirs- soil, animals

Types of dermatophytoses Tinea capitis- Scalp Tinea corporis-Body Tinea cruris- Inguinal region Tinea pedis- foot web space Tinea versicolor- Upper trunk

Microscopic feature- Hyphae and yeast in the stratum corneum

Tinea corporis (ring worm)

Appears as a circular scaly raised area with clearing in the centre

Cutaneous candidiasis Yeast- candida albicans Nail, nail folds, webs of fingers and toes,

perineum of infants- diaper rash Microscopic features-Yeast like forms and

pseudohyphae

Cutaneous candidiasis

Dermatitis Inflammation of the skin secondary to

immune reaction Acute chronic

Acute eczematous dermatitis Acute immune mediated inflammatory

lesion Red papulovesicular oozing lesion

PathogenesisDelayed type of hypersensitivity reaction Exposure to antigen in the epidermis Sensitization of T lymphocytes and production of T

memory cells On repeated exposure to same antigen, T cells

recruitment at the site of antigenic exposure Release of cytokines Recruitment of inflammatory cells Inflammatory response Occurs within 24 hrs

Chronic dermatitis: Seborrheic dermatitis Chronic inflammatory disease Region with high sebaceous glands- scalp,

forehead Fungal infection- malassezia furfur

Clinical appearnance Macules and papules with greasy base Scaling and crusting Dandruff of the scalp

Psoriasis Common chronic inflammatory disease All ages affected Association with- arthritis, myopathy,

enteropathy T cell mediated inflammation Results in proliferation of keratinocytes,

angiogenesis and inflammation

Clinical features Site of affection- elbows, knees, scalp,

lumbosacral areas, intergluteal cleft Scaly plaque- silver white in colour Nail changes-yellow brown discolouration

with pitting

Lichen planus Chronic inflammatory disorder Self limiting disease Cell mediated immune reaction Malignant transformation in chronic

mucosal lesions

Clinical features Itchy lesions Flat topped papule – coalesce – plaque Dark brown color in dark skinned

individual due to loss of melanin pigment Multiple lesions, symmetrical distribution-

extremities- wrist, elbows

Malignant Tumors of skin Squamous cell carcinoma Basal cell carcinoma Melanoma

Squamous cell carcinoma It is the 2nd most common skin malignancy Sun exposed area Men>females Elderly age group

Predisposing factors Sun exposure Chronic ulcers Old burn scars Ionizing radiation Industrial exposure to carcinogens- tar

UV light – DNA damage- cancer development

Squamous cell carcinoma

Cauliflower like growth orUlcerated lesion

Morphology Tumor arising from epidermal epithelium Invades basement membrane and infiltrates

underlying dermis Nests of malignant tumor cells Stratification Keratin pearls in well differentiated tumors Necrosis- poorly differentiated tumors

Squamous cell carcinoma

Basal cell carcinoma Most common skin tumors Sun exposed areas- face Slowly growing tumors Rarely metastasize Locally invasive- rodent ulcers

morphology Ulcerated lesion with pearly white borderMicroscopic examination- Arises from the basal layer of the epidermis or follicular

epithelium Nest of tumor cells resembling basal layer of the epidermis Peripheral palisading Retraction artifact Cells- small, scant cytoplasm, round to oval hyperchromatic

nuclei Mucoid stroma Inflammatory infiltration in the stroma

Basal cell carcinoma

Basal cell carcinoma

Malignant melanoma