Tympanic Membrane Landmarks

Techniques of Examination:

1. Inspect each auricle and surrounding tissues for deformities, lumps, or skin lesions. Movement of the

auricle (tug test) is painful in acute otitis externa but not in otitis media.

2. Make sure to choose the correct speculum size by selecting the largest one that will still be comfortable

for your patient and place speculum on otoscope.

3. Hold the otoscope in your dominant hand and use your other hand to pull the pinna upward, backward,

and slightly away from the head to straighten out the path of the ear canal.

4. An alternate technique for holding the otoscope is between your thumb and index finger and resting the

ulnar side of your hand on the patient’s cheek so that if they move quickly, your hand and otoscope will

also move with their unexpected movements.

5. Insert speculum gently into ear canal, directing it down and forward. Inspect ear canal as you advance,

looking for discharge, redness, foreign bodies, or swelling.

6. As the tympanic membrane comes into view, note its color, transparency, integrity, position, and

landmarks. Pivot the speculum and adjust your line of sight to visualize the entire membrane.

7. The normal tympanic membrane should appear translucent and pearly gray. Visualize landmarks

including the cone of light, umbo, handle of the malleus, pars tensa, and pars flaccida. Look for

retraction, perforation, and evaluate mobility of membrane using pneumatic otoscopy.

Recognizing Acute Otitis Media

Pneumatic otoscopy is recommended as the primary diagnostic method in the American Academy of

Pediatrics (AAP), American Academy of Family Physicians (AAFP), and American Academy of

Otolaryngology-Head and Neck Surgery (AAOHNS) clinical practice guideline for otitis media with

effusion in young children.

References

1. American Academy of Pediatrics. http://www.aap.org/otitismedia/www/vc/ear/rvw/rvw2.cfm

2. Otoscopic Exam. http://www.kcom.edu/faculty/chamberlain/Website/Sparks/Physical/Oto.htm

3. Bickley, Lynn S. Bates Guide to Physical Examination and History Taking. Lippincott Williams &

Wilkins, 2003.

4. Virtual Pediatric Hospital. http://www.virtualpediatrichospital.org/providers/VirtualPedsPatients/

Case01/Captions/OMDDAOM.shtml

5. American Academy of Family Physicians; American Academy of Otolaryngology-Head and Neck

Surgery; American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Pediatrics

2004 May;113(5):1412-29.

Getting to the ear drum…1 4

1. S

   Moving the auricle and tragus constitutes the “tug test”, and is painful in external otitis media, but not in otitits media. Touching behind the ear may be painful in the latter.

   elect largest ear speculum the canal will accommodate.

2. Position head so instrument can be used comfortably.

3. Examine the problematic ear last to avoid spreading.

4. To straighten canal, grasp auricle and pull firmly but gently upward, backward and slightly away from the head.

5. Grasping the handle between your thumb and index finger, brace yourself against the patient’s face using your other fingers, to ensure unexpected movements are followed (pencil grip).

6. Gently insert speculum, aiming slightly down and forward.

7. Inspect the ear canal as you enter for any discharge, foreign bodies, redness of the skin or swelling, note cerumen may interfere with your view.

8. Inspect the ear drum.

Examining the ear drum…2

1. Inspect the eardrum, noting color and contour, the cone of light is useful in orientation.

2. Identify the handle of the malleus and inspect the short process of the malleus.

3. Gently move the speculum to see as much of the drum as possible.

4. The tympanic membrane consists of the pars tensa and pars flaccida, the malleus handle is in the middle of the tensa, superior to this is the lateral process of the malleus, the most easily recongnizable structure. The tip of the handle inferiorly is the umbo with the light reflex normally extending from this.

5. Identify handle, if not present look for the lateral process. Inspect the pars tensa systematically, starting in the posterior superior quadrant and moving forward, downward and backwards. Carefully inspect the pars flaccida.

Useful questions to ask yourself…2

1. Can the external canal clearly be visualized? If filled with debris is it safe to remove this material? If ear is possibly perforated, patient should be referred to ENT.

