disorders affecting the OUTER EAR Flashcards
what is the average size of the adult ear?
The average adult ear is ~ 2.5 cm (1 inch) long and ~ 0.7 cm (0.3 inches) in diameter
what are the 2 branches the pinna is supplied by?
by two branches of the external carotid artery with an extensive network of connections between the two branches, which are the:
1)Superficial temporal artery
2) Postauricular artery
where does the venous drainage end?
Venous drainage ends in the external and internal jugular veins
what sensory innervation is in the pinna
1) by various cervical spinal nerves ->(lesser occipital nerve)
2) branches of the trigeminal nerve ->(auriculotemporal)
3) vagus nerve-> (auricular branch)
why is it hard to reconstruct the pinna?
because of the intricate and delicate topography and blood supply makes reconstruction of the auricle difficult
can genetic factor affect the pinna?
yes!
can genetic disorders of the pinna be recessive or dominant?
both!
can the outer ear indicate middle and inner ear abnormalities ?
-Some auricular deformities may be an indication of middle and inner ear abnormalities, which may cause hearing loss or deafness
For this reason, it is good practice to inspection the outer ear during otoscopy
correlations with auricle anomality’s can indicate type of problems with what body part?
Children with auricular anomalies show a slightly increased risk of concurrent renal abnormalities, which may require medical/surgical intervention
what is mircotia?
The term describes underdevelopment of the outer ear
what is the range of microtia ?
Represents a range of findings from complete agenesis (absence of pinna) to somewhat small ears with atretic canals
what does microtia look like?
The most common finding is a sausage-like or “peanut” ear
who is more likely to get microtia between men or females ?
Twice as many males as females affected
is the right ear or left ear typically seen to get microtia ?
The right ear is most often involved, and it is rarely bilateral
what is atresia ?
no opening of the ear canal
where is bilateral mircotia seen?
it’s frequently seen with patients who have treacher collins (at arch) syndrome)
what is a constricted ear?
The helix kind of enlarges
The encircling helix is tight
what is included in a constricted ear?
loop ear and a cup ear
what is a loop ear?
This is where the helix kind of buldges up
an inferior bending of the superior helix
what is a cup ear?
an increase in the bowl size
what is auricular appendages ?
Common anomaly, often a result of accessory auricular hillocks from which the auricle develops
are auricular appendages unilateral or bilateral?
Usually, unilateral
what is typically involved in auricular appendages?
May contain skin alone or skin and cartilage
can HL be seen in auricular appendages ?
May present with associated hearing loss
A complete audiologic evaluation is necessary
what is auricular sinuses/pits?
Usually harmless, pit-like depression anterior to the auricle
what might cause auricular sinuses /its?
May be a result of failed closure of part of the first branchial groove
can auricular sinuses/pit be blocked with stuff?
May become blocked with debris or secondarily infected
auricular trauma can be a result of ?
Thermal injury (burns or frostbite)
Penetrating injury
Blunt injury
why is the auricle susceptible to trauma?
Because of its prominent, and unprotected position, they’re just out there
what are treatments for auricular trauma?
Auricular trauma often requires antibiotics and tetanus prophylaxis but may also require surgical reconstruction
what is an auricular hemotoma?
-blood vessels separate under the cartilage
-Can occur as a result of blunt force trauma and contact sport
-Blood vessels in the perichondrium (membrane covering the cartilage of the outer ear) get separated from the underlying cartilage
what happens when cartilage receives oxygen and nutrients in auricular hematoma?
it results into scarring
Because the cartilage receives oxygen and nutrients from the perichondrium, the separation can result in devitalization of the avascular cartilage and subsequent fibrosis (scarring)
what happens if the hematoma is left untreated?
cauliflower
If the hematoma is left untreated, new and asymmetric cartilage forms from the perichondrium resulting in a distorted/thickened external ear or CAULIFLOWER EAR!!!
where is auricular hemotoma typlically seen?
commonly seen in wrestlers, boxers and football players
where are penetrating injuries seen?
