EXTERNAL EAR

DISORDERS
SRIDEVI.R

Introduction

A deformity, dysmorphism, or
dysmorphic feature is a major
difference in the shape of a body part or
organ compared to the average shape of
that part.

Types of deformity
Microtia
Macrotia
Anotia

small ear
large ear
absent ear

Shape of the ear

Cup-shaped
Lop-ear
Dysplastic

Elfin ear (pointed)

Lobe malformations

Position of the ear

Melotia

Low set ears

Synotia
ear located on the cheek due to lack of aural
ascent
ears are very close to each other in the midline
Auricular fistulas


External acoustic meatus
Auricular appendages
Atresia
Duplication
Septation

Normal ear

Lobe ear
Peri auricular fistula

Microtia

Definition: Microtia means small ears. The condition

may range in severity from uncomplicated hereditary
microtia transmitted as a dominant and rather harmless
trait[1] to severe forms with conductive hearing loss.
Etiology: Non-syndromic microtia has an autosomal
dominant transmission in a minority of families[2].
Isolated microtia is uncommon.
Pathogenesis: Abnormal development of the first and
second branchial arches.
Associates anomalies: Commonly associated with the
following:

Microtia-anotia

Definition: Deformed or absent pinna

with an atretic ear canal. Most forms are
associated with conductive hearing loss.

 Macrotia:

Definition: Macrotia means large ears. The auricle is usually very

large but well shaped without other ear malformations. The most
exaggerated portion is the scaphoid fossa. The condition is usually
bilateral and symmetric and may cause psychological disturbance
due to excessive size of the ears.
Etiology: Autosomal dominant inheritance in some cases[6].
Pathogenesis: unknown.
Associates anomalies: Commonly associated with the following:
Marfan syndrome: The cartilage is somewhat floppy
in addition to the ear being large.
Cerebro-oculo-facial-skeletal syndrome (COFS):
(Neurogenic arthrogryposis, microcephaly, micro-ophthalmia)
Large ear pinna

 Anotia

Definition: Complete absence of the

auricle. Skin of the cheek passes smoothly
over the aural area without definite
elevation or depression.
Etiology: Extremely rare, sporadic and
usually unilateral. Ruzic reported seven
cases[10]. May be associated with facial
paralysis and absence of the tonsil on the
abnormal side.

Cup-shaped ear
Definition: Small auricles that grow
forward over the meatus. Peterson and
Schimke (1968) observed cup-shaped
ears in members of 5 generations with at
least 4 instances of male-to-male
transmission. Their proband had PierreRobin syndrome[11].

Lop ear

Definition: The external ear stands away

from the head at a greater angle (Normal
angle of the auricle to the median plane
averages 25 degrees in boys and 18 degrees
in girls). Lop ears are usually larger than
normal ears.
Etiology: Autosomal dominant inheritance in
some cases. Rogers (1968) has suggested that
the lop ear resembles a fetal stage of pinna
development, suggesting arrest of
development at that stage[12].

Dysplastic ear

Definition: Abnormally shaped auricles.

Usually associated with chromosomal
anomalies:

Lobe malformations

Adherent lobe: frequent variation that

occurs less often in men than in women.
Absent lobe: seen in Seckel syndrome.
Cleft lobe (coloboma): longitudinal cleft
of lobe which may be partial but usually
extends to but not through , the incisura
intertragica.

 Melotia

Definition: Ear located on the cheek.

Pathogenesis: May represent lack of
aural ascent due to underdevelopment
of the auricle. There is also the
embryological evidence, that melotia
represents extraordinary big preauricular
appendages[14]

Low-set ears
Definition: An ear that is set below an
arbitrary line drawn between the lateral
canthus of the eye and the occipital
protruberance is considered low-set.
Etiology: probably multifactorial.

