otitis externa

otitis media
Impacted cerumen

Diffuse otitis externa and

eczema

Circumscribed
furuncle

Necrotizing

Circumscribed lesion
caused by acute
baccterial infection of
cartilagionus portion of
ear canal
Pathogen
esis:

Inflam. Condn of EAC

involving canal skin(eczema,
dermatitis, 2mech. Injury,
toxicity, allergy)acute
bacterial infection w/ mixed
flora of gm (-) orgs.
(P.aeruginosa, P. mirabilis) and
anaerobes *warm moist envt
promote devt of DOE
swimmers otitis

Local mechan.
Trauma&contamination
of ear canal(eg. Ear
plug, dusty envt, bath
water)obstruction of
hair follicles/glandular
ductsstaphylococcal
infection of
pilosebaceuos units

>Dangerous form of
OE
>occur almost
exclusively in older
pts. w/ DM
>simple
OEinfected w/ P.
aeruginosaulcerati
on and osteitis of
foor of ear
canal*bone infection
may subsequently
spread to middle ar,
skull base,
retromandibular
fossa and parotid
compartment

Symptom
s

>Main initial -itching

>pain - present w/ acute
infection
>obstn of ear
canalconductive hearing loss

Very painful, tender

swelling that can cause
mild hearing loss

>Initial hx: insidius

persistent OE doesn't
heal
>moderate
painsevere as the
condition takes a

Diagn
osis

Diffuse otitis externa

and eczema

Circumscribed
furuncle

Necrotizing

Eczema of ear canal, w/o

acute infection: canal skin
is dry, cracked and scaly

I&P: tragal tenderness

accompanied by a
circumscribed, very painful
swelling in cartilaginous portion
of ear canal
Otoscopy: pronounced swelling
of ear canal w/ debris in residual
lumen
Simple hearing test: canal
may be swollen shutsome
degree of conductive hearing
loss
Bacteriologic exam: purulent
center can be opened w/ a small
blunt hook to obtain a smear
*recurrent furuncles should
prompt examination for
predisposing syst. Condition e.g.
DM

I: signs of infxn in
surrounding tissues
Otoscopy: almost
always show ulcer on
canal flr. w/ exposed
brownish bone and
fetid discharge
Smear: P. aeruginosa
CT: extent of
infection and bone
destruction
*DM almost always
present, other
immune defects
should be excluded

>Spread to auricular
cartilageperichondritis

Otitis media,
mastoiditis, petrositis,
soft tissue abscess,
cranial nerve deficits (
VII, VIII, IX, X, X1),
sepsis, venous sinus
thrombosis,
meningitislife
threatening

Infection:diffuse swelling
>fetid
dischargeanaerobes
*Bacteriologic examnecessary only in pesistent
r recurrent infection/
diagnosis is uncertain

Compl
icatio
ns

Cracked skin inOE can

allow bacterial
entryperichondritis,
,cellulitis or abscess
formation
*necrotizing OE may
develop in predisposed pts.

>Superinfection w/
Pseudomonasnecrotizing OE

Diffuse otitis externa

and eczema

Circumscribed
furuncle

Necrotizing

Treatment

>1st , most impt. Stepmeticulous, repeatd

cleansing and drying of
ear canal followed by
instillation of antiseptic,
antibiotic drops that will
reduce the swelling

Ear canal-meticulously
cleaned then treated
locally for 1-2 days w/
70% alcohol(applied
hourly to a self
expanding foam/gauze
wick inserted to the ear
canal)*
Crusts-dissolved w/
antibiotic containing
ointment strips
After swelling
subsides-antibiotic
containing ointment
strips instilled
*nsaids-administered for
pain
Abscesses-incised once
clearly demarcated
*systemic antibioticsystemic
symptoms/severe local
signs of infection

Otitis
Externa

Acute Otitis
Media

Chronic
Otitis Media

Tragal pain

present

absent

absent

Ear Canal

swollen

normal

normal

Ear drum

n/red

Bulging/small
perforation

perforated

Discharge

Sticky/yellowi
sh

Mucoid discharge thru a TM

perforation

Nodes

frequent

Less frequent

Fever

(+)

(+)

Hearing

Normal or

(-)

OTITIS EXTERNA
>usually refers to inflammation of the
external auditory canal
>its not always easy to distinguish
among various inflammatory
conditions of the external ear
*a profuse, mucopurulent aural
discharge often originate in the
middle ear and not in the external
ear

