The document discusses various conditions of the external ear, including congenital deformities, infections, and other pathologies. It describes congenital conditions like Darwin's tubercle, Mozart's ear, bat ears, and microtia. Infections of the outer ear discussed include perichondritis, furunculosis, otitis externa, and malignant otitis externa caused by Pseudomonas in diabetics. Other topics covered are hematoma, frost bite, keloids, referred otalgia, wax impaction, and fungal infections like otomycosis.

1. DISEASES OF EXTERNAL EAR

2. ANATOMY- PINNA

3. ANATOMY- PINNA(cont)
• Average adult female ear is 59 mm tall and the average male is 63mm
tall.
• 85 % of height of ear is achieved by 3 years of age and almost 100%
by 10 years of age.
• The size of ear remains the same size till the age of 60 when it
gradually enlarges particularly the lobe.
• The average adult ear protrudes 19 mm from the mastoid skin
• The ear lies between the level of the eyebrow and a line of few
millimetres beneath the nasal columella.
• The distance between the lateral canthus of the eye to the front of
the ear is just over the length of the ear.

4. CONGENITAL CONDITIONS
• CAUSES : Heridity , Drugs , Irradiation , Viral Infection etc.
Darwin’s tubercle : an inherited Wildermuth’s ear : Prominence
condition.Presence as a small antihelix and under- development
elevation in post-sup part of helix. of helix & a/w CHL & SNHL.

5. CONGENITAL CONDITIONS(cont)
Mozart’s Ear : An dominant
inheritance condition of the
auricle, characterized by the
bulging appearance of the
antero-superior portion of
the auricle due to fusion of
the crura of the antihelix,
an inversion in the normal
form of the cavum conchae
resulting in its convexity and
a slit-like narrowing of the orifice
of the external auditory meatus.
Wolfgang
Amadeus Mozart

6. CONGENITAL CONDITIONS(cont)
Bat Ears:
• Prominence is due
to an absent anti-helical fold
but in some cases, the conchal
bowl is excessively deep
• Recommended to do surgery
only after 5 years of age.

7. Lop Ear
Crux anhihelics
is poorly formed
CONGENITAL CONDITIONS(cont)

8. Cup Ear
Antihelix is undeveloped
CONGENITAL CONDITIONS(cont)

9. CONGENITAL CONDITIONS(cont)
ACCESSORY AURICLES:
• Small elevation of skin containing a
bar of elastic cartilage.
• Anterior to tragus or
ascending crus of helix
, but may extend along
a line joining the tragus
and angle of mouth.
• Excision

10. CONGENITAL CONDITIONS(cont)
Mirror Ear or Polyotia:
• Persistent pre-auricular tissues lying
on posterior cheek resembling extra
ear.

11. CONGENITAL CONDITIONS(cont)
Cryptotia (The Hidden Ear):
• Lower two thirds of ear visible, upper
auricular sulcus seems lost.
• Upper pole is tethered and lower lobe
is prominent.
• When ear is pulled away from the
side of the head, the upper pole
cartilage becomes evident, having
hidden beneath scalp skin.

12. CONGENITAL CONDITIONS(cont)
Pre Auricular Sinus:
• Faulty fusion of 1st & 2nd arch
• Opening :
1) Anterior border of ascending
limb of helix
2) Line extending b/w tragal notch
& angle of mouth
3) Pinna (or) Lobule
• Extend upto the level of tympanic ring.
• C/F : Asymptomatic , If infected –
chronic discharge , recurrent abscess &
calculus
• Treatment : Excision ( careful for facial
nerve)

13. CONGENITAL CONDITIONS(cont)
Anotia Microtia Macrotia

14. PERICHONDRITIS/CHONDRITIS
• Infection or inflammation of perichondrium or cartilage of Auricle &
EAC
• Classification
• Erysipelas of External ear ( Inf. of overlying skin)
• Cellulitis of External ear (Inf. of soft tissue )
• Perichondritis ( Inf. Involving perichondrium)
• Chondritis ( Inf. Involving cartilage )
• Org : Pseudomonas Aeruginosa , Staph. Aureus.
• Signs & Symptoms:
Pain over auricle and deep canal, Pruritus, Induration. Edema
Advanced cases- Crusting & weeping, Involvement of soft tissues