2. Can the TM and handle of the malleus be seen? Handle gives an idea of where the TM should have been if missing.

3. Is the TM intact? Note the difference between a retracted ear drum and perforation. If there is debris around the pars tensa or over the flaccida, patient may have a cholesteatoma, refer to ENT.

4. Is the TM the right color/transparency? Gold/blue/dull membrane indicates fluid in the middle ear. White patches are tympanosclerosis. Chalk patches and thick patches from prior surgery are not clinically important unless hearing is affected.

Common Problems…2

1. Unable to see properly? Check light and ensure battery is charged.

2. Red drum is all that is visible? Most likely posterior canal wall, try tilting otoscope anteriorly/superiorly or pulling the pinna further.

3. Anatomy is very abnormal? Start by looking for the lateral process of the malleus. Normally this is present despite other processes occurring in ear, orient yourself with it.

4. Is that a perforation? Usually obvious, however deep retractions can look similar. Blood vessels in the middle ear mucoas confirm the presence of a perforation. ENTs will often use pneumatic otoscopes to better evaluate this.

Normal TM Retracted TM Serous Otitis TM Cholesteatoma Perforated TM Ear Tube in place

Clinical Examples of Tympanic Membranes…3

References

1Bickley, Lynn S. Bates’ Guide to Physical Examination and History Taking: Eight Edition. Lippincort Williams and

Wilkins, 2003. 156-7.

2”Photographs of Ear Tubes, Eardrums, Infections, Cholesteatmas, and Acute Otitis Media.”

http://www.entusa.com/eardrum_and_middle_ear.htm. Accessed June 4, 2007.

3”How to Use an Otoscope.” http://www.comdis.wisc.edu/staff/mrchial/howotoscope.htm. Accessed June 4, 2007.

4“External Ear.” http://www.infovisual.info/03/048_en.html. Accessed June 4, 2007.

Stridor:

Usually an emergency.
A harsh and variable pitched vibratory sound due to partial obstruction of the upper airway.

Inspiratory with snoring is usually a nasal problem (polyp, Foreign body, atresia).

Gurgling with muffled voice is usually a pharyngeal problem (tonsils, mono, epiglottitis).

High pitched inspiratory with voice change and hoarseness is usually a laryngeal problem (Epiglottitis/ croup if febrile, laryngeal mass/ subglottic stenosis/ vocal cord paralysis if afebrile).

If both inspiratory and expiratory then usually a tracheal problem (Foreign body or mass).

If expiratory wheezes, then a bronchial problem, consider asthma or Foreign body.

Epiglottitis --> any age, + drooling, 40% afebrile, pt is sitting up and leaning forward, usually H. influenza, enlarged "thumbprint" epiglottis on X-ray, toxic looking, mild stridor. Emergency.

Croup --> 6mo-3yo, variable fever, pt is lying down, due to viral laryngospasm, X-ray with subglottic narrowing, ballooning of hypopharynx is variable, have a barking cough and hoarse voice.

Foreign Body --> age>9mo, +drooling, variable posture. Peanuts, plastic toys.

Peritonsillar Abscess --> >12yo, +drooling, high fever, upright posture with painful neck mov't. Group A Strep (GAS), stridor mild/ absent, severe pharyngitis.

Retropharyngeal Abscess --> age <6yo style="color: green;">X-ray shows enlarged retropharyngeal space.

Bacterial Tracheitis --> age 1-5yo, high fever, variable posture, H. flu/ S. aureus, X-ray shows irregular tracheal wall, toxic looking, see tracheal pseudomembrane on ETT intubation.

Congenital --> Choanal atresia in newborn, laryngeal paralysis.

Chronic Stridor --> laryngomalacia, subglottic stenosis, laryngeal lesions, vocal cord dysfunction, laryngeal papilloma, retained Foreign body.