External auditory canal

Diffuse
Circumscibed
Necrotizing
Bullous
otomycosis

Diffuse otitis externa

Pathogenesis:
Inflammatory condition of external
auditory canal involving canal
skin(eczema, dermatitis, 2mech. Injury,
toxicity, allergy)
acute bacterial infection with mixed flora of
gm (-) orgs. (P.aeruginosa, P. mirabilis)
&anaerobes
*warm moist environment promote

Symptoms
>itching- Main initial
>pain - present w/ acute infection
>conductive hearing loss 2 obstn of ear canal

Diagnosis
Eczema of ear canal, w/o acute infection: canal skin
is dry, cracked and scaly
Infection:diffuse swelling
*fetid dischargeanaerobes

Complications
Cracked skin in OE
can allow bacterial entry
perichondritis,cellulitis or abscess formation
*necrotizing OE may develop in predisposed
pts.

Treatment
>1st , most impt. Stepmeticulous, repeated
cleansing and drying of ear canal
followed by instillation of antiseptic,
antibiotic drops (reduce the swelling)

Circumscribed
furuncle

Circumscribed lesion caused by acute bacterial

infection of cartilaginous portion of ear canal
Pathogenesis:Local mechanical
Trauma&contamination of ear canal(eg.Ear plug,
dusty envt, bath water)
obstruction of hair follicles/glandular ducts
staphylococcal infection of pilosebaceuos units
Symptoms: Very painful, tender swelling that can
cause mild hearing loss

Diagnosis:
I&P: tragal tenderness accompanied by a circumscribed,
very painful swelling in cartilaginous portion of ear canal
Otoscopy: pronounced swelling of ear canal w/ debris in
residual lumen
Simple hearing test: canal may be swollen shutsome
degree of conductive hearing loss
Bacteriologic exam: purulent center can be opened w/ a
small blunt hook to obtain a smear
*recurrent furuncles should prompt examination for
predisposing syst. Condition e.g. DM

Complications:

>Spread to auricular
cartilageperichondritis
>Superinfection w/
Pseudomonasnecrotizing OE

Treatment:
Ear canal-meticulously cleaned treated locally for 1-2 days
w/ 70% alcohol* (applied hourly to a self expanding
foam/gauze wick inserted to the ear canal)
Crusts-dissolved w/ antibiotic containing ointment strips
After swelling subsides-antibiotic containing ointment
strips instilled
Abscesses-incised once clearly demarcated
*nsaids-administered for pain
*systemic antibiotic-systemic symptoms/severe local signs of
infection

Necrotizing Otitis Externa

>Dangerous form of OE
>occur almost exclusively in older pts. w/ DM
Pathogenesis:
>simple OEinfected w/ P. aeruginosaulceration
and osteitis of floor of ear canal
*bone infection may subsequently spread to middle
ear, skull base, retromandibular fossa and parotid
compartment

Symptoms:
>Initial hx: insidious persistent OE doesn't heal
>moderate painsevere as the condition takes a
chronic course

Diagnosis:
I: signs of infection in surrounding tissues
Otoscopy: almost always show ulcer on canal
floor. with exposed brownish bone and fetid
discharge
Smear: P. aeruginosa
CT: extent of infection and bone destruction
*DM almost always present, other immune defects
should be excluded

Complications:

Otitis media, mastoiditis, petrositis,

soft tissue abscess
cranial nerve deficits (VII, VIII, IX, X, XI)
sepsis, venous sinus thrombosis,
meningitislife threatening

Treatment:

Ear Canallocally debrided, cleaned at regular

intervals
*minimal bone involvementhigh dose antibiotic
effective against P. aeruginosa admin. x 6 weeks
*DM-closely monitored and adeq. Controlled
>poor response to conservative treatment/
extensive involvement/ if complications
ariseaffected bone is resected

Bullous OE
Pathogenesis:
>Flu-related/ hemorrhagic Otitis externa presumed to
have viral etiology but exact causal agent is unknown
>influenza virus-isolated in sporadic cases
>infectiontoxic capillary damage in thin epithelial layer
of meatal skin & tympanic membraneformationof
hemorrhagic epithelial Bullae