15. PERICHONDRITIS/CHONDRITIS(cont)
Aetiology:
• Result of trauma to auricle
• Laceration of auricle , Surgery to ext.ear , frostbite ,
burns , chemical injury , inf. of hematoma of pinna ,
high piercing of auricle for insertion of ear rings
• Spontaneous (overt diabetes)
• Connective Tissue Disease
Treatment:
– Antibiotics-Topical & oral antibiotics
– I & D (if abscess)
– Irrigating with 1.5 % acetic acid & gentamycin
Sequelae:
– Cauliflower ear

16. PERICHONDRITIS/CHONDRITIS(cont)
Prevention:
• By careful ear piercings away from cartilaginous pinna.
• Avoid Surgery in and around ear – to prevent from trauma
• Hematoma of auricle to drain properly.
• Meticulous management of burn injuries with prophylatic antibodies
against gram negative bacteria.
• Removal of eschars and crusts.

17. PSEUDOCYST/SEROMA OF PINNA
• A soft cystic swelling may develop on pinna due to collection of fluid under
the skin. There is no definite cyst wall. The exact aetiology is not known but
possibly this extravasation of fluid is due to trauma of which the patient
may be unaware.
• Treatment Aspiration or incision drainage under aseptic precautions is done
followed by pressure bandage.
• In case of recurrence, removal of the
necrosed cartilage and painting of the
wound with a weak solution of iodine
is recommended
Aspirated Serous Fluid

18. HEMATOMA OF PINNA
• Hematoma of pinna is usually seen in fights where due to trauma a fluctuant
swelling appears under the skin.
Usually, there are no constitutional symptoms
unless an infection supervenes. Its persistence
deprives blood supply to perichondrium, leading
to infection and necrosis. If not treated may lead
to cauliflower ear also called Boxer’s ear
• Treatment is by incision and drainage and proper compression of the wound
to prevent accumulation of blood or fluid. This can be done by applying
quilting sutures and/ or a tight bandage. Antibiotics to prevent secondary
infection and anti-inflammatory are also given.

19. FROST BITE OF PINNA
• The pinna being exposed to variations in temperature and the blood
vessels being superficial (deep only to the skin), extremes of cold
affect it readily. Frost bite occurs particularly in the upper and outer
portions of the pinna.
• Treatment involves slow thawing. Vasodilator drugs like nicotinic acid
and nylidrine are also prescribed.
• As a preventive measure, exposure to cold should be avoided.

20. KELOID OF PINNA
• It is common after pinna injury/prick.
• Prone for recurrence even after excision.
repeated excision may lead to huge mass.
• It is common near the ear and on the neck.
• Triamcinolone injected at the base repeatedly
in small lesions, may help
• Large lesions may be excised, followed by
Triamcinolone locally or Radiotherapy to
reduce the recurrence rate.

21. BENIGN SKIN PATHOLOGY OF PINNA
Seborrhoeic Keratosis
Gouty
Tophi
Solar keratosis

22. REFERRED OTALGIA WITH NORMAL TM

23. REFERRED OTALGIA WITH NORMAL TM(cont)
Via Trigeminal Nerve
• Teeth: infection, impacted 3rd molar, malocclusion
• Oral cavity: infection, ulcer, malignancy, Ludwig’s angina, sialadenitis, salivary calculus
• Temporo-mandibular joint: arthritis, dysfunction
• Nose & PNS: impacted DNS, sinusitis, neoplasm
• Nasopharynx: infection, post- adenoidectomy, adenoiditis, tumor
• Trigeminal neuralgia
Via Glossopharyngeal Nerve
• Tonsil: tonsillitis, peritonsillar abscess, posttonsillectomy, neoplasm
• Oropharynx: infection, ulcer, retropharyngeal +parapharyngeal abscess, trauma, neoplasm
• Eagle’s syndrome (stylalgia)
• Glossopharyngeal neuralgia