 Melotia

Auricular fistula
Definition: Blind-ending narrow tubes or pits. Most are harmless,
occasionally they can get infected, form retention cysts and cause chronic
discharge.
Etiology: Autosomal dominant inheritance with variable expressivity and
incomplete penetrance. Many occur sporadically and are associated with hereditary
deafness. Report of large kindreds such as that of Bhalla et al , in which there are
no associated features or lateral cervical sinuses suggests that this is a distinct
mendelian dominant. The pedigree was traced through seven generations indicated
in the expression of the occurred bilaterally as a small pit just anterior to the crus at
the root of the ascending helix. The abnormality was found to be inherited through
an autosomal dominant gene with incomplete penetrance[16].
Incidence: 0.9% in European populations.
Locations:
Anterior margin of the ascending limb of the helix.
Center of the lobule natural earring hole
Colloaural: from the floor of the external meatus down to the angle of the mandible

Auricular appendages

Definition: tags of skin with or without a cartilaginous base frequently

located in the line of junction of the mandibular and hyoid arches. This is
a common malformation occurring in approximately 1.5% of the
population. May be sessile or pedunculated.
Sites of location:
In front of the auricle
Within the ear
Behind the ear
On the lobule
Appendages on the cheek between the auricle and the angle of the
mouth are often associated with microtia, melotia or oblique facial
features. True polyotia seems to be extremely rare and has been
reported by Bol and Dekleyn (Acta otolaryng 1:187,1918)
Darwinian tubercle: a small projection from the descending part of the
helix. Darwin regarded this variation as a remnant of the pointed ears of
some

External otitis

It involves inflammation of the epithelium of

theInflammation of the external ear canal and/or pinna
Can be localized (associated with a furuncle) or diffuse
(usually a bacterial or fungal infection or allergy)
Can be acute or chronic (longer than 6 weeks)
May be secondary to skin conditions
Can be serious; necrotizing otitis externa is rare and
usually occurs in immunocompromised or malnourished
patients
Pruritus is usually the first symptom
Tenderness of the ear or canal

description

Pain in the ear and also of the pinnamade worse

by manipulation of the pinna and by exerting
pressure on the tragus. Also pain on eating
Discharge from the ear
Conductive hearing loss
Crusting around the ear canal opening
Lymphadenopathypostauricular, preauricular, and
lateral cervical lymph nodes
Involvement of cranial nerves (VII, IX-XII) in late
stages
auricle and ear canal

Epidemiology
Incidence and prevalence:
Unknown, but higher in the summer and
humid months
People with asthma, eczema, or
allergic rhinitis are three times more likely to
develop otitis externa
Demographics:
All ages affected
Occurs equally in males and females

Causes

Causes:
Gram-positive organisms:

Gram-negative organisms:

Eczema
Psoriasis
Seborrheic dermatitis
Allergies

Rare causes include secondary to primary skin conditions (eczematous otitis externa):

Aspergillus niger (these occur in 10% of otitis externa cases in the U.S.)
Candida albicans

Secondary to primary skin conditions (eczematous otitis externa):

Bacteroides species
Clostridium species
Anaerobic streptococci

Fungi:

Pseudomonas aeruginosa
Escherichia coli
Proteus mirabilis
Klebsiella pneumoniae

Anaerobic bacteria:

Staphylococcus aureus
Streptococci groups D and G

Herpes simplex
Herpes zoster

A serious cause is P aeruginosa. Aninvasive infection may lead to necrotizing otitis externa

Risk factors:

Excess moisture (swimming, bathing, or increased

environmental humidity)
Trauma (scratching or foreign body)
Irritants in the ear (hair spray, hair dye)
Self-cleaning (pushing debris deeper into the canal)
Primary skin conditions
Coexisting debilitating diseases (eg, diabetes mellitus
type 1 or type 2, leukopenia, malnutrition)
Associated disorders
Asthma
Eczema
Allergic rhinitis

Diagnostic evaluation

History physical examination

Otoscopy
Culucture & sensitivity

Collaborative therapy

Analgesics
Warm compresses
Cleansing canal
Ear wick
Anti biotic drops

Preventive measures

Avoid swimming in polluted pools

Treat primary skin conditions
Treat underlying coexisting conditions
Consider using prophylactic agents against otitis externa;
these are typically mixtures of vinegar and alcohol
Decrease water entrance in earsuse of ear plugs and/or a
hairdryer to dry the ear canal
Decrease trauma by decreasing the insertion of foreign
objects
Avoid allergens such as hair sprays and hair dyes
Do not use over-the-counter ear drops for more than one
week
Always see a physician if symptoms don't resolve

What is cerumen?