Adults --> pharyngeal neoplasia, lingual angioedema, mucopus in larynx/trachea (with defective cough mechanism), Laryngeal inflammation (diphtheria, acute laryngitis from irritant gases, TB, syphilis, Wegener’s, sarcoid). Ankylosis of crico-arytenoid joint from RA.

Compression of larynx/ trachea (goiter, Ca, Riedel’s thyroiditis, Ca, aortic aneurysm, mediastinal growth, cellulitis, Ludwig angina, fungal infection.

Laryngeal nerve palsy, Narrowing of both main bronchi (Ca, TB, amyloid, tracheomalacia, stricture in sarcoid.

Eval in Child: take non threatening approach; observe from distance on caregiver's lap. Look for ability to drink, sustain cramming , vocalize, smile (show a toy), move, color, consolability. Don't stimulate child with stethoscope on chest.

• There is some evidence that being out in the cold increases some risks associated with getting an infection: 1.) vasoconstriction of nose vasculature; 2.) nasal mucosal temp. decreases; 3.) “increases risk” whatever that means.

• Bacterials Infections – nose naturally has corynebacterium, staph (1/2), alpha hempolytic strep.

• May include vestibulitis, folliculitis, cellulitis (erysipelas from staph/strep), or sinusitis.

• ACUTE SINUSITIS – the seat of sinusitis is in the anterior ethmoids, and amoxicillin are the first line of treatment (cepahalosporins, augmentin, fluoroquinones are second line)

  • Pus in the sinuses, often caused by Strep Pneumo., H flu, or M. catarrhalis; Dx by H&P, CXR, nasal endoscopy in some cases.

  • Treatment – Antibiotics – amoxicillin, TMP-SMX, cefuroxime, quinolones, topical decongestants for less than 3 d., mucolytics, antihistamines if allergy-related

  • Surgery used only as a last resort where complications arise in eye or brain. If unresponsive, aspirate the maxillary sinus for culture. If complications, more done.

• CHRONIC SINUSITIS – consider the underlying etiology of allergy, polyps, CF, immunodeficiency.

  • Organisms include Staph, gram negative rods, and anaerobes.

  • Dx – H & P, CT scans, nasal endoscopy.

  • Tx – manage underlying condition, antibiotics for longer periods (>3,4 wk), steroids, or surgery in some resistant cases.

HISTORY

• Non-specific questions might include: pain, congestion, runny nose, bleeding, post-nasal drip

• More focused questions may include: seasonal congestions?, sneezing fits?, itchy palate (common in some allergies), fevers, chills, night sweats, international travel hx?, immunocopmrimised? (invasive fungal sinusitis can be fatal in these pts), DM? (Zygomycetes), fam. Hx. Of CF?, nasal trauma?, breathing difficulty? (esp. w/ WG, sarcoid), hematuria (WG), TB exposure?, Nickel or woodworking exposure? (sinus/nasal cancer), dental disease or teeth pain?

PHYSICAL EXAM – KNOWING YOUR ANATOMY IS EXTREMELY IMPORTANT HERE!

• Face (swelling, erythema, tenderness), Eyes (vision, chemosis – conjunctiva swelling, proptosis=exopthalmos – eyes sticking out, epiphora – eye tearing, EOM), Oral Cavity (dentition, trismus – difficulty opening the mouth.

• NEURO (TRIGEMINAL NERVE – KNOW IT UP AND DOWN) – the maxillary branch of V runs through the rotundum and gives off the infraorbital branch.

1. V2 – infraorbital nerve - numbness over the upper lip

2. V2 – ant. sup. alveolar n. – maxillary incisor problems

3. V2 – post. sup. alveolar n. – maxillary molar problems

4. V2 – greater palatine n. – numbness over the palate

5. V3 – inf. Alveolar n. – numbness over the chin

6. V3 – lingual n. – weird taste

Nasal Exam – use the speculum to examine anterior septum (deviation, bleeds), turbinate swelling, valve area, “cottle maneuver” (lateral pulling of the cheek improves nasal breathing); use the endoscope to explore the lateral wall of the nose:

1. Inferior Meatus – nasolacrimal duct empties

2. Middle Meatus – anterior ethmoids, maxillary, and frontal sinuses drain here.

3. Superior Meatus – posterior ethmoid sinus drains here.

• Technique – 30 degree 4 mm telescope that goes into inf. Meatus, middle turbinate to the sphenoethmoidal recess, middle meatus.