Symptoms:
>disease begins w/ severe otalgia of sudden onset
>often followed by a bloody discharge from Ear canal
>both conductive & sensorineural hearing loss-may develop
Diagnosis:
Otoscopy: serous or hemorrhagic bull formationnseen on bony portion of
ear canal / TM
>rupture of bullaspontaneous Bleedingdries, forms crust
Diff. Dx:
Toxic or traumatic injury to EC or middle ear (barotrauma)
Complications:
Middle/ inner ear involvement (labyrinthitis)associated sensorineural
hearing loss, and vertigo
Treatment:
Specific antiviral treatment-n/a
local anesthetic Ear drops & nsaids-Pain
Systemic antibiotics-suspicion of bacterial involvment of middle/inner ear

Pathogenesis:
Otomycosis

>cerumen often harbors saprophytic fungi that

have no specific pathologic significance
>Aspergillus, Candida albicans, Mucor,
&dermatophytes
may aggressively infect skin of medial ear
canal if milieu has been altered (by the use of
steroid & antibiotic containing ear drops)

Symptoms: severe itching and feeling of

fullness (less by pain)

Diagnosis:
otoscopy:fungi appear as white, yellow, or
black membrane lining the swollen
erythematous skin of ear canal
*bony portion of canal-affected almost
exclusively
>Mycelia-can be identified in direct samples
Causative org. established by microbiologic
exam.

Course: refractory course, has a tendency to recur

Complications:
Fungal infection of TM epithelium perforation &
subsequent otitis media
Treatment:
Ear cleaning & drying thoroughly-essential
local antimycotics can be administered
*salicylate containing solution-soften uppermost
epithelium Layerenhance antifungal action of
medication
*Systemic antimycolytic tx-immune suppressed pts.

Otitis media

Acute OM
Recurrent acute OM
Otitis media w/ effusion
Chronic Suppurative Otitis Media
Chronic Otitis Media w/
cholesteatoma

Otitis media

Epidemiology: common in infants & small

children but may occur at any age
50% of infants:1 or more episode in 1st yr of life
Pathogenesis:
Infection that ascends to middle ear through
Eustachian tube
Bacteria isolated in 2/3 of cases
S.pneumoniae
H. Influenzae
main causative org.
B. Catarrhalis
Respiratory virus-1/3 of cases
*adenoid-frequent nidus for infection in children,
even if unenlarged

 Factors that:
Increase risk:
Craniofacial anomalies, previous
episode of acute OM or presence
of chronic serous OM
Parental smoking
Leaving infants at day care
centersexpose to a particularly
harmful microbiological flora
Decrease risk:
Extending period Of breastfeeding

Symptoms:
initial: severe earache
*babies: rubbing affected ear or by
nonspecific symptoms
Fever-usually present during 1st 24
hours
*infants:nonspec.: irritability,
vomiting, diarrhea
>perforation of TM-aural discharge
and improvement or resolution of
otalgia

Diagnosis:
Pe:mastoid shows no swelling but may be
moderately Tender to pressure
Otoscopy:opaque, thickened, erythematous,
sometimes bulging TM
*TM-immobile by pneumatic otoscopy
Conductive hearing loss-present
Bacteriologic exam: not performed when
TM is intact, * should always be done in
spontaneous rupture
Complication: acute mastoiditis-most
common
Tx: nsaids or acetaminophen-pain relief
*decongestant nose drops or irrigations-may
be necessary for relieving nasal obstruction

Recurrent Acute Otitis Media

Occurrence of 5 or more
acute middle ear
inflammations in 1 year
3 episodes w/in 6
months
Due to
relapse/reinfection
Middle ear heals
between episodes
No effusion present in
tympanic membrane
A disease of infants
and children

Recurrent Acute Otitis

Media
Treatment
Prophylactic antibiotics-effective but controversial
due to devt of resistance

Vaccinations against pneumococci can help

prevent new episodes

Adenotomy - can decrease the bacterial burden in

the nasopharynx and improve eustachian tube
dysfunction

Serous Otitis Media

Definition: refers to
an inflammatory
effusion behind an
intact tympanic
membrane not
associated with acute
otologic symptoms or
systemic signs
Classified as:
Acute-upto 3 weeks
Subacute-upto 3
months
Chronic >= 3 months

Serous Otitis Media

Epidemiology:most common ear

disease in preschool age. Generally
both ears are affected
Symptoms: hearing loss, speech and
language developmental delay &
perceptual impairment may occur in
bilateral cases

