Core Curriculum Syllabus: Commmon Diseases of the External and Middle Ear

The External Ear

A. Infection

  • External Otitis ("Swimmer's Ear")
    • Symptoms: pruritus, otalgia varying from sense of fullness to throbbing pain, hearing loss.
    • Signs: Edema and erythema of canal skin, tenderness of tragus, foul-smelling secretions, possible periauricular cellulitis.
    • Treatment: Clean EAC; Topical otic neosporin-polymyxin B (or colistin)-hydrocortisone for gram negative bacilli (most commonly Pseudomonas aeruginosa) for 10 days; impregnated wick for severe edema; adequate analgesic.
    • Preventive Measures for Recurrent Otitis Externa: Ethyl alcohol drops (70%) or acetic acid - nonaqueous solutions (2%) after swimming or bathing. Avoid self-instrumentation.
  • Necrotizing External Otitis (Malignant External Otitis)
    • Symptoms & Signs: Progressive pain and drainage from the EAC. Granulation tissue often present. Pseudomonas aeruginosa invasion of soft tissue, cartilage and bone. Occasional facial nerve palsy.
    • Treatment: Radical surgical debridement with combination semi-synthetic penicillin and aminoglycoside for 4-6 weeks. Significant mortality in diabetics who acquire disease.
  • Perichondritis
    • Symptoms: Pain and warmth of the pinna following trauma or infection.
    • Signs: Erythema, induration, and possible fluctuance of part or all of the auricle.
    • Treatment: Most common organism: Pseudomonas aeruginosa. Betadine or boric acid wet-to-dry dressings to open wound. If perichondritis progresses to chondritis with abscess, then incision, drainage, and debridement of non-viable cartilage is necessary.
    • Obtain cultures.
  • Otomycosis
    • Symptoms: Itching or mild otalgia. Secondary bacterial infection may produce intense pain.
    • Signs: Aspergilla nigrans produces a grayish membrane with hyphae visible under microscope. Erythema of underlying epithelium.
    • Treatment: Clean EAC. Topical cresyl acetate or 1% gentian violet and/or boric or acetic acid and alcohol drops.
  • Bullous Myringitis
    • Symptom: otalgia.
    • Signs: Hemorrhagic blebs on TM and adjacent canal.
    • Treatment: Incision of blebs if severe pain. Prophylactic oral antibiotics to prevent otitis media. Anesthetic otic drop.
  • Herpes Zoster Oticus (Ramsey Hunt Syndrome)
    • Symptoms: Otalgia, malaise, headache, possible dizziness.
    • Signs: Vesicular eruption of distal canal and concha. Occasional 7th CN paralysis.
    • Treatment: Analgesics. Middle cranial fossa decompression of facial nerve if progressive degeneration.

B. Allergy

  • Contact Dermatitis
    • Symptoms: Burning, itching, pain
    • Signs: Variable. Range from erythema to hyperpigmentation of skin. Fissures with weeping.
    • Agents incriminated: Shampoos, hair sprays, perfumes, ear plugs, and earrings. Most common: Nickel allergy to earrings.
    • Treatment: Remove allergen. Topical corticosteroids.
  • Eczema
    • Symptoms and signs: Itching, scaling, and fissuring: More aggressive forms will present with weeping, crusting, and secondary bacterial infections.
    • Predisposing factors: Seborrheic dermatitis, atopic dermatitis, psoriasis, and other skin conditions.
    • Treatment: Topical steroid lotions and creams.

C. Trauma

  • Hematoma of Auricle
    • Etiology: Blunt trauma results in accumulation of blood between perichondrium and cartilage.
    • Differential Diagnosis: Perichondritis, cellulitis, and relapsing polychondritis.
    • Treatment: Repeated aspiration under sterile conditions and mastoid pressure dressings.
    • Complication: Organization and calcification of clot with necrosis of underlying cartilage leads to "cauliflower ear".
  • Laceration of Auricle
    • Simple: Thorough cleaning of wound with antiseptic solutions. Conservative debridement of necrotic skin edges and cartilage that cannot be covered with perichondrium. Closure of perichondrium to prevent notching. Cosmetic closure of skin. Prophylactic antibiotics.
    • Complicated: Same principles. Contaminated or extensive wounds may require staging with use of grafts or reconstructive flaps.
    • Avulsion, Treatment: Amputated parts should be cleaned and placed in iced physiologic saline until reconstruction. Anticoagulants and prophylactic antibiotics may improve success.
  • Burns
    Treatment similar to general burn management except:
    • Prophylactic antibiotics are indicated to prevent suppurative perichondritis; and,
    • Stenting of a burned meatus necessary to prevent stenosis.
  • Lacerations of External Canal
    Injury predisposed to stenosis. Canal should be carefully examined, cleaned, and debrided under microscope. Skin of meatus should be reapproximated and denuded areas covered with split thickness skin graft supported in place with rosette of antibiotic impregnated gauze and packing.
  • Foreign Bodies of EAC
    • Insects. Immobilize with topical 2% lidocaine or ether and remove with gentle irrigation or alligator forceps under direct vision.
    • Materials: All shapes and sizes in all age groups! Key to successful removal is use of proper instruments: microscope, alligator forceps, right-angle hook, suction, and local anesthesia. Young children often require general anesthesia to remove impacted objects without further injury. Topical otic antibiotics if localized reaction to foreign body.