• Inflammation – extremely common cause of the runny nose. Causes include 1.) allergies; 2.) infections (bacteria (rhinosinusitis), viruses (flu, colds), fungal (allergic, noninvasive, invasive), other (parasites)); 3.) polyps; 4.) immune deficiency – IgA, IgG subclasses; 5.) CF, even in adults!

• Structural –1.) septal deviation – midline of nose

2.) valve collapse – a valve is a triangular junction of the septum w/ soft alar tissue & inferior turbinate below; if pulling skin to the side makes it better, this is higher on the DDx.

3.) CSF leak – rhinnorhea (nose)

• Systemic – WG (systemic, necrotizing granulomatosis vasculitis potentially affecting the kidney, lung, ear, nose, throat, or larynx), sarcoidosis (non-caseating granulomatosis potentially affecting the lungs, larynx, nose, and skin), TB (caseating granulomas), SLE, syphilis

• Neoplastic – 1.) inverted papilloma - 10% will have cancer; most common benign nose/sinus neoplasm, comes with a high risk of recurrence.

2.) Cancers – SCC – most common head and neck cancer; adenocarcinoma; “small blue cell tumors” – lymphoma, sarcoma, melanoma.

3.) Dental – dentigerous cysts, ameloblastoma.

1. The auricle is examined first for any abnormality such as in position, size, shape, color, consistency, tenderness, or accessory auricles.
2. The mastoid process is examined for signs of inflammation.
3. The External auditory canal: For discharge, pain sensation on moving,

Then an ear speculum is introduced in the external auditory canal after its straightening by pulling the auricle upwards and backwards in adults downwards and backwards in children.

N.B. Good illumination is essential for examination of the ear and can be provided by:

1. Reflected light by a head mirror.

2. Head light.

3. Battery powered Otoscope (Provides magnification).

4. Oto-microscope (Provides magnification).

5. Endoscopic Examination (Provides magnification).

The structures seen are:

1- The external auditory canal.

2- The tympanic membrane: The prominent landmarks on the membrane are

1. The handle of malleus, which normally runs downward and backwards towards the centre of the membrane (The Umbo).

2. The cone of light, which appears in the antero-inferior part of the membrane due to reflection of the examination light.

4- Pneumatic Otoscope (Siegle’s speculum): It is an ear speculum provided with air pump to increase or decrease air pressure in the external auditory canal and with a magnifying lens by 2.5 times.

Indications:

1. To test mobility of the tympanic membrane.

2. To detect small lesions of the tympanic membrane by its magnification.

3. To perform fistula test.

I. Congenital anomalies:

1. Anotia: Absent auricle.

Figure 21: Anotia.

2. Microtia: Small deformed auricle.

They are often associated with (atresia of the external auditory canal).

3. Macrotia: Abnormally enlarged auricle in relation to the other auricle.

• Treatment: Plastic operation

4. Protruding (Bat) ears: (The commonest anomaly).

The ears of some children appear more prominent than usual (because the antihelix is underdeveloped). The prominence may cause unhappiness to the child once he goes to school.

Girls can generally hide their ears beneath hair, but boys cannot.

• Treatment: Corrective operation (otoplasty) is performed at the age of 4 years and on.

5. Pre-auricular fistula and sinus:

These are narrow tracks ending blindly. They are remnants of the cleft between the first and second branchial arches. They appear as shallow pinpoint depressions in the skin just in front of the helix leading to a fistulous tract. When the mouth of the track is closed, it is filled with sebaceous material and forms a cyst. When it is infected and ruptures granulations come out.

