EARS, NOSE & THROAT (ENT)

Topic: Diseases of the External Ear, Middle Ear and Mastoid

Lecturer: Dr. Uy, Sidney

DISEASES OF THE EXTERNAL EAR  Predisposing Factors for Otitis Externa:

1.) Cerumen o Change from acidic to alkaline pH
 Product of both sebaceous & apocrine glands in the cartilaginous part o Increase in temperature & humidity
of the ear canal o Trauma
 WET TYPE of cerumen is more common than the dry type.  Examples are trauma due to :
 Has protective qualities:  Excessive cleaning
o Vehicle for removal of epithelial debris & dirt away from the  Swimming
ear drum
o Lubrication  Management of Otitis Externa:
o Prevents dryness of the skin of the external auditory canal o Careful cleaning of the ear canal either by suction or cotton
o Bactericidal effects swipes
o Evaluation of discharge, canal wall edema & ear drum
 Management of Impacted Cerumen: o Decide if an ear wick is to be used.
o Ceruminolytics  softens the ear wax o Selection of local medication
 Water
 Mineral oil Image showing How to use an Ear Wick in treating Otitis Externa
 H2O2 (Hydrogen Peroxide)
 Ex: Otosol, Audiclean, Auraglar
Generic name of these Otic/Ear drops is
Sodium Docusate

o If the impacted cerumen has already softened, removal can

already be done. Impacted cerumen can be removed by:
 Curette
 Water irrigation
 Suctioning

Images illustrating how removal of impacted cerumen is done:

Curette Suctioning

Lecture Discussion: How to Use an Ear Wick in treating Otitis Externa

Ear Wick  ensures that the otic drops would reach inside the ear canal.
Because if the external auditory canal is really swollen and is almost closed
up, the otic drops might not reach the inner part of the ear canal. We usually
use a sterile gauze or sterile cotton as an ear wick.
Water Irrigation
 There are 2 types of Otitis Externa:
1. Otitis Externa Circumscripta (Furunculosis)
2. Diffuse Otitis Externa (Swimmer’s Ear)

Otitis Externa Circumscripta (Furunculosis)

 Confined only on one side
 Confined to the fibrocartilagenous part of the
ear canal
 Usually begins in a pilosebaceous follicle
Lecture Discussion: Water Irrigation
 Usual agent: Staphylococcus aureus or S. albus
This can only be done if the patient’s ear wax is already softened. The only
 Ear can develop abscess if left untreated.
contraindication is if the patient has perforated tympanic membrane 
you cannot do aural irrigation  Pointing can occur.
 It resembles a pimple inside the ear canal
2.) Otitis Externa  Treatment:
 Another common disease of the external ear o Antibiotic otic drops
 It is an external infection of the ear. PND otic drops are usually used  Polymyxin B,
 Only the external auditory canal is affected. Neomycin, and Dexamethasone otic drops
 It is usually caused by BACTERIA, FUNGI or VIRUS.
o Analgesic
 It can be non-infectious such as in the case of NON-SKIN DERMATOSIS.
o Warm moist compress
o Drainage (if needed)

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 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the External Ear, Middle Ear and Mastoid
Lecturer: Dr. Uy, Sidney