D. Cysts and Tumors

  • Cysts
    • Pilar (Sebaceous) cysts arise in hair follicles. Present as discrete, mobile masses frequently with overlying orifice. May become secondarily infected. Treatment is complete excision.
    • Epidermal cysts derived from layer of epithelium. Filled with keratin debris. Treatment consists of complete excisional biopsy.
    • Preauricular cyst and fistula
      • Results from faulty fusion of mesodermal hillocks that form the auricle. Fistula opening located in front of the incisura. Recurrent infection can be troublesome. After injection of methylene blue into the fistulous tract, the tract and cyst are excised.
  • Benign Lesions
    • Keloids
      • Predisposition among Blacks. Hypertrophy of connective tissue in traumatized areas. Most common area: ear lobe secondary to ear piercing. Treatment is complete excision followed with injections of cortisone.
    • Exostosis
      • Periosteal outgrowths in the osseous canal of cold-water swimmers. On rare occasion will cause a conductive hearing loss or impact cerumen. In those cases, surgical removal is indicated.
  • Malignant Lesions
    • Precancerous: Actinic Keratosis
      • Flat, scaling lesions on the sun-exposed regions of face, neck, and hands. Tend to occur in those with fair complexion. May give rise to squamous cell carcinoma. Treatment with topical 5-fluorouracil or liquid nitrogen is very effective.
    • Basal Cell Epithelioma
      • Classically presents as discrete nodule with smooth, raised edges and central crater. Superficial telangiectasias occur on edges. Locally invasive. Poor control may result in invasion of EAC, middle ear, TMJ, or parotid. Treatment of choice is wide surgical excision or Mohs chemosurgery. Invasion of EAC requires en bloc resection of the canal.
    • Squamous Cell Carcinoma
      • Most commonly presented as raised, ulcerated lesions on helix. Preferred treatment is wide surgical excision or Mohs chemosurgery. Pre- or postoperative radiation therapy is reserved for advanced lesions. Invasion of EAC or temporal bone requires temporal bone resection. Nodal metastasis occurs in extensive lesions. Parotidectomy and radical neck dissection performed to control clinically evident metastasis.

The Middle Ear

The symptoms of middle ear pathology are limited to otalgia, tinnitus, and hearing loss. When proper otologic examination fails to reveal the etiology of otalgia, one should think of referred pain. Sensation to the ear is provided by cranial nerves V, VII, IX, X, and the C1-2 plexus; hence, diseases elsewhere in the head and neck may refer pain to the ear. A useful mnemonic is the "10 T's of otalgia":

  1. TMJ
  2. Tonsils
  3. Throat
  4. Tube (Eustachian)
  5. Teeth
  6. Tongue
  7. Tics (Glossopharyngeal)
  8. Trachea
  9. Thyroid
  10. Tendons

