1 - External Ear Flashcards
Otalgia
Ear pain
Otorrhea
Discharge from the ear
External auricular canal anatomy?
Slide 10
TM anatomy
Slide 11
The ossicles are?
Malleus - hammer
Incus - anvil
Stapes - stirrup
Openings of the middle ear?
Oval window
- deep to the stapes
- opens to the vestibule/semicircular canals
Round window
- connects to the cochlea
Structures of the inner ear?
Cochlea
- organ of corti
Semicircular canals
- responsible for vestibular control
CN VIII
- vestibular nerve branch
- cochlear nerve branch
Eustachian tube
What is the mastoid process?
Portion of temporal bone
- numerous air cells
- communacates w mid ear space
MC malignant neoplasm of auricle?
Basal cell carcinoma
- 45% of auricular carcinoma
Typical BCC is?
Nodular lesion that may be:
- ulcerated
- bleeding
Often caught early (slow growing)
Rare to mets
BCC variations?
Nodular
- single nodule
Superficial spreading BCC
- spread out multi lesions
Pics on slide 20
20% of cutaneous malignant neoplasms and especially common in males?
Squamous cell carcinoma (SCC) of the auricle
Risk factors for SCC?
Immunosuppression Age Non-healing ulcer Chemical exposure UV radiation
Presentation of SCC?
Plaque
Nodule
Ulceration
Prone to bleeding
How aggressive is SCC?
More aggressive than BCC
- gen req excision of larger margin
6-18% mets
Precursor to SCC?
Actinic keratosis (AK)
Unpredictable tumor that affects all ages and has high mortality?
Malignant melanoma
Presentation of malignant melanoma?
Pigmented lesion that changes by:
- Growth
- color
- margin
- ulceration
- bleeding
- deeply pigmented
Begins in epidermis and invades dermis
Prognosis of malignant melanoma?
Related to depth of invasion
- thin - 10% mets
- thick - 90% mets
Epidermal inclusion cyst presentation?
Mass often w Central punctum that is:
- Well defined
- Non-tender
- Soft,
- mobile
- Cystic
- slow growing
Tx for EIC?
Often spontaneously resolve and leak foul smelling fluid
Or
Inj small amount of triamcinolone (kenalog) into surrounding dermis
- speeds resolution of inflammation and prevent i/d
Or
Excision
- wait 4-6 weeks till not inflamed so the wall wont be ruptured
Why do auricular hematomas occur?
Blunt trauma leads to blood accumulation
The cartilage lacks blood supply so it gets stuck there
- hematoma develops
- necrosis can develop
Clinical presentation of auricular hemnatoma
Ear with
- Edematous
- Flucculant
- Ecchymotic
- Loss of land marks
Tx for auricular hematoma?
Evacuate hematoma Pressure dressing/splinting Prophylactic abx (doxy/cephalexin)
Refer to ENT if >7 days old
Complications of auricular hematoma?
Necrosis/infection
Cauliflower deformity
- if not tx in 48-72hrs
The auricle is innervated by
- Auriculotemporal nerve
- superiorly and anteriorly - Greater auricular and lesser occipital nerve
- posteriorly and inferiorly - Vagus nerve
- concha and ext auditory meatus
With lacerations to ear you may need to?
Use local anesthetic to facilitate evaluation
Warning signs that your ear trauma may include the middle ear?
Hemotympanum Amber/clear fluid in ear Otorrhea HL w webber/rinne Retroauricular hematoma (battle sign) Facial nerve dysfunction
Warning signs for basalar skull fx?
CSF in ears/nose
Deficits of CN VIII
- webber rinne testing
Which ear lacerations need referral?
Plastic, maxillofacial surgeon, ENT or neuro if:
- auricular avulsion
- laceration w EAC extension
- laceration w middle or inner ear injury
- Lacerations w basilar skull fx
- chronically split earlobe or cleft (heavy earrings or allergy to metal)
Fixing lacerations in the ear (basics)
Primary closure - preferred
- delayed >24hrs or infected
Pressure dressing to prevent edema/hematoma
What type of abx should be given for ear lacerations
Cartilage-penetrating abx
- quinolones
When doing ear anastheisia you should never use?
No epi - nothing with a tip
Local block vs regional block for ear lacerations?
Local block - sufficient for most simple lacerations
Regional block - extensive lacerations
- doesnt distort the tissue
The how to is on slides 43-45 if you want to learn how to do it
Cellulitis, perichondritis, chondritis?
Infection of:
- Cellulitis - skin
- Perichondritis - tissue around the cartilage
- Chondritis - cartilage
Clinical presentation of the auricle -itises?
Often indistinguishable from each other
- swollen
- warm
- TTP
- erythematous
Pain w deflection of auricle (pinch auricle)
Tx for the auricular -itises?
Mild - PO floroquinolone f/u 24 hrs
Moderate-severe - IV abx
- flouroquinolone
- aminoglycosides (maybe)
- semisynthetic penicillin
Surgical debridement (PRN)
Send them to ENT to avoid poor cosmesis
Diseases of external auditory canal (EAC)
- list
Cerumen impaction FOB Traumatic external otitis AOE Pruritis MOE Exostosis and osteomas Neoplasm
Purpose of cerumen?