24. REFERRED OTALGIA WITH NORMAL TM(cont)
Via Facial Nerve:
Herpes zoster oticus, vestibular schwannoma
Via vagus nerve:
Larynx + hypopharynx: neoplasm, infection, tuberculosis, trauma, foreign body
Via second & third cervical nerves:
Herpes zoster, cervical spondylosis & arthritis

25. FURUNCULOSIS
• Acute localized infection of single hair follicle.
• Lateral 1/3 of posterosuperior canal
• Obstructed apopilosebaceous unit
Signs:
• Edema, Erythema, Tenderness, Occasional fluctuance
Symptoms:
• Localized pain, Ear blockage, Pruritus
• Exudates a scanty sero-sanguinous discharge
• Hearing loss (if lesion occludes canal)
• The lymph nodes adjacent to the pinna are enlarged with a furuncle or
furunculosis, and a tender mastoid node may mimic a cortical mastoid abscess.

26. FURUNCULOSIS (cont)
Pathogen: S. aureus
Treatment: Local heat, Analgesics, Topical antibiotics /Hygroscopic Dehydrating agents.
• Oral antibiotics, IV antibiotics for soft tissue extension. Incision and drainage reserved for localized
abscess
• For recurrent : Eradication therapy with oral flucloxacillin (14 days), nasal mupirocin , as the
organism may be transferred by the patient’s finger from the nasal vestibules. Nasal swab becomes
a relevant investigation, particularly with recurrent furuncles.

27. OTITIS EXTERNA
• Is an inflammation of the EAC skin that is characterized by general
edema & erythema a/w itchy discomfort and ear discharge.
• Can be Acute or Chronic
(Lasts <6 weeks, Bacterial infection ) (Lasts >6 weeks, Allergies/Autoimmune Diseases.)

28. OTITIS EXTERNA(cont)
Predisposing factors :
• Anatomical ( narrow / obstructed ear canal) ,
• Dermatological ( Eczema , Sebhorrhoeic dermatitis )
• Allergic ( Atopy , Non–atopy , Exposure to top.med)
• Physiological ( Humid environment , Imm.compramised)
• Traumatic ( Skin maceration , ear probing , rad.theraphy )
• Microbiological ( P.aeruginosa , Active COM , Fungi infection )
• Bathing : In fresh water lakes containing Pseud.aeruginosa ”swimmer’s ear”
• Any condition that disturbs the lipid/acid balance of the ear will predispose.

29. OTITIS EXTERNA(cont)
Aetiology:
– Bacterial – Staph. aureus, Pseudomonas, Proteus
– Fungal – Aspergillus niger, Candida albicans
– Viral – Herpes simplex,Herpes zoster
– Reactive – Eczema, Psoriasis
Clinical Menifestations:
• Red, swollen ear canal • Foul discharge from ear.
• Itchiness, Fever
• Ear pain( Pain worsened when external ear is touched).
• Temporary conductive loss.
• Severe cases : Ear canal narrowed through exudates/ Lumen obliteration.
• Involvement of periauricular soft tissue: fullness of post auricular sulcus

30. OTITIS EXTERNA(cont)
Treatment :
• Systemic antibiotics, anti-inflammatory drugs.
• Local treatment- removal of debris and wick soaked in antibiotic steroid cream.
• Avoidance of any predisposing factors.
COMPLICATIONS:
• Abscesses.
• Narrowing of ear canal- in Chronic
• Inflamed or perforated eardrum
• Cellulitis.
• Malignant otitis externa: Mostly occur with person with diabetes mellitus.