Diagnosis:
Made otoscopically:
tympanic membrane often appears opaque,
thickened, and occasionally retracted
Color may be pale, reddish, yellowish or bluish
depending on the effusion

Pneumatic otoscopy-decreased or absent

mobility of tympanic membrane

Complication: most frequent-acute otitis

media
Treatment:
Acute/ subacute form-conservatively
Chronic form-surgically if significant hearing loss
is present, paracentesis(incision of the tympanic
membrane)-provide access for aspiration of
effusion which will immediately restore the
hearing loss
Incision closes spontaneously in 1-2
weeks,allowing new fluic collection to
formprevented by inserting a myringotomy tube
Myringotomy tube-not impair hearing but is
associated with risk of middle ear infection from
ear canal

Chronic suppurative Otitis Media

chronic tympanic membrane
perforation, even without active
signs of mucosal inflammation
TM perforation heal spontaneously
In few wks, non healingresult of
chronic Inflammationn

May be dry

(w/o active signs of

inflammn eg. Pain discharge, &
swelling)or wet/draining (bacteria
have infected middle ear through the
nonintact TM; may be acute or chronic )

*Hence clin. Man./otoscopic appearance change

over course of the disease

Pathogenesis
Usually multifactorial, following factors
Play a role:
Chronic inflammation 2 Eustachian
tube dysfunction

Genetic & constitutional factor that

affect healing capacity & resistance of
mucosa
Special anatomic char. Of middle
ear( pneumatization & relative sizes)
Nature, pathogenicity, virulence &
resistance of infecting org.

 symptoms
Initially:chronic otorrhea(gen.
mucopurulent discharge through
the non intact TM)
Infection clears, few or no
symptoms other than variable
degree of hearing loss
Recurrence:may cause pain(not
always present)

Diagnosis
Hx and otoscopic findings
Examn reveals:
Made from

Central perforation in TM( appreciated only in

dry ear)

TM and middle ear may show addtl

features: calcifications, atrophic areas, retractions,
ossicular destn
Conductive hearing loss-more pronounced in
draining ear
*smear should be taken for bacteriologic examn

Treatment:
Local measures:
Repeated, meticulous cleansing and drying of ear
Ear drops that contain ototoxic subst. (aminoglycoside) if used at
all, should be used only for acute swelling and for <3days
Adeq. protection while bathing(ear plugs) To prevent reinfection
*acute supppurative episodes occasionally require systemic
antibiotics but not consistently necessary
(selection should be directed by sensitivity testing)

When ear has been dry for approximately 3 months,

surgical closure of tympanic membrane can be performed
(tympanoplasty)
Chronic, intractable supppuration-require ablative surgery
of middle ear(mastoidectomy or modified radical operation)

 Course
May be dry for years and cause
few complaints, if any
May present with recurrent or
persistent otorrhea depends in large
on pts diligence in protecting ear & practicing
aural hygiene

Complications
Mastoiditis or abscess formn-rare and atypical
In chronic cases-conductive hearing loss is gen.
accompanied by devt of cochlear hearing
lossprob. the result of toxic serous labyrinthitis

Chronic Otitis Media w/ cholesteatoma

Formed by squamous epithelium w/in middle ear
cleft starting as a retraction pocket in the
TMresults in accumulation of keratotic debris
Visible through the perforation as keratin flakeswhite & smelly
Expands & damages vital structures such as
dura. Lateral sinus, facial nerve and lateral
semicircular canal.*potentially lethal if untreated

gen. Definition
Osteoclastic inflammn of mucosal spaces
in middle ear
Often w/ coexisting infection

Epidemiology:occur at any age group, rare

in small children
Pathogenesis:
Primary cause:impairment of middle ear
ventilation

 Eustachian tube dysfunction

causes a neg. pressure to
develop in middle ear (continous- tubal
patency; transient-negative pressure in
nasopharynx eg. sniffing)

Retraction pocket forms in TM(lined by sq. epit. That

tend to migrate on TM and ext. canal)

On entering middle ear, causes inflammation and

bone resoption

Secondary infection of squamous debris further

intensify these effects

 Treatment
Surgical-due to bone destruction
Main goal:eradicate
inflammatory process in mastoid
and tympanic cavity
2nd line goal:improve hearing
(tympanoplasty)

Otogenic complication of otitis

Complication
sequelae

Temporal bone
Middle ear
Facial nerve paralysis, TM perforation

Mastoid
Petrositis, reduced pneumatization

Inner ear
Labyrinthitis
Sensorineural hearing loss

Extratemporal
Intracranial
Brain abscess, meningitis,etc.