Diffuse Otitis Externa (Swimmer’s Ear) 4.) Herpes Zoster Oticus (Ramsay Hunt Disease)
 Swimmer’s ear  Viral infection of external ear
Usually affects patients that went swimming in a water that is  Manifestations:
dirty with ear trauma. o Facial nerve paralysis
o Otalgia or ear pain
 The whole ear canal is inflamed o Herpetic eruptions in the auricle and
 Occurs commonly during hot, humid weather  aggravating factor surrounding area
 Etiology is Pseudomonas aeruginosa
 Manifestations:  Treatment:
o Severe pain o Since it is a viral infection, its treatment is symptomatic.
o Tragal tenderness o It usually resolves on its own but it takes a long time.
o Swelling of canal  Self-limiting
o Patient may present with scanty discharge o Pain relievers can be given.
o Normal or slight hearing loss due to the swelling of ear canal o Steroids are given to accelerate the inflammation of the ear.
o Lymphadenopathy can be present in severe cases.
 Neck nodes or Cervical lymph nodes 5.) Perichondritis
 Effusion of serum or pus between the perichondrium
 Treatment: and the ear cartilage
o Ear wick is used since the ear canal is very inflamed and is  It has the appearance of “cauliflower ear” which is
almost closing. very common among boxers.
o Otic drops  It is due to regular trauma or inflammation
 Antibiotics & Steroids  Manifestations:
o Severity will determine if there is a need to give oral antibiotics o Red, tender, warm and swollen auricle
 Penicillins
 Macrolides – if allergic to penicillins  Management:
 Quinolones o Antibiotics are given either orally or parenterally
o Topical medications  if there are external lesions
3.) Otomycosis (Fungi) o Otic drops can be given.
 Fungal infection of the ear canal o Antibacterial ointments with steroids
 Common in o Evacuation of fluid through 2 big incisions then bolster packing
immunocompromised patients afterwards
 Also common in patients with o Excision of necrotic cartilage
poor hygiene
 Common etiologies are EAR MALFORMATIONS
Pityrosporum and Aspergillus Lop ears Excessively protruding ears
(A. niger and A. flavus) Anotia Congenitally absent ear
 Manifestations: Microtia Congenitally small ear
o Itchiness Macrotia Congenitally big ear
o Patient may sometimes present with ear blockage because the Atresia Ear did not form
molds of the fungus are embedded in the ear canal.
o Patient may present with dry ear.
o In physical examination with otoscopy:
 Blackish spores with hyphal elements can be seen.
 It has a “wet newspaper” appearance

 Management:
o Regular ear cleaning
o All the hyphal elements must be removed inside the ear canal
because the patient will not recover even if otic drops are given
but still there are hyphal elements left inside the ear canal.
o Otic drops are given once all the hyphal elements have been
removed.
o Antifungal otic drops given usually for 2 weeks
Candibec solution, Kenacomb otic  are brand names of GRADING OF EAR MALFORMATIONS
the antifungal otic drops Grade 1 Smaller than normal but the ear has mostly normal anatomy
Their generic name is Clotrimazole Part of the ear looks normal, usually the lower half
Grade 2
The canal may be normal, small or completely closed
o Acidification is done for easier eradication of the fungi Just a small remnant of peanut shaped skin and cartilage
Grade 3
There is no canal, which is called “aural atresia”
Complete absence of both external ear and ear canal
Grade 4
Also called “anotia”

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 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the External Ear, Middle Ear and Mastoid
Lecturer: Dr. Uy, Sidney

Lecture Discussion: Ear Malformations

If the patient has already Grade 3 or 4 ear malformation  request for a
temporal bone CT scan to ensure if the patient has normal ossicles, external Lecture Discussion:
auditory canal, middle ear, and inner ear.
Treatment for Exostosis &
 If the patient has normal structures for the middle ear & inner ear
Osteoma is surgical excision. If
 you can now do surgery to create an external auditory canal
so that the patient can hear left untreated, it may cause
 If the patient has intact middle ear but inner ear (cochlea) has hearing loss because it might
problems  you can do surgery (cochlear implant) or bone block the external auditory canal
anchored hearing aids (blocking the sound entering
going into the ear drum). Also it
PRE-AURICULAR SINUS ANOMALIES might cause infections, irritation
 1st Branchial Cleft Anomalies (Pre-auricular sinus) or inflammation.
 Cyst or sinus tract involving pinna & ear canal

 Contains endodermal tissue only

Type I
 Free of cartilage
 Has both epithelium of 1st cleft and cartilages
from 1st and 2nd arches
Type II  Sinus tract drains intermittently & can be
infected
 It usually needs surgery