Cerumen, also called earwax, is made by

the body to protect the ears. The earwax
has both lubricating and antibacterial
properties. Most of the time, the old
earwax is moved through the ear canal
by motions from chewing and other jaw
movements. At that time, it reaches the
outside of the ear and flakes off.
Cerumen is produced in the outer part of
the ear canal, not deep inside the ear.

What does it mean when cerumen becomes impacted?

We say that cerumen is impacted when it has

built up in the ear canal to such a point that
there may be signs that something is not
quite right. It is important to note that,
ideally, ears might never need cleaning
they are designed to clean themselves.
Impaction often happens when people use
items like cotton swabs or bobby pins to try
to clean their ears. This only pushes the
earwax farther into the ears and can also
cause injury to the ear.

What are the symptoms of cerumen impaction?

A feeling of fullness in the ear

Pain in the ear
Difficulty hearing, which may continue to
worsen
Ringing in the ear (tinnitus)
A feeling of itchiness in the ear
Discharge from the ear
Odor coming from the ear
Dizziness

Who experiences earwax buildup?

Earwax buildup can happen to anyone.

However, it is more likely to occur in:
People who use hearing aids or earplugs
People who put cotton swabs or other
items into their ears
Older people
People with developmental disabilities
People with ear canals shaped in such a
way as to impede natural wax removal

How is cerumen impaction

diagnosed?

Your health care provider can look into your ears with
a special instrument, called an otoscope, to see if
earwax buildup is present.
How is cerumen impaction treated?
Earwax removal can happen in a few ways; some of
these methods can be done at home.
Cleaning the outside of the ear by wiping with a cloth.
Putting cerumenolytic solutions (solutions to dissolve
wax) into the ear canalthese solutions include
mineral oil, baby oil, glycerin, water, peroxide-based
ear drops (such as Debrox), hydrogen peroxide, and
saline solution.

Irrigating or syringing the earthis involves using

a syringe to rinse out the ear canal with water or
saline, generally after the wax has been softened
or dissolved by a cerumenolytic.
Removing the wax manually using special
instrumentsthis should be done only by a health
care provider who might use a cerumen spoon or
suction device.
Note: Irrigation should not be done by any persons
who have, or suspect they have, a perforation
(hole) in their eardrum or tubes in their ear.

What are possible complications of cerumen impaction?

If left untreated, excessive earwax may

cause symptoms of cerumen impaction
to become worse. These symptoms
might include hearing loss, ear irritation,
etc. A build-up of earwax might also
make it difficult to see into the ear,
which may result in potential problems
going undiagnosed.

How can cerumen impaction be prevented?

Do not stick anything into your ears to

clean them. Use cotton swabs only on
the outside of the ear. If you have a
severe enough problem with earwax that
you need to have it removed by a health
professional more than once a year,
discuss with them what the best method
of prevention (if any) is for you.

Getting an object stuck in the ear is a relatively

common problem, especially in toddlers. The vast
majority of items are lodged in the ear canal, which
is the small channel that ends at the eardrum.
Because the ear canal is quite sensitive, you can
usually tell if there is something in your ear.
Most cases of foreign bodies in the ear are not
serious and can usually wait until the morning or
the following day for removal. The object does,
however, have to be completely removed quickly
and with the least amount of discomfort and
danger.

Common objects found in ears include

food material, beads, toys, and insects.
Children often place items in their ears
out of curiosity.
Although earwax (cerumen) is not
technically a foreign body, it does
frequently accumulate in the ear canal
and can cause discomfort or decreased
hearing just like other foreign bodies.