31. Malignant Otitis Externa
• Malignant otitis externa was described by Meltzer and Kelemen in 1959.
• It is a fulminating severe form of otitis externa caused by pseudomonas
seen in elderly diabetic patients, male preponderance.
• It may also be seen in those patients suffering from acquired immune
deficiency syndrome (AIDS) or malignancy and are on immunosuppressive
drugs like azathioprine, methotrexate, cyclophosphamide and
cyclosporine.
• Patients using steroids or having hypogammaglobulinemia may also be
affected by this disease.
• The disease has also been called as skull base osteomyelitis.
• History of trivial trauma to the ear often by ear buds

32. Malignant Otitis Externa (cont)

33. Malignant Otitis Externa (cont)
Clinical Features:
• It is called malignant as it behaves like a malignant process by causing destruction of tissues
of canal, pre- and post auricular region by various enzymes such as lecithinase and
hemolysin.
• Spread of this disease occurs through the fissures of Santorini and osteo - cartilaginous
junction. Granulation tissue at the bony cartilaginous junction
• Posteroinferior wall of external auditory meatus shows granulations and lower cranial nerves
involvement such as VII, IX, X, XI. Facial nerve may be paralyzed more frequently than other
nerves.
Common Pathogens:
• Pseudomonas aeruginosa, Staphylococcus aureus, Aspergillus & rarely Proteus
Differential Diagnosis:
• Paget’s disease
• Carcinoma of external auditory meatus
• Granulomatous disorders

34. Malignant Otitis Externa (cont)
Differential Diagnosis:
• Paget’s disease
• Carcinoma of external auditory meatus
• Granulomatous disorders
Diagnostic Work Up:
• Pus swab. Hb, TLC, DLC.
• CT scan, bone scan to rule out osteomyelitis
• Serial Gallium-67 scans,which indicates active inflammation at the site.
• Brush cytology & Biopsy – to exclude neoplasm
• Syphillis & TB should be excluded.

35. Malignant Otitis Externa (cont)
Treatment:
• Heavy doses of antibiotics such as gentamicin/ tobramycin/ cefotaxime 1
gm IM/IV and ciprofloxacin 750 mg twice daily for a period of 6 to 8 weeks.
• Hyperbaric oxygen therapy is very effective and helps by improving
phagocytic action due to higher tissue oxygen tension levels.
• Local debridement of necrotic tissues and bone.
• Packing of a wick soaked in antibiotic cream.
• Strict control of diabetes is most important.
• Wide surgical excision of infected tissue and bone may be required
sometime.
• Mortality is 67 percent in patients with facial nerve palsy, while it is 80
percent in patients with multiple cranial nerve involvement.

36. OTOMYCOSIS
Is a fungal infection of external auditory canal usually caused by Aspergillus
fumigatus, Aspergillus niger or Candida albicans.
•Common in hot , humid climates & is often secondary to prolonged use of topical
Antibiotics.
•Occur because the protective lipid/acid balance of the ear is lost.
•It is confirmed by microscopic examination
Aspergillus Candida

37. OTOMYCOSIS(cont)
Symptoms :
• Often indistinguishable from bacterial OE, Dull pain
• Pruritus deep within the ear, Mild edema. Canal erythema
• Hearing loss (obstructive), Tinnitus
• White, grey ,green , yellow or black fungal debris
Treatment:
• Thorough aural toilet, removal of debris and Topical antifungals.
• Local application of gentian violet.
• Use of amphotericin B is sometimes done in resistant cases
• Resistant otomycosis – Exclude fungal inf. anywhere including Athelete’s foot .
• Immunotheraphy with Trichophyton , Epidermophyton & oidomycetes extracts
and dust mite , is the treatment of choice.