Protects the skin of the canal
- acidifies to prevent bacteria/fungus
- hydrophobic (lipid rich) preventing skin penetration and maceration
Who gets cerumen impaction?
Kids 1:10
Adults 1:20
What causes cerumen impaction?
- Obstruction form EAC disease
- exotoses
- infection/derm disease
- cutaneous manifestations of systemic (SLE etc) - Narrowing of EAC
- tumors, hiar, cartilage collapse, trauma - Failure of epithelial migration
- aging, atrophy, hearing aids, q tips - Overproduction
- local trauma, retained water, idiopathic
Clinical presentation of cerumen impaction?
Usually asymptomatic
Symptomatic
- hearing loss
- otalgia
- fullness
- itching
Tx of symptomatic vs asymptomatic cerumen impaction?
Symptomatic
- remove it, it’ll help their hearing
Asymptomatic
- leave it alone
Therapeutic options for cerumen impaction?
Cerumenolytic agents
- primary care 1st line
Irrigation
Manual removal
No method is “superior”
Who should not get cerumenolytics?
Pts with TM damage
- otorrhea
- otalgia
- h/o freq infections
Types of cerumenolytics?
Mineral oil + peroxide
Carbamide peroxide 6.5% (deprox)
Cerumenolytics complications?
Allergic reaction Otitis externa Earache Transient HL Dizziness
What type of fancy medical water is used for cerumen impaction irrigation?
Tap water or saline
- dont get fancy
It says you can use a syringe but it takes way more water than that, trust me
What should you follow irrigation with?
Acidification
- 2% acetic acid or boric acid powder
Complications of irrigation
Retention of water behind cerumen - maceration and infection TM perforation HL Tinnitus Vertigo Pain
When should you make ENT do the cerumen removal?
When its complex and needs their fancy microscope guidance machine
- TM perf
- recurrent impaction
- doesnt respond to routine measures
- h/o chronic otitis media or TM perf
Guidance for pts w recurrent cerumen impaction (2/2 a disease usually)
- Cotton ball dipped in mineral oil and in EAC x 10-20 min once/week
- Removal of hearing aid during sleep
- Routine cleaning by you 6-12 mo
When dealing with FOB in ear sometimes flushing will help. When should you avoid irrigation?
Organic objects
- beans
- insect
- etc
If you look in a kids ear and see a bug what should you do?🐜
Hit it with 2% viscous lidocaine
- kills bug
- anesthetizes skin of eac
External otitis is aka?
AOE
Swimmers ear
Otitis extrena clinical presentation?
Its pretty basic ear infection
Slide 81 if you wanna look. You should be able to get it though
AOE tx?
Mild
- 2% acetic acid (VoSol)
- Vosol (rx)
Moderate - polymyxin B/hydrocortisone (cortisporin) - aminoglycosides (gentamicin sulfate) Quinolones (ciprofloxacin or ofloxacin) - Ofloxacin otic
Why may you consider not using aminoglycosides (gentamicin) on the ear balls?
May be ototoxic
AOM plus (list) is prob getting combo therapy of ototipic and systemic meds
Cellulitis DM Aids h/o ear radiation Severe otitis externa Sig edema (blocking access to canal)
During AOM tx pts should?
Avoid promoting factors
- no water in ear
- cotton ball w Vaseline in ear during bathing
- no water sports x 10 days
- education on proper ear hygiene
What is necrotizing otitis externa aka malignant otitis externa?
Sever bacterial infection of EAC at skull base
- pseudomonas
- spreads to bone and wreck it ralph’s your head
Malignant otitis externa diagnosis?
CT w bone windows
Presentation of necrotizing otitis?
External otitis spreads to bone Deep otalgia EAC granulation Foul otorrhea CN palsies (bad sign)
Why is it called malignant?
The look and high mortality of the infection
- not actually cancer
Tx for necrotizing otitis externa?
ENT consult
IV ciprofloxacin
Oral cipro (select pts)
Meds x several months
Surgical debridement if refractory
How effective is tx for necrotizing otitis externa?
With early diagnosis and tx 90-100%
Usual cause of ear pruritis?
Self induced from excoriation or excessive cleaning
Tx for ear pruritis?
Avoid causes Avoid soap in ear Mineral oil to hydrate Kenalog topically Oral Antihistamines Topical isopropyl etoh (drying)
Structural ear canal d/o?
Exostoses
- multi EAC lesions, firm, bony, broad-based lesions
- composed of lamellar bone,
- reactive bone formation
Osteomas
- pedunculated bony EAC lesion attached to tympanosquamous or tympanomastoid suture line
How are structural ear canal d/o diagnosed?
Exostoses and osteomas are usually asymptomatic so generally found incidentally
though can also cause occlusion of EAC
- impaction
- external otitis
- HL
Tx for structural ear canal d/o?
Single/small - observe
Multi/large - surgical removal
MC neoplasm of ear canal?
Squamous cell carcinoma
When to suspect SCC?
Apparent otitis externa doesn’t resolve on therapy
Suspect malignancy
EAC neoplasm prognosis?
High 5 yr mortality
- invades lymph of cranial base
Tx for EAC neoplasm?
Wide surgical resection
Radiation
Which neoplasms are generally more indolent?
Adenomatous tumors originating from the ceruminous glands
So i sent that bitch an ear
Bitches love ears
- Vincent van Gogh