• Treatment: When it is only a dimple, it can be left alone. If recurrent infections occur, the fistulous tract has to be excised.

6. Accessory auricle: Small-elevation, formed of skin and cartilage in front of the auricle.

• Treatment: Surgical excision.

II. Trauma:

1. Laceration:

• Causes: open trauma as knife injury, bite, or pulling of an earring.

• Complications: perichondritis.

• Treatment: immediate surgical repair, antibiotics.

2. Haematoma of the auricle: Accumulation of blood between the auricular cartilage and its perichondrium.

• Causes:

1. Blunt trauma, commonly in boxers (boxer's ear).

2. Spontaneous as in elderly and haemorrhagic blood diseases.

• Clinical picture:

The auricle is painful, swollen, bluish and cystic (if early)or soft (if late).

• Complications: perichondritis.

• Treatment: Antibiotics, aspiration under aseptic conditions (if early) or incision and evacuation ( if late ), followed by firm pressure dressing to prevent recollection of blood.

3. Frost bite:

• Occurs mainly in very cold weathers (under 0º C), because of the exposed position of the auricle, the reflex vasoconstriction of the subcutaneous capillaries and crystallization of blood inside them (cold and pain sensation)≫ Accumulation of metabolites in the interstitial tissue ≫reflex vasodilatation (congested red and hot auricle) ≫acute ischemia≫necrosis of the auricle.

• Treatment: Rapid thawing ≫40º C, anticoagulants, analgesics, antibiotic. No rubbing because the tissue are friable.

III. Perichondritis:

Inflammation of the auricular perichondrium mainly due to pyogenic bacteria.

• Causes:

1. Infected haematoma or laceration.
2. Septic surgical incision.
3. Furunculosis of the external auditory canal.
4. Post- operative infection.
5. Criminal or animal bite.
6. Radiation

• Clinical picture: The auricle is painful, swollen, hot, reddish soft and tender. The lobule is free, because it has no cartilage. Later on deformity occurs.

• Complications: Cartilage necrosis (due to separation of the cartilage from its perichondrium by the accumulating pus) ≫fibrotic≫deformed auricle called “cauliflower ear”.

• Treatment: Intravenous antibiotics, Small incision(s), removal of necrosed cartilage≫drainage.
  

Congenital atresia of the external auditory canal:

• Cause: Failure of canalization of the external auditory canal.
• Clinical picture: Unilateral or bilateral completely narrowed or absent external canal or appears as a blind pit. It may be associated with microtia.

• Investigations:

  1. CT scan: to assess the condition of the middle and inner ears.

  2. Audiological evaluation of the type and degree of the conductive hearing loss.

• Treatment:

1. Auditory rehabilitation for infants with bilateral atresia.

2. Surgical reconstruction of the external canal, if the inner ear proved to have normal structure by CT scan and normal function by audiological evaluation

• Bilateral atresia: at the age of 5 years.

• Unilateral atresia: after puberty.

Trauma:

• Causes:

1. Self-inflected: by scratching the canal skin by an ear bud, hairpin.

2. Iatrogenic: unskillful ear wash or instrumentation.

3. Heavy blow on the chin while the mouth is opened ≫ transmitted to the tempro-mandibular joint ≫ fracture of the tympanic bone of the external canal.

4. Corrosive and caustic injuries ≫ may lead to cicatrical stenosis of the external auditory canal ≫ conductive deafness.

5. Accidental trauma with fracture base of skull.

   • Clinical picture:

1. Bloody otorrhea.

2. Laceration is seen by examination.

   • Complications:

Infection ≫ Otitis externa ≫ Stenosis.

• Treatment:

1. Antibiotics .

2. Avoid entry of water into the ear canal during head wash by putting an earplug or a piece of cotton soaked with an ointment.

Foreign body (F.B.)

• Incidence: Most commonly in children and mentally retarded persons.

• Types:

1. Animate foreign bodies as flies, larvae (myasis), mosquitoes, or fleas.

2. In-animate foreign bodies:

• Vegetable foreign body as beans and peas, they swell with water.