38. WAX/CERUMEN
• Wax is secreted by ceruminous and sebaceous glands in the
cartilaginous part of external auditory canal. To these secretions are
added desquamated keratin, debris and dust to form the wax.
Ceruminous glands produce watery secretions, while sebaceous
glands produce fatty secretions. Due to oxidative processes, it
becomes brown in color.
• The wax is excreted out due to movements of jaw, while eating or
talking. It collects in excessive amount in dry hot humid or dusty
occupation or if there is excessive desquamation from canal. Wax
performs antibacterial function and it is a nature’s way for removal of
dust and foreign material

39. WAX/CERUMEN(cont)
Clinical features:
• Sense of blockage, itchiness,
• Impaired hearing, earache,
• Tinnitus and vertigo.
Treatment:
• If hard, it should be softened by wax solvents,
i.e. soda glycerin, etc. and then removed
by syringing with sterile normal saline
water at body temperature or may be
with wax hook or suction.

40. SYRINGING
• A proper sized syringe is filled with warm
water and the jet of water from the nozzle is
directed along the posterosuperior canal wall.
• If the wax or foreign body is directly hit by the
stream of water it moves deeper and may get
impacted.
• Excessive force used while syringing may
damage the canal wall or the tympanic
membrane.
• If the water used is not at body temperature,
it produces caloric stimulation with symptoms
of giddiness and vomiting.

41. HOOKING

42. FOREIGN BODIES OF EAR
• Non living
• Living
Can be removed by:
1. Forceps
2. Syringing
3. Suction
4. Microscopic removal
5. Post aural approach
Buttton Batteries – may spontaneously leak
alkaline electrolyte solution on exposure
to moisture – liquefaction necrosis –
removed in urgency.

43. KERATOSIS OBTURANS
• Keratosis obturans is also called cholesteatoma of external auditory
canal.
• It is a condition seen in 5 to 20 years of age, in which there is a firm
mass consisting of wax, desquamated keratinized epithelium and
cholesterol granules.
• Exact etiology is not known, but hyperemia of canal skin and
irritability of epidermis may contribute.
• The mass causes erosion and widening of bony canal. Failure of
epithelial migration may lead to accumulation of epithelial debris.

44. KERATOSIS OBTURANS(cont)
Clinical Features:
• Pain, deafness, granulation tissue formation,
symptoms and signs of chronic sinusitis
and bronchiectasis.
• On examination, pearly white mass of
keratin material is seen.
Treatment:
• Mass is softened by soda glycerin solution and
removed periodically under anesthesia.
• Gram (-) ve infection – treated topically
• Refractory cases – Canaloplasty

45. HERPES ZOSTER OTICUS
• Is a viral infection of the inner, middle, and external ear.
• Manifests as severe otalgia and associated cutaneous vesicular eruption,
usually of the external canal and pinna.
• When associated with facial paralysis, the infection is called Ramsay
Hunt syndrome as Antibiotics to prevent secondary infectionit was
described in 1907 by Hunt James.
• In its severe form, there may be sensorineural hearing loss and disturbed
vestibular function and even signs and symptoms of viral encephalitis

46. HERPES ZOSTER OTICUS(cont)

47. HERPES ZOSTER OTICUS(cont)
Pathophysiology:
• Reactivation of the Varicella Zoster Virus along the geniculate
ganglion.
• Transmission of the virus via direct proximity of cranial nerve
(CN) VIII to CN VII at the cerebellopontine angle.
• Transmission via vasa vasorum that travel from CN VII to
other nearby cranial nerves.
• Cranial nerves V, IX and X may also be involved.

48. HERPES ZOSTER OTICUS(cont)
Clinical Features:
• Burning blisters in and around the ear, on the face, in the mouth, and/or on the tongue.
• Severe otalgia , hearing loss , hyperacusis , tinnitus, dysgeusia (alteration in taste)
• Vertigo, nausea, vomiting
• Eye pain, lacrimation,
• In patients with Ramsay Hunt syndrome, vesicles may appear before, during, or after
facial palsy.
• Vesicles seen over external auditory canal, concha,and pinna , post-auricular skin .

49. HERPES ZOSTER OTICUS(cont)
Treatment:
• Antibiotics to prevent secondary infection.
• Antiviral drugs such as acyclovir in the form of tablets (800 mg 4-5 times a day)
and cream.
• Anti-inflammatory drugs
• Corticosteroids in the form of tablets and local cream
• Facial nerve palsy is managed in the usual way.