 Management:
o Usually, excision is done if not infected. Darwin’s Tubercle Keloid Scarring
o If infected, antibiotics (macrolides or beta lactams are given).
o If there is an abscess, drainage must be done. BENIGN SKIN LESIONS
o The whole sinus tract must be removed.  Sun damaged skin
Solar Keratosis
 Painless
Lecture Discussion: Management of Preauricular Sinus  Scaly
Proper treatment is surgical excision. If left untreated, a Type II Preauricular  “Cutaneous horn”
sinus would cause recurrent infections, and sometimes abscess. To prevent  No treatment is usually done
those from happening you have to tell the patient to undergo surgical  You can advise to undergo
excision. cryotherapy or excision of
the solar keratosis
ACCESSORY AURICLE (SKIN TAG)
 Nothing is done Seborrheic Keratosis
 It does not need surgery.  Round
 It can be removed through surgery (for  Dark
patients who are vain)  “liver spots”
 Sun damage
 No treatment is usually done
 You can advise to undergo
EXTERNAL EAR TUMORS cryotherapy or excision of
 Single, rounded growth with bony peduncle the seborrheic keratosis
to inner 3rd of the bony canal
Osteoma  If symptomatic and causes recurrent Tophi
infections, it can be removed.
 Due to gout
 Usually, no treatment is done.
 Painless, smooth, uric acid
 Dense
crystals subcutaneously
Exostosis  Rounded protuberance of hypertrophic canal
deposited
bone
 Can be resolved by treatment
 Resembles a pimple inside the ear canal
of the gout
 Can be big or small
Ear Polyps
 Can sometimes be infected
 Keloid Scarring
 Surgically removed
Darwin’s Tubercle  Thickening on the helix at the junction of the
upper and middle thirds
Carcinomas of the Ear  Basal cell carcinoma
 Squamous cell carcinoma

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 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the External Ear, Middle Ear and Mastoid
Lecturer: Dr. Uy, Sidney

MALIGNANCIES OF THE AURICLE  Management:

Basal Cell Carcinoma o Hearing loss is associated with thickened and retracted ear
drum.
o For retracted ear drum, MYRINGOTOMY is done.

 Wide excision is advised. 1.) Perforation

 Margins at excision must be
Types of Perforation: Causes of Drum Perforation:
negative.
 Tubal  Sudden changes in pressure, as in
 Patient may be subjected to  Central barotrauma, blast injuries
chemo or radiotherapy after.  Marginal  Foreign bodies, pointed objects
 Pars Flaccida or Attic  Ear cleaning or manipulations

Squamous Cell Carcinoma

 There may be a need to

remove the whole ear
because it may distally
spread.
 Patient may be subjected to
chemo or radiotherapy after.

 Central perforation – most common type (90-95% of patients with

perforated ear drum)
FOREIGN BODIES IN THE EAR
 Very common especially in pediatric patients Clean Traumatic Perforations Contaminated Perforations
 Can be insects inside the ear  Heal spontaneously  Ear drops and systemic
 Usually put in by the patient  The ears must be kept dry. antibiotics are given.
 The foreign body must be removed.  Antibiotics may be given if with  Closure is done when infection
 If it is an insect, it must be killed first before it can be removed. pain & inflammation. resolves.
o Kill it with mineral oil or lidocaine spray  Closure is done through
 Usually removed with forceps or suction TYMPANOPLASTY.

 Management:
DISEASES OF THE TYMPANIC MEMBRANE
Tympanosclerosis o If it is an inactive type, there is no treatment done.
o Antibiotics are given for actively draining infections.
o Oral antibiotics may be given if it is severe

 Thickened ear drum 2.) Myringitis

 Inflammation of the ear drum
 Usually self-limiting
 Can cause bulging ear drum

Retracted drum
Bullous or Hemorrhagic Myringitis
o There are blebs or bullae in the ear drum
o Ear drum is not perforated.
 Ear drum is retracted o The ear drum may contain serous fluid, blood or both.
inwards o Ear drum may appear red or purple.
o Usually caused by Mycoplasma pneumoniae

 Management:
o Antibiotic ear drops (PND otic drop)
Bulging drum
o Pricking of blebs
 Fine needle or knife
 Swollen ear drum
 Can be due to tumor or
otitis media

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 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the External Ear, Middle Ear and Mastoid
Lecturer: Dr. Uy, Sidney

EUSTACHIAN TUBE DISORDERS  Treatment:

Functions of Eustachian Tube: o Decongestants
 Ventilation o Cessation of diving
 Drainage  Precaution/Management:
 Protection of middle ear from nasopharyngeal contamination Barotrauma o Avoid flying/diving when + colds
(continued) o Equalize pressure
o Decongestants before flying/diving
Assessment of Eustachian Tube Function:
o Instruct the patient to do valsalva and
 Lateral displacement of the drum Toynbee to equalize pressure.
 Listening while patient does: o Instruct the patient to chew gums
o Toynbee – swallowing with nostrils pinched
o Vasalva – blowing hard with mouth & nose closed 3.) Otosclerosis
 Usually autosomal dominant
1.) Abnormally Patent Eustachian Tube  Affects both men & women
 The Eustachian tube is open all the time.  Progressive conductive hearing loss in early adulthood
 Air enters the middle ear with respiration.  Pathology:
 History: o Normal bone is replaced by soft bone (otospongiosis) in area
o Significant weight loss  loss of fatty tissue around ET opening of stapes footplate  fixation of footplate

 Manifestations:
o Otophony/Autophony – the patient hears his own respiration
o Sensation of ear fullness
o “plugged up” feeling

 Physical Examination:
o Drum is thin & atrophic
o Drum moves in & out with respiration

Schwartze Sign:
 Management:
o You do myringotomy
o Insertion of ventilation tube
To equalize the pressure between the middle ear and
external ear

2.) Eustachian Tube Obstruction

 Causes:
o Inflammation or congestion of ET
o Adenoiditis or nasopharyngitis
o Tumor in the ET or nasopharyngeal area blocking the ET o Red pulsating mass is seen inside the ear drum
opening o Drum is pink or orange due to vascular otospongiosis
o Foreign body in the ET
o Scarring due to extensive surgery  Physical Examination:
o Destruction or lack of anchorage of tensor veli palatini muscle o Drum is normal
o Schwartze’s sign: drum is pink or orange due to vascular
 Lack of anchorage of tensor veli palatini muscle otospongiosis
 There is no delineation between oro and nasopharynx.
 There will be middle ear infection because bacteria  Management:
Cleft Palate
can easily go into the middle ear. o Middle ear surgery
 Inadequate ventilation of the middle ear o Stapes is removed and malleus is directed into the footplate
 Inflammation
OTITIS MEDIA
 Damage to tissues caused by changes in barometric Natural History of Otitis Media:
pressure during diving or flying, with ET blockage
 Pressure difference between atmosphere & middle
ear reaches 90-100 mm Hg making the ET cartilaginous
part collapse
Barotrauma  Diving or flying, during descent
 Manifestations:
o Pain, ear fullness, hearing loss
 Physical Examination:
o Drum is congested
o Hemorrhagic blebs or hemotympanum
o Drum perforation

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 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the External Ear, Middle Ear and Mastoid
Lecturer: Dr. Uy, Sidney

Otitis Media continued….. Serous & Mucoid Otitis Media continued…..

 Very common especially in pediatric patients  Causative Factors:
 There is infection of the middle ear via the Eustachian tube (fever). o Eustachian tube dysfunction (ETD)
 A patient with otitis media usually has had cough or colds a week before o Adenoidal hypertrophy
which is left untreated. o Chronic adenoiditis
 There is mucosal edema in the middle ear and ET. o Cleft palate
 There is hyperemia of the tympanic membrane and purulent middle ear o Nasopharyngeal tumors
effusion which leads to bulging tympanic membrane. o Barotrauma
 If left untreated, it leads to pressure necrosis of tympanic membrane o Pharyngitis/sinusitis
resulting in perforation. o Radiation therapy
 Mucopurulent discharge comes out o Immunologic/metabolic deficiency

1.) Acute Purulent Otitis Media  Physical Examination:

 There is obstruction of ET o Immobile drum on pneumatic otoscopy
 “Abscess in the middle ear” o Amber or yellow color drum (serous OM)
 Most common Etiologies: o Dull & opaque drum (mucoid OM)
o Pyogenic bacteria o Malleus appears short, retracted & chalky white
 Strep pneumoniae (most common)
 H. influenzae (children & adolescent)  Treatment:
 Beta Hemolytic Strep o You treat the cause of the otitis media
o Antibiotic, decongestants, ET ventilation exercises (Toynbee,
 Manifestations: valsalva), allergy hyposensitization
o Pain o Allergic rhinitis should be treated because the infection can go
o Fever into the ear since there is nasal congestion in these patients.
o Malaise o Allergic rhinitis is treated to relieve pressure in the middle ear.
o Headache o Surgery: Myringotomy, ventilation tube insertion, removal of
o Earache fluid
o Anorexia in children Surgery is usually the last resort after 4-6 months of
o Nausea and vomiting in children medical management without any known improvements.