A. Inflammation and Infection

  • Serous otitis media (otitis media with effusion) refers to the accumulation of non-purulent middle ear fluid due primarily to eustachian tube dysfunction and secondarily to metaplasia of mucosa.
    • Etiologies
      • Nasopharyngeal obstruction: adenoid hypertrophy, neoplasia, iatrogenic.
      • Intratubal obstruction: URI, allergy, sinusitis.
      • Middle ear obstruction: chronic otitis media, cholesteatoma, tumor.
      • Failure of physiological opening: cleft palate, submucous cleft, some neurological disorders.
      • Other Contributing Factors: Metaplasia due to recurrent or chronic infection, hypothyroidism, diabetes mellitus, immune deficiency syndromes, connective tissue disorders.
    • Symptoms: Mild otalgia, stuffiness, autophony, hearing loss.
    • Signs: Retracted, discolored TM. Diminished TM mobility.
    • Medical Treatment:
      • Treat nasal congestion or drainage.
      • Treat concurrent infections - adenoids, middle ear, sinuses, pharynx.
      • Antibiotics for OME.
      • Control allergies.
      • Valsalva maneuvers for insufflation.
      • Politzerization.
    • Sequelae of Persistent SOM:
      • Conductive hearing loss (10-30 dB).
      • Recurrent suppurative otitis media.
      • Impaired auditory processing with impaired socialization and delayed speech and language development in young children.
      • Ossicular erosion, tympanosclerosis, cholesteatoma formation.
    • Surgical Treatment of SOM:
      • Pressure equalization tubes. Recent studies have demonstrated that adenoidectomy may provide additional benefit but there is still some controversy regarding this
    • When to Recommend Tubes:
      • SOM for more than 3 months.
      • Three-four episodes OM/year in an ear with chronic or recurrent SOM.
      • Hearing handicap.
  • Acute Suppurative Otitis Media
    Refers to an acute exudative middle ear disease secondary to bacteria.
    • Clinical Stages of Acute Suppurative Otitis Media
      • Hyperemia
      • Exudation
      • Suppuration
      • Resolution
      • Coalescence
      • Complications:
        • Acute surgical mastoiditis
        • Facial nerve paralysis
        • Acute labyrinthitis
        • Sigmoid sinus thrombophlebitis
        • CNS infection
    • Pathogens:
      • Infants: gram negative enteric bacilli
      • Under age 5: pneumococcus, H. influenza, streptococci
      • Over age 5: pneumococcus, H. influenza (less prevalent), streptococci
    • Drugs of Choice
      • According to appropriate cultures
      • Amoxicillin (30-40 mg/kg/d) in 3 doses-every 8 hours
      • Cefaclor (20-40 mg/kg/d) in 3 doses-every 8 hours
      • Trimethoprim (6-12 mg/kg/d) and Sulfamethoxazole (30-60 mg/kg/d) in 2 doses q 12 hrs
      • Erythromycin (50 mg/kg/d) and Sulfisoxazole (150 mg/kg/d) in 4 doses-q 6 hrs
  • Chronic Suppurative Otitis Media
    COM refers to a permanent tympanic membrane perforation with associated middle ear and mastoid disease. Intermittent or continuous otorrhea usually exists.
    • Types of Perforations:
      • Central
      • Marginal
      • Attic - usually association with cholesteatoma
      • Perforations are often accompanied by purulent drainage and otic polyps
    • Evaluation:
      • Pure tone and speech audiology
      • Mastoid films
    • Treatment:
      • Clean under microscope
      • Topical otic antibiotics
      • Treatment of predisposing conditions: smoking, allergy, chronic sinusitis, chronic tonsillitis, uncontrolled diabetes mellitus, etc.
      • Surgery
    • Goals of Surgery (Tympanomastoidectomy)
      • Eradicate infection
      • Restore hearing
      • Close middle ear cleft
  • Tympanosclerosis
    Submucosal hyaline degeneration in the tympanic membrane and middle ear mucosa. Extensive involvement of the TM and ossicles may result in conductive hearing loss. On rare occasion middle ear surgery is advised to restore hearing. Medical therapy and PE tubes do not prevent progression of disease.

B. Cholesteatoma

  • Definition: A confined epithelial sac which expands by collection of desquamated cells and debris
  • Classifications:
    • Congenital: Very rare. Cholesteatoma results from entrapment of an epithelial cell rest within the temporal bone during embryological differentiation of the temporal bone. No TM perforation. Usually presents as pearly white mass behind intact TM or as facial weakness.
    • Primary acquired: Perforation or retraction pocket in the pars flaccida. Different theories of pathogenesis
    • Secondary acquired: Marginal pars tensa perforation allows squamous epithelium to migrate inward
  • Complications: Erosion of ossicles, sensorineural hearing loss, labyrinthitis, facial nerve paralysis, meningitis, brain abscess, sigmoid sinus thrombophlebitis, petrous apicitis, neck abscess (Bezold's)