50. BULLOUS MYRINGITIS
• Myringitis bullosa is a viral infection characterized by formation
of vesicles on the tympanic membrane and on the adjacent skin
of the deep meatus. Self-limiting
• Confined b/w outer epithelium & lamina propria of tympanic
membrane. Inflammation limited to TM & nearby canal.
• Viral infection ( Influenza ) , Mycoplasma pnuemoniae.
• Primarily involves younger children.

51. BULLOUS MYRINGITIS(cont)
• Multiple reddened inflamed blebs, Hemorrhagic vesicles
• Severe throbbing pain in the ear.
• Otoscopy reveals a congested tympanic
membrane with vesicles on its surface,
commonly in the upper part.
• The membrane is mobile.
• Blood stained discharge & Hearing loss
Treatment: Analgesics
Topical antibiotics to prevent secondary infection
Incision of blebs is unnecessary

52. BENIGN TUMOURS
Lipoma – post-auricular sulcus
Papilloma
• Viral Papilloma - outer meatus
• Removal – curetting under L.A / laser
• Diffuse Papilloma
• Typical papilliferous apperance
• Extend to deep meatus & obscure TM
• Remove permanently but recur

53. BENIGN TUMOURS
Exostosis/ Osteomas:
• Exostosis occur in bony meatus and are usually multiple.
• Exostosis is a bony outgrowth from bony meatus, which may be single pedunculated
or multiple of sessile type. It may be bilateral.
• Osteomas are single and occur at the junction of bony and cartilaginous meatus.
• Etiology is not known, but may be due to cold water bathing or trauma and infection.
Clinical features
• Asymptomatic when small, but if large may occlude the
• meatus causing irritation and deafness.
Treatment
• No treatment if asymptomatic, but if large, electric drill is used to remove it avoiding
injury to VII nerve.

54. BENIGN TUMOURS(cont)
Adenoma:
1. Sebaceous adenoma arises from sebaceous glands of cartilaginous meatus and is
treated by excision.
2. Ceruminoma (Hydradenoma) arises from ceruminous glands and is a rare tumor
resembling sweat gland tumors and may become
malignant.
Smooth innervated polypoidal swelling in outer EAC

55. MALIGNANT TUMOURS
Squamous Cell Ca
• Squamous cell carcinoma can occur on pinna or in external auditory canal.
Indurated ulcer with everted margins.
• Commonly an elderly patient, bleeding from ear or blood-stained discharge,
bleeding polyp or granulation and enlarged lymph nodes. Facial nerve
may beinvolved. Biopsy under L.A
• Cancer of pinna requires radical excision (i.e. total auriculectomy) and cancer
of external auditory canal (EAC) needs wide excision of tumor by extended
radical mastoid operation followed by radiotherapy.

56. MALIGNANT TUMOURS(cont)
SQUAMOUS CELL CA

57. MALIGNANT TUMOURS(cont)
Basal cell carcinoma (rodent ulcer):
• Basal cell carcinoma arises from basal layer of epidermis and starts as a nodule
on pinna. Margins of ulcer are not everted and no lymph node metastasis.
• Seen in tragus , border of helix , meatal entrance. Later cases – whole auricle is
involved , with underlying bone and parotid gland involvement.
• Resection of tumor if small and localized, but if extensive, complete excision
followed by plastic reconstruction.
• Radiotherapy is for inoperable tumours only.

58. MALIGNANT TUMOURS(cont)
Basal cell carcinoma

59. MALIGNANT TUMOURS(cont)
MalignantMelanoma:
• Nodular pigmented leision which tends to enlarge rapidly and eventually to
ulcerate.
• Regional L.N Involement & Diatant metastasis
• Local Disease – Excision & Skin Graft
• Large Tumours – Wedge (or) Wide Excision
• Radical excision involves complete excision of pinna & and dissection of
regional L.N

60. MALIGNANT TUMOURS(cont)
MalignantMelanoma