Seen with knife wounds, human and animal bites, and motor vehicle accidents
what can result from penetrating injuries ?
Can result in complete or partial avulsion (separation) of the auricle
can penetrating injuries be reattached?
-Re-attachment is possible and often successful if done relatively early, preferably within five hours of the injury
-If the ear is completely torn off, it should be transported in a cold, sterile container for re-attachment
what is penetrating injuries ?
they’re blunt force trauma
what is perichondrits ?
Inflammation of the perichondrium and cartilaginous layer can be categorized as
Infectious or suppurative perichondritis
Noninfectious termed relapsing perichondritis
why is perichondritis considered a misnomer?
The term perichondritis is a misnomer because
cartilage is almost always involved in
treatment in auricular hemotona, for both humans and animals, in terms of bites?
prophylatic tetanus and antibiotics is mandatory
thermal injuries are due to?
frost bite and burns
why is important to protect the skin in a thermal injury?
because there is no protective layer of skin so it’s a bigger risk of infection
the bigger the burn the more risk the infection
what is perichondritis pt2
inflammation of the cartilage due to frost bite or bug bite or piercing but either way there is puss
what causes perichondritis ?
Injury, burns, insect bites, ear piercing, boils, etc.
perichondritis has an insidious (slowly might note notice right away) onset of?
-Initially presenting with a dull ache, warmth, and redness
-If untreated, it can progress to cartilaginous necrosis and deformity
can an infection of the auricle be bacterial or viral?
Infections of the auricle can be bacterial or viral
what is the most common VIRAL infection that goes with CN 7?
The most common viral infection with accompanying VII N paralysis is herpes zoster oticus (shingles) or Ramsay Hunt Syndrome
what is shingles or ramsay hunt syndrome caused by ?
Caused by reactivation of latent varicella zoster (chicken pox) virus in geniculate, spiral, and vestibular ganglion, and VII nerve sheath
what is shingles or ramsay hunt syndrome ranked on facial nerve palsy?
The 2nd most common cause of facial nerve palsy (3 to 20%)
what is the earliest symptom seen in shingles or ramsay hunt syndrome?
-The earliest symptom is pain and painful rash in the ear canal, concha, or below/behind the auricle
-The rash is caused by the virus localizing in the skin and resulting in painful vesicular (blister) eruptions
what other cn can be involved in infections of the auricle?
Other cranial nerves involved including VIII N; hearing loss & vertigo
what is the medical intervention of an infected auricle?
-Clinical symptoms begin to resolve within 12 to 14 days
-Medical intervention is required, typically with antiviral drugs & steroids
in infected auricle, what is affected?
just the skin! not the auditory system
what is allergic contact dermatitis caused by?
Caused by exposure to medicinal and cosmetic products (particularly jewelry containing nickel)
-it can happen to anywhere on the body
what is it called when the auricle has an allergic reaction?
when the auricle is prone to allergies, what can be a result form this?
The auricle is prone to allergies resulting most commonly in contact dermatitis
how does the auricle look like in allergic contact dermatitis ?
The auricle becomes red, inflamed, and there may be pain
what is treatment for allergic contact dermatitis ?
Topical antibiotics and steroids
what is seborrheic dermatitis caused by ?
believed to be due to infection by a yeast-like organism, Malassezia furfur ( yeast)
but it’s not really known
what is Seborrheic dermatitis?
skin inflammation
what can result from Seborrheic dermatitis?
-Results in scaly superficial eczematous dermatitis (not contagious)
-which then Often causes otitis externa
what is the treatment of Seborrheic dermatitis?
Decrease yeast colonization and inflammation by antimycotic drugs, topical steroid cream, and drops
-antibiotics because its fungal
what does neoplasm mean?
new tissue
-itcan be either benign or malignant
what do benign neoplasm include what ?
Benign neoplasms include cysts and keloids
(keloids are scar tissue)
what are sebaceous cysts?