C. Trauma

  • Tympanic Membrane Perforations
    • Etiology
      Sudden alteration of air pressure in the EAC: Compression (slap, hit, skiing), blast, instrumentation (Q-tip), burn, skull fracture, or lightning
    • Danger signs:
      CSF otorrhea implies basilar skull fracture. Vertigo, nausea and vomiting, nystagmus, may be due to oval or round window fistula, labyrinthine or brain concussion.
    • Management:
      • Baseline audiograms
      • Keep ear dry
      • Antibiotics if infection develops. Labyrinthine fistulae may require exploration and repair to preserve hearing
    • Prognosis:
      • 90% heal spontaneously, and
      • 10% require tympanoplasty
  • Temporal Bone Fractures (see section on Paralysis of the Facial Nerve)
  • Barotrauma
    • Definition: Refers to injury to the ear following a pressure change in the middle ear compartment. Failure of middle ear ventilation leads to negative pressure relative to the outside environment.
    • Pathogenesis: TM and mucosa retract toward middle ear space and cause pain. Vacuum results in a change in capillary permeability with transudate and possibly bleeding. Eustachian tube "lock" occurs during airplane or diving descent.
    • Treatment: Decongestant/antihistamines, Valsalva and insufflation, chew gum and swallow frequently. If no response, myringotomy. Should take prophylactic measures when flying or diving.
  • Perilymph Fistula
    • Vigorous coughing or straining, sneezing, or nose blowing can result in rupture of the round window or subluxation of the footplate. Leakage of perilymph causes dizziness and hearing loss. Initial management is bed rest. If no improvement or if deterioration, surgical exploration is indicated.

D. Tumors

  • Glomus Tumors
    Glomus tumors (nonchromaffin paragangliomas) are the most common "benign" neoplasms of the ear. Are malignant by location, as continued slow growth results in erosion and involvement of surrounding structures
    • Symptoms and signs: Hallmark is unilateral pulsatile tinnitus synchronous with pulse rate. Progressive hearing loss and otalgia. Cranial nerve involvement VII - XII.
    • Physical exam reveals a bluish mass behind the tympanic membrane. Brown's sign: Increased EAC pressure with a pneumatic otoscope leads to blanching of mass
    • Diagnosis confirmed with arteriography or jugular venogram. Extent of disease evaluated with polytomography and high-resolution CT scanning
    • Differential diagnosis: Venous hum, high jugular bulb, carotid aneurysm, A-V malformation, and idiopathic hemotympanum
    • Treatment: Surgical removal ranges from transcanal tympanotomy to base of skull resection. Radiotherapy is recommended for tumors extending beyond the boundaries manageable by surgery, for post-operative recurrences, and for non-surgical patients
  • Malignant Neoplasia
    • Squamous cell carcinoma is the most common middle ear malignancy. Symptoms include aural discharge, bleeding, pain, decreased hearing, and otic polyps. Can resemble COM! Treatment is temporal bone resection vs palliative radiation depending on extent of disease

E. Congenital Disorders

  • Otospongiosis (Otosclerosis)
    • Definition: A primary bone dyscrasia affecting 4-8% of Caucasian and 1% of Black temporal bones. Involvement of oval window results in footplate fixation and persistent conductive hearing loss (1% Caucasians). Involvement of cochlear endosteum can produce sensorineural hearing loss through release of "toxins" during bone metabolism.
    • Pathogenesis: Autosomal dominant gene with variable penetrance. Role of sodium fluoride in preventing expression of dyscrasia under investigation
    • Symptoms: Hearing loss, tinnitus, dizziness
    • Signs: Usually normal examination. Schwartze's sign: red discoloration under drum due to active focus on promontory. Weber lateralizes to involved ear
    • Treatment:
      • Medical: Hearing aid. Sodium fluoride 20-30 mg/d with calcium and vitamin D supplementation for sensorineural component
      • Surgical: Stapedectomy successful in more than 90% of cases
  • Lop Ears
    • Increased angulation of auricle due to a poorly developed antihelix or large concha
    • Dominant inheritance with variable penetrance
    • Amenable to surgical correction, preferably before child enters school
  • Microtia
    • Atresia of auricle and/or external canal. Variable in degree
    • Associated anomalies: preauricular appendages, facial nerve anomalies, hypoplasia of mandible or maxilla
    • Signs: Absence of meatus or external canal ends in blind sac. Conductive hearing loss
    • Treatment: Cosmetic reconstruction of auricle at 4-6 years of age. Preferential seating in classroom for unilateral involvement. Hearing aids for bilateral involvement as soon as possible. Surgical reconstruction of external canal, tympanic membrane, ossicular chain often deferred until patient can give own consent--earlier in selected cases

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Last modified: Jan. 23, 2006