• Non-vegetable foreign body as pieces of papers, beads or buttons, they do not swell with water.

• Clinical picture:

  1. May be asymptomatic.

  2. Hearing loss, when the foreign body occludes the external canal.

  3. Animate foreign body causes severe irritation, and noise in the ear.

4. The foreign body is easily detected on clinical examination .

• Treatment:

1. Instruments (such as hooks):

• Can remove all foreign bodies.

• Should be used to remove impacted or large vegetable foreign body.

• General anaesthesia is necessary in cases of impacted foreign body and uncooperative patients as children .

2. Ear wash:

• Can remove most foreign bodies.

• Contraindicated in case of impacted or large vegetable foreign body.

• Insects should be killed by alcohol or oil before wash.

3. General anesthesia and a post-auricular incision and widening of the bony canal may be needed in cases of impacted foreign bodies especially when other measures fail.

figure 22: Removal of a foreign body with a hook.

• Complications:

Produced by the foreign body enterance or during unskilled attempts of its removal:

1. Injury of the external canal, tympanic membrane, ossicles.

2. Otitis externa or otitis media.

• Inflammation of the skin lining of the external auditory canal.

• Types:

1. Bacterial:

• Diffuse otitis externa.

• Localized otitis externa (furunculosis).

• Necrotizing otitis externa.

2. Fungal:

• Otomycosis.

3. Viral:

• Herpes zoster oticus.

• Herpes simplex.

4. Parasitic:

• Aural myasis (Larvae of flies).

5. Allergic: edema of the external canal with painful vesicles.

Associated with skin eczemas and history of allergen contact.

6. Seborrhoeic: associated with scalp seborrhoeic dermatitis.

Diffuse otitis externa

• Bacterial infection of the whole skin lining of the external auditory canal.

• Causative organisms: Streptococci, Staphylococci Pseudomonas aeruginosa, B. proteus.

• Predisposing Factors:

1. Skin laceration:

2. Skin maceration:

• Hot humid atmosphere with excessive sweating and frequent bathing.

• Discharge of chronic suppurative otitis media.

3. Diabetic or allergic patients.

4. Lack of hygienic habits as drying ears after bath with dirty towels.

• Clinical picture:

1. Earache increases on moving the jaw e.g. during mastication.

2. Hearing loss when edema is severe and occludes the external canal.

3. Otorrhoea: scanty and purulent.

4. Tenderness on moving the auricle and pressure on the tragus.

5. Skin of the canal is red, oozing, tender, and swollen≫ narrow lumen.

6. Pre and post-auricular lymphadenitis.

7. Normal tympanic membrane if it can be seen.

• Treatment:

1. Prevention of the predisposing factors e.g. proper hygienic habits.
2. Systemic treatment: antibiotics and analgesics.
3. Local treatment:

• Aural toilet i.e. repeated removal of the ear discharge by suction or dry mopping.

• Packing the canal with a gauze strip soaked with antibiotic / corticosteroid or Aluminum acetate 8% ear drops.

Furunclosis

• Localized bacterial infection of a hair follicle, in the skin lining of the outer cartilaginous part of the external auditory canal.

• Causative Organism: Staphylococcus aureus.

• Predisposing Factors:

1. Trauma or scratching the canal skin by a contaminated ear bud or hair pin.
2. Diabetes mellitus ≫ recurrent cases.

• Clinical picture: and differential diagnosis (see mastoiditis).

• 

• Figure 23: A fruncle in the external auditory canal.

• Investigations: Detection of blood sugar level, especially in bilateral and recurrent cases.

• Treatment:

1. Systemic treatment: antibiotics (anti-staphylococcal) and analgesics.
2. Local treatment:

• Aural toilet i.e. repeated removal of the ear discharge by suction or dry mopping.

• Packing the canal with a gauze strip soaked with glycerin ichthyol 10% (glycerin is hygroscopic i.e. decreases edema) or antibiotic drops.