Fluid filled cysts
that are generally seen following trauma such as ear piercing
-they can be secondary infection
what is the treatment of sebaceous cyst ?
antibiotics and then surgical excision
what are keloids?
Benign outward overgrowth of scar tissue
where are keloids seen?
Commonly seen following ear trauma, ear piercing, and viral infections like herpes varicella zoster
can keloids spread?
Keloids can spread to adjacent tissue
what is the treatment of the keloid ?
Surgical excision
Steroid injections
what is malignant neoplasm?
skin cancer? but they’re rare
what is the most common malignant neoplasms?
The most common is squamous cell carcinoma,
squamous cell carcinoma, represent what area of the auricle ?
represents ½ to 2/3 of all skin cancers involving the auricle
are basal cell carinoma common skin cancers?
Basal cell carcinoma is the most common skin cancer but its occurrence in the auricle is fairly uncommon
cutaneous malignant melanoma is what ranked skin cancer in the US?
-Cutaneous malignant melanoma is the 6th most common cancer in the U. S.
-Auricular melanomas represent 7 to 20% of all head/neck cutaneous melanomas
what is the cancer of connective tissue?
Rhabdomyosarcoma (cancer of connective tissue) is the most common soft tissue childhood tumor
what are signs/ symptoms of Rhabdomyosarcoma
otalgia, otorrohea, bleeding, and bone destruction
where are foreign objects typically seen?
in the external ear canal
what are things considered as EAC?
-Beads
-Insects
-Complaints of an itching or tickling sensation or patients report that they can hear something “moving”
-Food
-Pebbles
-Small alkaline batteries that can cause chemical burns
how are forgein objects removed ?
These objects can be removed with a hook, or suction; with or without local anesthesia
what is ear canal stenosis?
a very narrow ear canal
stenosis can lead to
-difficult to see the ear canal
-it’s easy for ear wax and debris to get stuck
-can cause a conductive hl
-difficulty in examining the exteranl auditory canal
-collection of wax and debris in the external auditory canal
-possible conductive HL because it will block off the ear canal
how can external auditory canal stenosis be repaired?
External auditory canal stenosis is repaired by widening the canal-canalplasty
what is congential aural atresia ?
Failure of canalization of the EAC can result in aural atresia
is aural atresia more common in men or females?
men
what condition is aural atresia more associated with ?
It often is associated with microtia and middle ear anomalies
can aural atresia be sporatic?
yes!
what syndromes are aural atresia associated with? and why?
treachers collins, trisomy 22, crouzons syndrome, and hemifacial microsomia (incomplete turns of the cochlea)
why?
Lower ½ of one side of face is underdeveloped and does not grow normally; sometimes referred to as 1st & 2nd brachial arch syndrome
how can we establish cochlear function in children with unilateral/bilateral atresia
a bone conducted ABR
how come aural atresia doesn’t affect the cochlea?
Aural atresia occurs after inner ear development, therefore, most patients (› 80%) have normal cochlear function but have a maximum conductive hearing loss (~ 60 dB HL)
-But incidence of inner ear malformations is higher in the atresia population (as high as 22%) compared to the general population
what is congenital aural atresia ?
complete failure of canalization
(no ear canal)
treacher collin ties in with what?
aural atresia
down syndrome is tied in with what ?
stenosis
when should aural atresia be repaired?
-Repair of aural atresia should take place after repair of a coexisting microtia
-Surgical repair usually occurs ~ age 6 to 8 years because the auricle is close to full size by then
what has the FDA approved in terms of aural atresia ?
baha’sfor kids over 5 years old
FDA has approved that children with bilateral or unilateral atresia can be fit with a surgically implanted bone-anchored hearing aid (BAHA) after 5 years of age
what type of HA can children with aural atresia can wear?
baha with headband
Children 5 years and younger can be fit a bone-conducted hearing aid/BAHA coupled to a soft or hard headband
how do baha’s kind of work (a general idea)
The BAHA utilizes direct percutaneous coupling of a vibrating transducer to a titanium implant anchored in the temporal bone
how can supra aural headphones affect the ear canals
it can cause the ear canal walls to collapse
Ear canal walls can collapse when standard supraaural headphones are placed over the ears
who is at risk of having a collapsing canal ?
younger children and older adults, because soft and deteriorating cartilage, respectively
what should we do if a patient is at risk of a collapsing canal?
