Ryan Martin Ko, M.D.
CERUMEN
Product of the sebaceous and ceruminous glands of the
external ear
Types: wet or dry
Functions: 1. vehicle
2. lubrication
3. prevents dryness
4. antibacterial
5. protection
CERUMEN
Symptoms
1. ear fullness
2. ear pain or otalgia
3. hearing loss
Treatment
1. Cerumenolysis w/ Sodium Docusate or soften w/ Mineral
or baby oil
2. removal by direct visualization (ear curette or suctioning)
3. irrigation
ACUTE OTITIS EXTERNA
OTITIS EXTERNA
Types:
1. acute circumscribed otitis externa/ furunculosis
2. diffuse otitis externa
3. malignant otitis externa
Predisposing factors:
1. change in pH of canal skin
2. environmental changes
3. mild trauma
OTITIS EXTERNA
Principles in management:
1. careful cleaning of the canal by suction or
cotton wipes
2. evaluation of discharge, canal wall edema
and TM, if possible
3. selection of appropriate medications
ACUTE CIRCUMSCRIBED
OTITIS EXTERNA
Furunculosis
Cause: infection of sebaceous follicle of EAC usually
by Staph. aureus
Signs/ symptoms:
- pain
- tenderness on manipulation
- decreased hearing
- purulent ear discharge
- circumscribed swelling
ACUTE CIRCUMSCRIBED
OTITIS EXTERNA
treatment:
(+) abscess formation drainage;
topical antibiotics
(-) abscess formation local heat;
analgesics;
topical antibiotics (otic drops)
Polymyxin, Neomycin, Dexamethasone (PND)
Quinolones: Ofloxacin or Ciprofloxacin
DIFFUSE OTITIS EXTERNA
“swimmer’s ear”
Secondary to acute or chronic
otitis media
Etiologic agents:
- Pseudomonas other gram-
negative organisms
DIFFUSE OTITIS EXTERNA
Signs/ symptoms:
1. pain
2. tenderness on manipulation
3. scanty ear discharge
4. diffuse swelling of whole ear canal
5. decreased hearing – occasionally
Treatment
1. mechanical cleaning
2. cotton wick application
3. Otic drops (Quinolones)
MALIGNANT OTITIS EXTERNA
MALIGNANT OTITIS EXTERNA
causes: uncommon; P. aeruginosa
1. diabetic patients
2. immunocompromised and debilitated patients
3. elderly patients
course:
- very destructive
- spread via fissures of Santorini to Parotid gland
- Osteomyelitis of temporal bone
MALIGNANT OTITIS EXTERNA
Signs/ symptoms:
1. pain on manipulation
2. TMJ pain
3. deep tenderness on palpation beneath the ear
4. otoscopy: intact TM; bone & cartilage
destruction; granulation tissues
5. cranial nerve problem especially VII
6. intracranial complications
MALIGNANT OTITIS EXTERNA
Treatment
1. local debridement
2. IV 3rd Generation Cephalosporin or Quinolones
3. pesistence or extension of infection
local excision
OTOMYCOSIS
Causes:
1. ear cleaning with contaminated implements
2. diabetics
3. immunocompromised patients
4. chronic use of antibiotic otic drops
Etiologic agents:
- Aspergillus
- Candida
OTOMYCOSIS
Signs/ symptoms
1. itchiness
2. diffuse swelling of EAC
3. mycelia or sporangia
4. discharge
5. decreased hearing – occasionally
OTOMYCOSIS
Treatment
1. clean ear thoroughly
2. clean again with antiseptic solution
3. dessicating agent
4. topical fungicidal preparations with
Clotrimazole
5. keep ear dry and avoid ear manipulation
FOREIGN BODIES
A. Animate
- cockroaches, ants, ticks
- severe discomfort and pain
- management
kill first prior to removal (oily substance such as
baby oil)
B. Inanimate
- may or may not produce symptoms
- stones, seeds, wads of paper
- remove with proper instruments such as curette,
suction tips, aural spatula
TRAUMA
A. Injury to auricle
- bruises
- hematoma “ Cauliflower ear ”
Treatment:
- evacuation of hematoma
- pressure dressing
- wound repair/suturing
TRAUMA
B. Perichondritis
Pus forms between cartilage and
perichondrium absorption
Etiologies:
1. injury
2. surgery
3. superficial infections
treatment:
1. antibiotics
2. I & D
TRAUMA
C. Traumatic rupture of TM
Etiologies:
1. secondary to probing
2. too forceful syringing of ear
3. forceful change of pressure in the EAC
Signs/ symptoms
- sudden pain and bleeding with decreased hearing
TRAUMA
Treatment:
1. most heals spontaneously
2. myringoplasty
Otitis Media
Infection of inflammation of the middle ear usually
originated from a URTI or Eustachian tube
dysfunction
Characterized by mucoid discharge, tympanic
membrane perforation, pain, headache, hearing loss,
tinnitus and sometimes dizziness.