Ear Foreign Body Causes

The vast majority of objects found in ears are

placed there voluntarily, usually by children, for an
endless variety of reasons. A caregiver should not
threaten a child when asking about this possibility,
because the child may deny having put something
in the ear in order to avoid punishment. This denial
could easily result in a delay of its discovery and
increase the risk of complications.
Insects are well known to crawl into the ear, usually
when you are asleep. Sleeping on the floor or
outdoors would increase the chance of this
unpleasant experience

Animate
In animate
Vegetable
Mineral objects

Foreign Body Symptoms

Fortunately, most people can tell if there is something in their

ear. The ear canal, where most objects get stuck, is very
sensitive. The ear canal ends at the eardrum, which is also
highly sensitive. The symptoms of having a foreign body in the
ear largely depend on the size, shape, and substance involved.
Occasionally, a foreign body in the ear will go undetected and
can cause an infection in the ear. In this situation, you may
notice ongoing infectious drainage from the ear.
Pain is the most common symptom. If the object is blocking
most of the ear canal, you may experience a decrease in
hearing on that side.
Additionally, irritation to the ear canal can also make you
nauseated, which could cause you to vomit.

Bleeding is also common, especially if the

object is sharp or if you try to remove it by
sticking something else into your ear.
One of the most distressing experiences with
this problem is having a live insect in the ear.
The insect's movement can cause a buzzing in
the ear and may be quite uncomfortable.
Fortunately, dripping mineral oil into the
affected ear will usually kill the insect. This is
safe as long as you do not have a hole in your
eardrum.

management

Depending on your particular medical community, your

doctor may wish to see you in the office or refer you to a
local emergency department or other specialist. Do not
expect any health care professional to be able to assess the
situation adequately over the phone. If there is any concern
for the presence of a foreign body in the ear, you should be
physically examined by a qualified medical professional.
Persistent pain, bleeding, or discharge from the ear could
mean that the ear passages have not been completely
cleared, part of the object could remain inside the ear, or an
infection of the ear canal has developed. These infections
generally respond well to antibiotic drops, but an exam and
prescription are necessary.

A foreign body in the ear can also damage the eardrum, which
may or may not affect hearing. Because you cant see the
eardrum from the outside, an exam of the ear is recommended.
In the majority of cases, the situation of having something in your
ear will not be life threatening. Usually you will have time to call
your regular doctor. The urgency of the situation primarily
depends on the location of the object and the substance involved.
Button batteries commonly found in many small devices and toys
can decompose enough in the body to allow the chemicals to leak
out and cause a burn. Urgent removal is advised.
Urgent removal is also recommended for food or plant material
(such as beans) because these will swell when moistened.
Urgent removal is indicated if the object is causing significant
pain or discomfort.

Exams and Tests

Most objects can be seen with good lighting and a

few instruments.
Occasionally, an object is discovered accidentally
when x-rays are taken for unrelated reasons. It is
important to realize that many materials such as
food, wood, and plastic will not be visible on a
routine x-ray.
Do not hesitate to ask your doctor to examine the
entire head and neck region. It is distinctly possible
that the person has multiple foreign bodies in both
ears and foreign objects in the nose.

treatment

Commonly used techniques include applying

gentle suction to the object, small forceps, or
instruments that have a loop or hook at the tip.
If the object is metallic, a long instrument may be
magnetized to assist in gently pulling the object
from the ear.
Another common technique involves irrigating the
ear. If the eardrum appears intact, warm water can
be gently squirted past the object using a small
catheter. The water will turn around at the end of
the ear canal and often wash the object out.

Any experienced professional can tell

you that children typically struggle with
these techniques. Struggling will
decrease the likelihood of success and
increase the chance for complications.
Sedation of the child may be considered
an option to allow calm and comfortable
removal of the object, if necessary

Malignancy of the external

ear

Auricle basal & sequamous cell

carcinomas

melanomas

Thank you