In patients at risk for collapsing canals, while examining the ear canal, exert pressure on portions of the pinna cartilage around the opening of the ear canal where the supraaural headphones sit
can the tragus contribute to causing a collapsing canal ?
yes,
sometimes a large tragus, which normally projects away from the opening of the ear canal can be flattened across the EAC opening by pressure of a headphone
-can cause occlusion
what are some audiological finding in collapsing canals?
-normal tymp
-a “conductive” HL in the higher freq with surpas
-thresholds get better when headphones are moved higher from the ear canal
-Rarely, patients may complain that they cannot hear as well with headphones as without
-Threshold will be better with inserts or in the sound field
how much HL can an occluded ear canal cause?
a 50 DB HL hearing loss
how can we manage a collapsing ear canal
-Use of insert phones (best
option)
-Placement of immittance
probe tips in the ear canal
-Use of stock ear mold(s) to
keep the canal open
( -the 2 above may result in high freq attenuation)
-Pull the pinna upwards
and backwards when
placing the headphones
-If suspecting collapsing
canal, hold the
headphone, if possible,
against the ear rather than
fixing it in place with the
headband
what is epithelial migration?
Cerumen and dead skin are carried out of the external auditory canal by an unusual lateral migratory property of the squamous epithelium (skin) lining the ear canal
how does ear wax look like as we get older?
itgets drier
Cerumen tends to become drier with age due to reduced number and activity of ceruminous and sebacous glands
The natural process of cerumen secretion and export to the periphery of the EAC can be affected by
a number of processes leading to cerumen impaction
impaction is more common in what gender?
Impaction is more common in males due to thicker and coarser hairs found at the lateral end of the EAC
what can block the flow of cerumen and lead to impaction??
Narrow canals, over-zealous use of cotton coated tips, and a hearing aid/earmold can all impede the normal flow of cerumen to the periphery leading to impaction
what are audiologic findings in cerumen impaction?
-sensation of obstruction
-on otoscopy, cerumen blocking the ear canal; TM structures not visualized
-tymp volume is less than or equal to 0.2ml
-mild conductive HL
-otalgia
-vertigo or dizziness
-coughing (via arnolds nerve, branch of X nerve in the EAC)
what is the management of cerumen impaction?
-Cerumen removal by
medical personnel
-Cerumen softening by
cerumenolytic agents
like olive oil, Murine, and
Debrox prior to removal
what is an inflammatory polyps?
basically abnormal tissue growth
Large inflammatory polpys (abnormal tissue growth) can present as masses in the EAC
What is inflammatory polyps typically seen with?
Typically seen with chronic otitis media, with or without cholesteatoma
what are causes of inflammatory polyps?
Foreign bodies in the EAC or TM such as retained PE tubes, canal cholesteatoma, and benign or malignant tumors
are inflammatory polyps painful?
no and you can give them to topical therapy and steroid-antibiotic drops
what happens if healing doesn’t happen in inflammatory Polyps?
a biopsy might be needed
what is the most common condition that affects the EAC?
otitis externa
what is otitis externa ?
It is an inflammatory condition of the skin lining the EAC
whatare the different types of otitis externa ?
It can be acute, chronic, diffuse, or localized
what is Acute diffuse otitis externa
It is typically a bacterial infection
acute diffuse otitis externa is caused by what?
-local trauma
-frequent swimming (swimmers ear)
-and it can occur spontaneously
what are some audiological findings in acute diffused otitis externa ?