• No squeezing ≫ perichondritis.

Surgical incision: only when pointing occurs.

Necrotizing otitis externa (Malignant otitis externa)

• A destructive and potentially fatal form of otitis externa, which extends beyond the external auditory canal to the base of the skull.

• Incidence: Rare, most commonly in elderly uncontrolled diabetics.

• Causative Organisms: Pseudomonas aeruginosa.

• Pathogenesis: The organism produces enzymes, which cause necrotizing vasculitis ≫ necrosis. Diabetic micro-angiopathy of the blood vessels ≫ necrosis.

• Clinical picture:

1. Severe stabbing earache.

2. Granulation tissue in the floor of the external canal, at the junction of cartilaginous part with bony part.

3. Otorrhoea: scanty, sero-sanginous and purulent.

• Investigations:

1. CT scans of the temporal bone → skull base destruction.

2. Bone scans (Gallium and Technetium) to assess severity of bone destruction and prognosis.

3. Biopsy: to exclude malignancy.

4. Culture and sensitivity tests of the discharge.

• Complications:

1. Spread of infection ≫Osteomyelitis of the temporal bone and skull base.

2. Cranial nerves palsy:

• Facial nerve, at stylo-mastoid foramen.

• Glosso-pharyngeal, vagus and accessory nerves, at jugular foramen.
  

• Treatment:

1. Systemic treatment:

• Control of diabetes.

• Massive antibiotic therapy (Anti-pseudomonas) e.g. quinolones and aminoglycosides, continued until complete cure in at least 6 weeks.

2- Local treatment:

• Aural toilet i.e. repeated removal of the ear discharge by suction

• Antbiotic ear drops.

3- Surgical treatment:

• Removal of granulations and debridement of necrotic tissues.

Herpes zoster oticus (Ramsey- Hunt syndrome)

• Causative Agent: herpes zoster virus of the geniculate ganglion of the facial nerve.

• Clinical picture:

1. Earache in and around the ear.

2. Vesicles on the auricle and in the external auditory canal.

3. Lower motor neuron facial nerve paralysis due to affection of the geniculate ganglion of the facial nerve.

4. May be associated with sensory-neural hearing loss and vertigo due to affection of the cochleo-vestibular nerve ≫ Ramsey-Hunt syndrome

• Treatment:

1. Ant-viral therapy as acyclovir (oral and local).

2. Corticosteroids (oral and local) in severe cases with affection of the facial and/or cochleo-vestibular nerves.

Otomycosis

• Fungal infection of the skin lining of the external auditory canal.

• Causative organisms: Aspergillus niger (black) and Candida albicans (white).

• Predisposing factors:

• Prolonged use of local antibiotic ear drops.

• Excessive sweating, seborrhea.
  

• Hot humid and dusty weather.

• Clinical picture:

1. Itching, the main symptom.

2. Otorrhoea, greyish white.

3. Hearing loss, when the fungus mass occludes the external auditory canal.

4. The lumen of the canal contains a whitish mass with black spots (a wet newspaper).

• Treatment:

1. Removal of the fungus mass by suction or ear wash.

2. Anti-fungal ear drops and creams e.g. clotrimazole, nystatin or 2% salicylic acid (keratolytic) in alcohol (fungicidal) for 3 weeks.

Tumors of the auricle:

1. Rodent ulcer or Basal Cell Carcinoma: - present as an indolent ulcer on the edge of the auricle. It will erode the auricle, and the skull if neglected. The tumor does not have lymphatic spread. Treatment is through wide local excision. Local flaps or free grafts close the defect. The tumor is radio resistant.

2. Squamous Cell Carcinoma: - is also common and has a more aggressive course with the local lymph nodes affected. Solar acanthosis and hyperkeratosis are precancerous lesions. Treatment is through wide local excision with neck node dissection. Radiotherapy is usually reserved for recurrences.

