Diseases of the

External Ear
DR MUBARAK MOHAMED
ENT LECTURER
Outline

 Anatomy of the external ear

 Diseases of the Auricle

 Diseases of the EAC

 Diseases of the Tympanic membrane

Auricle(Pinna)

 The auricle made of yellow elastic cartilage except the lobule

 Covered with skin

 It has different elevations and depressions on its lateral wall.

 Incisura terminalis is space between the tragus and crus of the helix which is
devoid of cartilage
 Attachment of the auricle to the skull is by
 ligaments anterior, posterior and superior ligaments
 Muscles anterior, posterior, and superior auricular muscles
 Skin
 Cartilage of the external auditory canal
auricle
External Acoustic Canal

 It extends from the bottom of the concha to the tympanic membrane

 Measures about 24mm

 It is not a straight tube

 The canal is divided into two parts: a) cartilaginous and b) bony parts
a) Cartilaginous canal

 Makes the outer part of the canal

 It is a continuation of the auricle cartilage

 It is 8mm long

 It has two deficiencies( fissures of santorini )

 It is covered with skin which contain ceruminous ,pilosebaceous glands which
secrete wax and hair follicles

 Furuncles(staphylococcal infection of hair follicles) are seen in the cartilaginous

canal
b) Bony part

 Inner two-third of the canal

 It is 16mm in length

 Narrowest part is the isthmus in which foreign body can be lodged

 Thin skin lining the bony canal doesn’t have hair and ceruminous glands and it
continuous over the tympanic membrane
Tympanic membrane

 It forms the partition between the EAC and the middle ear

 It is obliquely set as a result, it is posterosuperior part is more lateral than its

anterio-inferior part.

 It is 9-10mm tall, 8-9mm wide and 0.1 thick.

 Can be divided into two parts(pars tensa and pars flaccida)

 It has 3 layers (outer epithelial layer, middle fibrous layer and inner mucosal
layer).
a) Pars tensa

 It forms most of tympanic membrane

 Its periphery is thickened to form the fibricartilaginous ring called the annulus
tymanicus which fits in the tympanic sulcus

 The central part of the pars tensa tented inward at the level of the tip of malleus
and is called the umbo.

 Cone of light can be seen radiating from the tip of the malleus to the periphery in
the anterioinferior quadrant
TM
b) Pars Flaccida

 Forms the upper part of the tympanic membrane

 Situated above the lateral process of the malleus

 It does not have middle fibrous layer

Blood supply

 Major blood supply comes from the posterior auricular branch of external carotid
artery.

 Branches from superficial temporal artery supply the anterior part

Nerve supply of the External Ear

 Sensory innervation
 Lesser occipital nerve C2
 Greater auricular nerve C2,3
 Cranial nerve X (Vagus)
 Cranial nerve V(Trigeminal)
Diseases of the Auricle
A) Congenital Disorders
1) Bat ear(Lop ear)
 this is an abnormally protruding ear.
 the concha is large with poorly developed antihelix and scapha
 It can be corrected surgically after the age of 6years
2) Preauricular appendages
 They are skin covered tags that appear
on line drawn from the tragus to the
angle of the mouth

 They may contain small pieces of

cartilage
3) Preauricular pit or sinus
 Commonly seen at the root of helix and is due
to incomplete fusion of tubercles.

 It may get repeated infection causing purulent

discharge

 Treatment is surgical excision of the tract.

Anotia,Macrotia and Microtia

 Anotia: complete absence of pinna

 Macrotia: Excessively large pinna
 Microtia
- It is major developmental anomaly
- Degree of microtia may vary
- May be unilateral or bilateral
- Associated with EAC, middle ear and inner ear anomalies.
B) Trauma to the Auricle
1. Heamatoma

 It is collection of blood between the auricular cartilage and its perichondrium.

 Due to blunt trauma seen in boxers, wrestlers and rugby players.

 Extravasated blood may clot and then organize, resulting in a typical deformity called
Cauliflower ear.
 Treatment: Aspiration of the heamatoma under aseptic conditions.if aspiration failed do Incision
and Drainage. + antibiotics
2. Lacerations
 Laceration of the auricle is common
condition
 It should be repaired as early as possible
 Use absorbable sutures for the cartilage, and
non absorbable for the skin
 Give the patient broad spectrum antibiotics
3) Avulsion of pinna

 Due to trauma

 If there is pinna attachment do

primary reattachment

 Complete avulsion needs

vascular surgeon
4) Keloid
 It is due to excessive growth of scar tissue
 Usually follows ear piercing or trauma
 Common in lobule or helix
 Common in black
 Treatment: excision of the keloid
 In case of recurrence (radiation / injection of
steroids)
Inflammatory

1) Perichondritis
 Infection of the auricle
 Results from infection secondary to lacerations, haematoma or surgical incisions
 It can also result from extension of infection from diffuse OE, or a furuncle in the
meatus
 Pseudomonas and mixed flora are the common pathogens
 Symptoms: red, hot and painful pinna which
feels stiff. Later abscess formation between the
cartilage and perichondrium

 Treatment: Systemic antibiotics. Drainage of

the abscess and tied dressing or removal part
of the cartilage.
Diseases of the EAC
A. Congenital Disorders

1. Atresia of external canal

 It may occur alone or in association with microtia

 It is due to failure of canalization of the ectodermal core that fills the dorsal part
of the branchial cleft

 Canal is obliterated with fibrous tissue or bone.