-Severe pain
-Generally conductive -hearing loss
-Whitish, watery otorrhea
-Acute swelling that may be
severe enough to close
the EAC
-physical puss
what are treatments of acute diffuse otitis externa?
-Analgesics for pain
-Topical antibiotics and steroids
-Removal of infected debris by physician
what is another name from otitis externa
swimmers ear
what are the 2 forms that exist in otitis externa ?
1)Furuncle (abscess)
2)Bullous myringitis
what is Furuncle (abscess)?
-affecting the hair follicle
-A staphylococcus aureus infection of a hair follicle in the EAC
-Extremely tender and painful, but self-remitting in a few days
-Symptomatic treatment for pain if needed
what is bullous myringitis ?
-localized viral or bacterial infection deep in the ear canalor on the TM
-Localized viral (e.g., influenza or herpes zoster) or bacterial infection (e.g., -Strep. pneumoniae) of TM and deep EAC
-Results in blood blisters of various sizes
-Extremely painful but again self-remitting in a few days
what are treatments for bullous myringitis?
-Symptomatic for pain
-Cleaning of debris in the EAC by a physician
where does chronic otitis external occur?
it’s a condition in the EAC?
what is the most common cause of chronic otitis externa?
The most common cause is seborrhic dermatitis which is a yeast-like organism
what are some symptoms you can see in chronic otitis externa?
red, scaly with no ear wax, itchy, NO PUSS
-Underlying skin appears red and scaly with lack of cerumen
-The bigger problem is itching rather than pain
-Watery discharge may occur
-This condition is prone to frequent acute flare-ups
-NO PUSS IS SEEN HERE
what is some treatment for chronic otitis externa?
tropical steroids?
what are some complications in the ear because of chronic otitis externa ?
-Stenosis of the EAC due to inflammation
-Formation of a false membrane across the EAC that may obscure the TM and result in a conductive hearing loss
how can fungal infection occur?
canhappen spontaneously or it could be because you use antibiotics to often
Fungal infection of the EAC can occur spontaneously or a result of frequent use of topical antibiotics, in which case it may be secondary to chronic otitis externa
what are some symptoms you see in a fungal infection ?
-The infection can be quite colorful ranging from blue-black, green, yellow, to white
-Produces extensive debris within the EAC
-Patients complain of a hearing loss and/or a wet feeling inside the EAC
what happens if you leave a fungal infection alone?
Untreated, it can destroy sections of the EAC, mastoid bone, and may cause meningitis, and death
what treatment can be used for a fungal infection ?
Topical anti-fungal medication
Removal of debris from the EAC by a physician
what is otomycosis?
the medical name for a fungal infection
what is the historic name for necrotizing external otitis (NEO)
malignant otitis externa
what type of patients can have an aggressive necrotizing external otitis infection ?
in the immunocompromised patient, such as
-Poorly controlled diabetic patients (most common)
-HIV and AIDs patients
what body part can be involved in necrotizing external otitis??
The disease can involve the temporal bone and skull base and then it is essentially osteomyelitis - skull-base osteomyelitis
when does necrotizing external otitis begin?
The episode begins as an acute otitis externa but because the host is immunocompromised, the infection spreads beyond soft tissue of the ear canal to the underlying temporal bone
what does necrotizing external otitis consist of ?
granulation and inflammatory tissue forming in the EAC replacing a significant portion of the bony EAC, which then mimics a malignant disease
in necrotizing external otitis, intratemporal and intracranial complications occur through what ?
-Intratemporal and intracranial complications occur through involvement of neurovascular pathways, including
-Inferior extension of the disease into the mastoid portion of the temporal bone can produce facial weakness/paralysis
-Medial extension into the petrous apex can affect CNs V & VI
-Inferior-medial extension can involve the jugular foramen and cranial nerves IX, X, & XI resulting in
-hoarseness, dysphonia and aspiration
what happens when necrotizing external otitis extends into the dura lining of the temporal bone?