Extracranial
Zygomatic abscess, postauricular abscess

Impacted Cerumen
Cerumen or earwax is produced
by cerumen and sebaceous
glands in skin of ear canal
Forms a protective film in which
fatty acids, lysozymes and
creation of acid milieu effectively
protect the skin of the ear canal
from various bacterial infection
Self cleansing of the ear canal,
with natural removal of
accumulated cerumen is
normally accomplished by
epithelial migration from
tympanic membrane toward the
external meatus

Impacted Cerumen
pathophysiology

Cerumen impaction may result

from a disturbane in the normal
slef cleasing mechanism or from
excessive cerumen secretion

Cerumen plug consist mainly of

secretion from the cerumen
glands mixed with sebum,
exfoliative debris and
contaminants

Imprudent cleaning of ear canal

(especially with cotton tipped
swabs) can displace the cerument
toward the tympanic membrane

Impacted Cerumen

Causes
When cerumen is pushed against the eardrum
by cotton-tipped applicators, hair pins, or
other objects that people put in their ears
When cerumen is trapped against the eardrum
by a hearing aid
Overproduction of earwax by the glands in the
ear canal
Abnormally narrow ear canal that tends to
trap the wax

Impacted Cerumen
Risk factors
Old age
Use of cotton
swabs in ears
Hearing aids
Earplugs

Impacted Cerumen
Symptoms:
pressure sensation
in ear with
concomitant
hearing loss
Some patient
complain of
vertigo or tinnitus

Impacted Cerumen
Diagnosis:
Otoscopy:obstruction of ear canal by
a yellowish to brown to black
material, consistency is variable

Impacted Cerumen
Complications
Otitis externa may
develop but
generally
complications are
very rare

Wax removal
1.) syringing
or instrumentation under direct vision
2.)curettage
3.)suction

syringing

Should never be done unless tympanic membrane is known to be normal

Once the accumulated ear wax has been softened using an ear wax removal
solution syringing enables the wax removal by irrigation.

irrigation solution kept the same as the body temperature (avoid caloric
response, thermal stimulation of the inner ear wherein pt. experiences an
unpleasant transient dizziness) and a syringe is used to slowly and gently stream
the water into the ear
solution flows out through the ear canal taking out the cerumen and other debris
along.

Direction of water is
superiorly against the
ear canal and
tympanic membrane

Wax
plug

fig. A
The patient should be
seated comfortably
a kidney basin which the
patient holds tightly
against the side of the
neck, is paced under the
ear to catch the effluent

Fig. B
Drying the canal after the
irrigation

 When introduction of water into

the ear
is
contraindicatedinstrumentatio
n (curettage/ suctioning)
becomes preferred method
since entry of water leads to
infection:
known or suspected tympanic
membrane perforation
After recent trauma

curettage

Cerumen can also be removed with a

curette which is another name for a ear
pick.
A modified curette is used to dislodge the
cerumen and scoop it out. Unlike cotton
swabs which push the wax much more
deeper into the ear canal, the currete
comes with a safety stop to make sure that

suctioning

In the hands of a skilled operator, soft wax may be

aspirated using a large suction tip.
Firm wax can be removed safely using a blunt hook or
ring ended probe.
Adequate illumination, unobstructed view of external
canal, cooperative patient and manual dexterity
essential so trauma can be avoided.

cerumenolytics
If syringing or instrumentation does not readily
dislodge a plug of wax, further attempts at removal
are likely to cause unnecessary trauma
Pt. is then advised to instill a bland ceruminolytic
into the ear canal for 5 days before returning
Best ceruminolytic -20-30% solution of Sodium
Bicarbonate in distilled water
Cerumen-not significantly softened by oily or
organic solution(however baby oil or olive oil is a
cheaper option that can be readily found at home)

Reference
Basic Otorhinolaryngology by Probst
Lecture Notes on Diseases of Ear,
Nose and Throat by P.D.Bull
Clinical Otoscopy by Hawke, Keene,
Alberti

Thank you for listening!