3. Basi-squamous term is used to describe a rodent ulcer that has nodal metastasis.

4. Malignant melanoma: - is common in white races living in sunny areas e.g. Australia. Wide local excision with radical neck dissection is the treatment. The tumor is radio resistant.

5. Kaposi’ sarcoma in AIDS patients.

Tumors of the External auditory canal:

can be benign or malignant

1-Benign tumors as: -

• Exostosis of the external canal with bone growth due to irritation of the periosteum e.g. cold water in swimmer’s ear. If large ≫ occlusion of the canal ≫ conductive deafness. Treatment is by drilling the bones and widening the canal.

• Osteoma differs from exostosis in being solitary and pedunculated. Treated by excision.

• Fibrous dysplasia ≫ the external canal is involved as a part of the affected temporal bone. Ground glass appearance on X-rays or CT is diagnostic. Treatment is by drilling and recontouring of the affected bones.

2- Malignant tumors as squamous cell carcinoma (SCC). It originates deep in the canal. It presents early with ear discharge (may be bloody), and deafness. It is difficult to differentiate from the carcinoma of the middle ear. In fact the two conditions are dealt with as a one disease. It commonly complicates chronic otitis media, or the later disease may masquerade the cancer. Biopsy is diagnostic. Since most patients present lately, treatment is mostly palliative. Temporal bone resection is performed with radiotherapy. Results are usually poor as it is impossible to obtain a cancer free margin (the temporal bone hosts important structures as the carotid artery, the jugular vein, and the facial nerve).

• It is a mixture of secretions of the ceruminous and sebaceous glands with desquamated skin cells.

• It is expelled outside the canal, in the form of flakes, by epithelial migration.

• Abnormal accumulation of ear wax (cerumen) in the external auditory canal Hearing loss.

• Functions of wax:

1. Lubrication of the skin of the external canal.

2. Prevent dust and sand to enter the ear as they stick to it.

3. Contains some fungicidal and bactericidal enzymes.

• Incidence:

Wax accumulation is the commonest cause of conductive hearing loss in adults.

• Causes of wax accumulation:

Failure of the natural cleaning mechanism because of:

1. Narrow external canal.

2. Attempt of the patient to clean his ear with cotton buds ≫ pushing the wax deeper into the canal.

3. Increased wax production due to skin irritation by soaps and shampoos.

4. Dehydration ≫ thick and hard wax.

• Clinical picture:

1. Unilateral or bilateral fullness of the ear, hearing loss, tinnitus especially after bathing.

2. A brownish mass in the external canal.

• Treatment:

Removal by ear wash or instruments.

If the wax is hard ≫ softened before wash by a wax solvent as glycerin bicarbonate ear drops.

• Indications:

1. Wax accumulation.

2. Otomycosis.

3. Foreign body in the external auditory canal: animate after it is killed or inanimate which does not swell with water.

4. Caloric test.

• Contraindications:

1. Impacted or large vegetable foreign body in the external auditory canal.

2. Tympanic membrane perforation (traumatic or dry).

3. Otitis externa.

4. A fistula between the middle and inner ears  labyrinthitis.

• Technique:

1. Use special syringe for ear wash.

2. Use warm sterile water at body temperature (37 C).

3. Pull the auricle by the left hand upwards and backwards to straighten the meatus.

4. Direct the nozzle upward and backward.

5. Be gentle and careful.

Figure 24: Ear wash.

• Complications:

1- Traumatic:

• Injury of the canal skin by the syringe due to sudden patient movement or by very hot water.

• Rupture of the tympanic membrane due to forcible jet of water directed toward the tympanic membrane . The patient feels sudden pain, hearing loss, tinnitus, slight bleeding from ear, and water in his throat.

2- Infective:

• Otitis externa, otomycosis due to use of unsterile water or syringe.

• Otitis media.

3- Reflex:

• Cough or syncope due to stimulation of the vagus nerve.

4- Vertigo and nystagmus:

• Due to caloric (thermal) stimulation of the inner ear by too cold or hot water.

5- Faulty technique ≫ impaction of the foreign body.