-Vascular complications –
e.g., sigmoid sinus thrombosis
-Intracranial complications
– e.g., otic hydrocephalus & meningitis
what is the diagnosis of necrotizing external otitis (NEO)
-In an immunocompromised patient with ear pain, NEO should always be suspected
-Biopsy of granulation tissue in the EAC to rule out malignant disease and obtain cultures for bacterial and fungal organisms
what is the treatment of necrotizing external otitis (NEO)
-Parental and topical antibiotics (resolves the condition in ~ 80% of patients) but may require meds for up to 6 months
-Treatment of underlying immunocompromising condition
what are common benign neoplasms?
1)exostosis
2)osteomas
what is exostosis ?
bony growth and the most common benign tumor of the EAC
what causes exostosis?
localized hyperplasia (abnormal cell increase) usually due to irritation or may be idiopathic
are exostosis bilateral or unilateral growths ?
Typically bilateral but usually starts as a unilateral growth
what type of individuals can get exostosis ?
Common in individuals with prolonged exposure to cold water
what happens if the exostosis get too large
If large, may lead to a conductive hearing loss by obstructing EAC
what are other symptoms seen at a later stage in exostosis
pain/discomfort, tinnitus, and associated otitis externa
what are treatments for exostosis?
Antibiotics, analgesics, and surgical excision of the growth
what are osteomas?
True benign bony tumors
how do exostosis and osteomas differ?
-While exostosis are irregular and multiple
-osteomas are smooth and usually singular
what is something important to remember in exostosis ?
recurrence can occur with recurrence of external otitis
what do symptoms of osteomas look like ?
symptoms similar to exostosis
what is the treatment for osteomas ?
surgical excision
are squamous cells carcinoma common in malignant neoplasm
yes
what is adenoid cystic carcinoma
a rare form of adenocarcinoma, and is found mostly in the head in neck
sarcoma is most common what population
in kids
squamous cell carcinoma, adenoid cystic carcinoma, and sarcoma may present what ?
May present with pain, drainage, and hearing loss, mimicking chronic otitis externa and delaying diagnosis
if patients are presenting with nonhealing gradulation tissues in the EAC, what should we do ?
should be biopsied
what are squamous cell carcinoma, adenoid cystic carcinoma, and sarcoma
malignant tumors
what is Osteoradionecrosis (ORN)
Osteoradionecrosis (ORN) is a rare and most serious complication arising from radiation of the base of skull bones due to cancer, but idiopathic variants do occur
what happens if the radiated bone becomes susceptible to infections in Osteoradionecrosis (ORN)
Radiated bone becomes susceptible to infection and healing is compromised
can a person still get Osteoradionecrosis (ORN) even years after the radiation ?
yes
can be localized or diffused in the External ear canal?
it can be both
how do localized Osteoradionecrosis (ORN) occur?
EAC is the portal of radiation
when are diffused EAC more common in ?
Diffuse EAC disease is more common in high dose radiation to the temporal bone
what are signs and symptoms of Osteoradionecrosis (ORN)
-Ear fullness
-Otalgia
-Foul odor
-Hearing loss (can be
conductive or SNHL)
-Discharge including bloody -otorrhea
-Tinnitus
what body part is the most common to be affect in Osteoradionecrosis (ORN)
the mandible bone
in microscopy, what does Osteoradionecrosis (ORN) look like ?
-Debris in EAC and occasionally granulation tissue
-Single or multiple areas of exposed devascularized bone that is yellowish in color and soft
-Persistent granulation tissue in the area should be biopsied
what is treatment for a localized Osteoradionecrosis (ORN)
-Less aggressive condition
-In-office debridement(removal of the damaged tissue)
-Topical antibiotics
what is the treatment for diffused osteoradionecrosis (ORN)
- More lethal condition
-Necrotic temporal bone is at risk for intratemporal and intracranial neurovascular complications
-Surgical debridement
-I/V antibiotics
what is a differential diagnosis for osteoradionecrosis (ORN)
chronic otitis media