Acute OM: <12 weeks
Chronic OM > 12 weeks
Stages of Otitis Media
Hyperemic stage (retracted TM, fever, pain)
Exudative stage (bulging TM, fever, pain)
Perforation stage (TM perforation, afebrile, painless,
otorrhea)
Coalescent Mastoiditis stage (Postauricular pain, +/- fever
and otorrhea)
Resolution or Complication stage
Complications of Otitis Media
Extracranial
Facial Nerve Paresis/Paralysis
Subperiosteal Abscess
Conductive/Sensorineural Hearing Loss
Labyrinthitis
Apical Petrositis
Intracranial
Meningitis
Brain abscess
Lateral Sinus Thrombophlebitis
Otitic Hydrocephalus
Facial Nerve Paresis/Paralysis
Facial Nerve Paresis/Paralysis
Facial Nerve Paresis/Paralysis
40% to 50% dehiscent
Acute OM
• direct extension
• tx: Myringotomy + antibiotic
Chronic OM
• 20 bone erosion by cholesteatoma or granulation
• tx: mastoidectomy with FN decompression
Subperiosteal Abscess
Types:
1. Post-auricular
2. Zygomatic/preauricular
3. Bezold’s
4. Parapharyngeal
Subperiosteal Abscess
Management:
IV antibiotics +/- steroids
Drain the abscess
Request for laboratory test including imaging studies
such as Towne’s view or CT Scan of the Temporal Bone
Axial and Coronal Cuts Bone Window, 1-1.5mm distance
Mastoidectomy
Hearing Loss
Hearing Loss
Management:
Control the infection
Request for hearing test (Pure tone Audiometry with
Tympanometry)
Laboratory tests and imaging studies
Mastoidectomy with Myringoplasty or Tympanoplasty
(for Conductive HL)
Mastoidectomy with post-operative hearing aid
application for Sensorineural HL
Labyrinthitis
Labyrinthitis
Direct extension into labyrinth in AOM
Bone erosion in COM
Hematogenous
S/Sxs:
• sudden/progressive/fluctuating hearing loss
• Vertigo
• N/V
• tinnitus
Labyrinthitis
Labyrinthitis
Treatment:
Acute cases high dose antibiotic +
myringotomy
Chronic cases high dose antibiotic +
mastoidectomy
Apical Petrositis/Gradenigo
Syndrome
Apical Petrositis/Gradenigo
Syndrome
Triad:
Diplopia (CN VI)
Otorrhea
Retroorbital pain (CN V)
Meningitis
Most common cause of meningitis is Chronic Otitis
Media (~90%)
Cause/s:
• hematogenous
• direct extension
• preformed pathways (Foramen, Fissures,
Canals and Ducts)
Meningitis
Clinical presentations:
Fever
Headache
Seizures
Hemiplegia
Coma
Meningitis
Treatment:
IV antibiotics that are able to pass the BBB
CT Scan of the Brain and Temporal Bone, Axial and
Coronal cuts, 1-1.5mm distance with contrast
Antiseizure medications
Mastoidectomy
Brain abscess
Brain abscess
Direct extension of extradural abscess or
extension of thrombophlebitis
Destruction of bone adjacent to the dura
Chronic OM with cholesteatoma
Brain abscess
Treatment:
IV antibiotics that are able to pass the BBB
CT Scan of the Brain and Temporal Bone, Axial and
Coronal cuts, 1-1.5mm distance with contrast
Antiseizure medications
Craniectomy with evacuation of abscess and
Mastoidectomy
Lateral Sinus Thrombophlebitis
Inflammation of the sinus adventitia and
penetration of the venous wall
Sxs:
septic fever (picket fence)
chills
pain
Lateral Sinus Thrombophlebitis
Lateral Sinus Thrombophlebitis
Treatment:
IV antibiotics that are able to pass the BBB
CT Scan of the Brain and Temporal Bone, Axial and
Coronal cuts, 1-1.5mm distance with contrast
Mastoidectomy
Otitic Hydrocephalus
Focal areas within the brain becomes edematous and
inflamed due decreased absorption of CSF in Lateral
Sinus Thrombophlebitis
Manifestations:
• signs/symptoms of increased ICP
papilledema
headache
• no CSF abnormalities
Otitic Hydrocephalus
Otitic Hydrocephalus
Treatment:
Treat Lateral Sinus Thrombophlebitis
Self-limiting decompression
Otitis externa Otiits media
pain Very severe Not as severe
Tenderness on present absent
manipulation
fever Usually absent Usually present
Hx of URTI (-) (+)
Hx of ear (+) (-)
manipulation
hearing Not impaired impaired
Mastoid x-ray normal mastoiditis
Thank you!