Lecture Discussion: MASTOID

The main difference between the ear pain of otitis externa from 1.) Acute Coalescent Mastoiditis
otitis media would be the tragal tenderness.  Found in untreated/inadequately treated otitis media patients
 When the patient has otitis externa  pain is on the  Etiology is same as otitis media
external side and when the tragus is examined, there is  Manifestations:
pain. o Pain, fever, hearing loss
 When the patient has otitis media  the pain is inside of o Post-auricular swelling
the ear. Even if you manipulate the external ear or auricle, o Sagging of posterior canal wall
tragus, there is no pain because the pain is inside the ear. o Mastoid tenderness

 Physical Examination:  Management:

o Drum is red & bulging, with blood vessels injected & prominent o Wide myringotomy
o Wide incision to evacuate all the pus inside
 Treatment: o Antibiotics, after Culture/Sensitivity test
o Antibiotics given for 10-14 days o Surgery (mastoidectomy)
o Amoxicillin 80 mg/kg/day - drug of choice
o Ampicillin 2.) Chronic Otitis Media & Mastoiditis
o Coamoxiclav Active Inactive
o Cephalosporins  Presence of infection  Previous active infection which has
o Sulfisuxonate & Erythromycin (macrolides for penicillin allergic  Draining ear due to “burn out”
patients) granulation tissue or  No otorrhea
cholesteatoma  Hearing loss, vertigo, ear fullness,
2.) Serous & Mucoid Otitis Media (Otorrhea) tinnitus
 Transudation of plasma from the blood  Dry perforation
Serous Otitis Media vessels in the middle ear due to hydrostatic  Tympanoslerosis, ossicular disruption
pressure differences
 Active secretion from glands & cysts in the
Mucoid Otitis Media
middle ear lining mucosa

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 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the External Ear, Middle Ear and Mastoid
Lecturer: Dr. Uy, Sidney

Chronic Otitis Media & Mastoiditis continued….. TUMORS OF THE MIDDLE EAR
Manifestations:  Originates from the glomus bodies that
relate to the jugular bulb in the floor of the
 Otorrhea Glomus Jugulare or
middle ear, or from nerve distributions from
o Purulent Glomus Tympanicum
the middle ear
o Mucoid (active secretory glands)
 Highly vascular tumor, bulging purplish
o Foul-smelling, putrid & dirty yellow (cholesteatoma) mass (Brown’s sign)
o Thin, watery (TB)  It sometimes extends out of the ear.
 Due to ear drum perforation, patient has conductive hearing loss. Carcinoma of the Ear  Most common malignant tumors of the
 Pain may be rare but may indicate complication. middle ear are adenoid cystic CA and
 Vertigo – erosion of semicircular canals adenocarcinoma.
 Perforation
o Marginal & attic (cholesteatoma) Management:
o Multiple (TB)  Surgery
 Chemotherapy
 Management:
o Conservative
 Keep water out of the ear.
 Cleaning with hydrogen peroxide or alcohol
 Antibiotic drops
Usually what is given is quinolone otic
drops/ofloxacin otic drops. Sometimes you can
also give oral antibiotics – quinolones
(ciprofloxacin/levofloxacin)

o Surgery
 Tympanoplasty – to restore hearing
You are creating a new ear drum

 Mastoidectomy – to produce safe & dry ear

This is done especially if the patient already has
cholesteatoma. When you are doing
mastoidectomy, you are also doing
tympanoplasty, the difference is that here, you
drill out all the affected tissue inside the mastoid
bone

3.) Cholesteatoma
 Found in chronic otitis media & chronic mastoiditis
 Keratinizing squamous epithelium (skin) entrapped in the middle ear &
mastoid
 Increases in size and erodes the bone
 Damage the ossicles
 Press on the facial nerve
 Treated by mastoidectomy

Complications of Chronic Otitis Media & Chronic Mastoiditis:

 Hearing loss – conductive, sensorineural
 Facial nerve paralysis
 Labyrinthitis
 Petrositis – CN V, CN VI
 Lateral sinus thrombophlebitis
 Brain abscess
 Meningitis

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