 Treatment: Surgical correction

B) Trauma to EAC

 Minor lacerations of canal skin result from injury due to scratching the ear with
hair pins, needles or match stick.

 Major lacerations result from gun shot wounds, car accidents or fights.

 Complication of trauma is ear canal stenosis

C) Inflammation of the External ear
canal
 It is called otitis externa (OE)

 It may be caused by
 infections like Bacteria(localized OE(furunle), Diffuse OE and malignant OE) or
fungal (0tomycosis) or viral (Herpes Zoster oticus and otitis externa haemorrhagica)

 Reactive( Eczematous OE, Seborrhoeic OE and Neurodermatitis)

1.Furuncle( Localised OE)

 A furuncle is a staphylococcal infection of the hair follicle

 There may be single or multiple furuncles

 Clinical presentation: Severe pain and tenderness, pain in aggravated by jaw and
pinna movement. May present with periauricular lymphadenopathy
 Treatment: early stage is treated with antibiotics, analgesia and local heat. Ear
packing with 10% itchthammol glycerine reduce pain and swelling. If abscess
formed Incision and Drainage is needed.
Ear furuncles
2.Diffuse Otitis Externa

 It is diffuse inflammation of meatal skin which may spread to involve the pinna and
epidermal layer of tympanic membrane.
 Cause: seen in humid climate, Excessive sweating and trauma or secondary to CSOM

 Common causative agent: Staph aureus, pseudomonas, E.choli or mixed microbial

infection

 Clinical presentation: may be acute phase which is characterized by hot burning

sensation in the ear, followed by pain and serous discharge. Chronic phase
characterized by irritation and strong desire to itch with meatal swelling and increase
in the amount of discharge
 Treatment
 Ear toilet
 Ear packing
 Analgesia
 Antibiotics
3. Otomycosis
 Is a fungal infection of the EAC

 Seen in hot and humid climate , in immunocompromised patient secondary to

topical antibiotic over use

 Causative agent: Aspergillus niger, A, fumigatus or Candida albicans

 Clinical presentation: intense itching, discomfort or pain in the ear, watery

discharge with a musty odour , and ear blockage.

 Otoscopic examination shows blakish/pale/whitish filamentous growth

Otomyscosis
 Treatment:
 Ear should be kept dry

 Ear toilet to remove all discharge and

epithelial debris

 Antifungal ear drops or ointment

( Clotrimazole or nystatin )
 Treatment of the underlying cause like
diabetes
4. Herpes Zoster Oticus
 Also called Ramsy-Hunt syndrome

 Caused by herpes zoster or herpes simplex

in the external ear canal and facial nerve

 Clinical presentation: triad( vesicles in the

EAC and concha, Ear pain, ipsilateral facial
nerve palsy)

 Management: Analgesics, Steroid and

Antiviral(Acyclovir tabs)
5.Malignant (Necrotising) OE
 It is inflammatory condition of the Ear and the skull base
 Caused by pseudomonas infection
 Common in elderly diabetic patients and immunocompromised pt
 Presents like diffuse otitis externa but the infection spreads to
skull base, jugular foramen , mastoid and TMJ.
 Investigation: Ct scan
 Treatment:
 high dose iv antibiotics for 6-8weeks
 Surgical debridement
 Control diabetics
E. Noninflammatory conditions
1. Impacted Wax
 Wax is produced in EAC only

 Is composed of secretion of sebaceous glands, ceruminous glands, hair, desquamated

epithelial debris, keratin and dirt.

 Wax is protective function as it lubricates the ear canal and entraps any foreign
material

 Normally, only small amount is secreted and expelled from the meatus
 Cause of wax impaction: narrowed
EAC, excessive wax production or
obstruction lesions of the EAC.

 Clinical presentation: sudden hearing

impairment, blocked sensation, and
tinnitus.

 Treatment: removal of wax by

 Ear syringing( warm water]
 Instrumental manipulation ( Cerumen
hook or probe)
wax
Foreign body of the ear

 Type of Foreign bodies in the ear

 Living: Maggots, insects
 Non-living :
 Vegetables( seeds,)
 Non-vegetable( stone , Beads, plastic or metal)

 Incidence: Common in children and mentally ill patient

 Clinical presentation: irritation, pain, decrease hearing .irritable sensation and noise
in the ear.
Methods of removing a foreign body

 Forceps

 Ear Syringing

 Suction

 Microscopic removal with special

instruments

 Postauricular approach
Diseases of tympanic membrane
Trauma of the tympanic membrane
 Tympanic membrane may be ruptured by trauma due to
 Faulty technique of cleaning the ear
 Forceful syringing
 Sudden change in air pressure e.g a slap or kiss or forceful blowing
 Blast
 Fracture of temporal bone.
 Clinical presentation:
 Symptoms: pain in the ear, Discharge, decrease hearing and tinnitus
 Signs: blood seen in the EAC , perforation of the tympanic membrane and conductive HL
 Treatment:
 Water precaution
 Antibiotics , anti-inflammatory and nasal
decongestants
 If perforation persists; edges of tympanic
membrane should be repositioned.
 If all the above failed, Myringoplasty or
tympanoplasty should be done to close the
perforation
Tympanic membrane perforations

 Can be central, attic

or marginal and are
associated with
chronic otitis media
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