The ear

1. Diseases of the outer ear

2. Cerumen impaction.
• The most common cause of CHL in adults.
• Risk factor:
– narrow canal
– hearing aid
– osteoma.
• Sym: Hearing loss, tinnitus and fullness.
• Treatment:
-Ceruminolytics drops
-Manual removal
-Syringing

3. • Indication for syringing:
– if pain or hearing loss
• C/I for syringing: :
– TM perforation
– the only hearing ear &
– previous ear surgery.
• Complications of syringing:
– Otitis externa
– Failure &
– TM perforation

4. Otitis externa
• It is a spectrum of infection
of skin of the EAC.
• Prevalence is estimated to
be 0.4% per year.
• Etiology:
– disturbance of acid/lipid
layer.
– P.aeurginosa, p.mirabilis
and s.aures are the
commonest bacteria.
• Predisposing factors:
– associated with swimming
("swimmer's ear")
– mechanical cleaning
– skin dermatitides
– aggressive scratching
– devices that occlude the
ear canal: hearing aids,
headphones, etc.
• Secondary bacterial infection is
the major feature of otitis
externa.

5. Staging
• Pro inflammatory stage: itching and fullness.
• Acute inflammatory stage:
– Stages: mild, moderate or severe
– Sym: Pain, itching, discharge and fullness.
• Chronic inflammatory stage:
– itching is the predominant symptom.

6. Diagnosis
• The diagnosis of otitis externa is clinical.
• Four major symptoms: pain, itching, discharge and fullness.
• P/E: edema, erythema, tenderness, scaling and thickened
canal wall skin.

7. Management options
• Aural toilet for all stage.
• Topical medications: antibiotic + steroid drops
• Systemic antibiotics: if severe or complication exist.
• Analgesics: for moderate and severe stage.
• Prevention-

8. Complications
• Cellulitis
• Perichondritis/ Chondritis.
• Chronic non resolving infection
• Parotitis

9. Necrotizing otitis externa
• It is a progressive, potentially lethal infection of the EAC,
surrounding tissue and skull base.
• Risk factors:
– DM, elderly and immuno compromised patients.
• Almost always due to p.aeurginosa and rarely aspergilus.
• Pathophysiology-

10. Clinical manifestation
• Severe otalgia-
• Purulent otorrea-
• Granulation tissue and edema of EAC-
• Facial nerve palsy-

11. Diagnosis
• Four important features for the diagnosis-
-Persistent severe otalgia > 1month
-Persistent purulent otorhea for months.
-DM,immunocompromised or elderly.
-Cranial neuropathy.

12. Management
• Daily aural toilet
• Antibiotics- for at least 6 weeks
• Hyper baric oxygen-
• Surgery- in refractory cases.

13. Otomycosis
• Accounts for 10% of all otitis externa.
• Affects 10% of the population.
• Prolonged topical antibiotic treatment is the most important
risk factor.
• Aspergilus(80-90%) and candida(10-20%).

14. • Itching is the predominant symptom.
• The most common finding is black, grey, green, yellow or
white discharge with debris
• Fungal hyphae-

16. Management
• Aural toilet-BORRIC ACID.
• Topical antifungal drops- clotrimazole ear drops.
• Systemic antifungal therapy-if invasive.

17. Osteoma
• Osteoma and exostosis are clinically and histologically distinct.
• Osteomata are solitary pedunculated osseous lesions that are
smooth and round arising from bony EAC.
• Middle aged and women are commonly affected.
• Etiology is unknown.
• Mostly asymptomatic.
• Treatment is indicated for symptomatic cases.

18. Osteoma.

19. Exostoses
• Exostoses are broad-based osseous lesions.
• They occur as multiple lesions and are often bilateral.
• Exostoses are far more common in males.
• It is due to cold water exposure.
• Most patients are asymptomatic.
• Surgery for symptomatic cases.

20. Exostoses

21. Diseases of the middle ear

22. Acute OM
• It is an acute inflammation of the middle ear.
• Commenest age group is b/n 18mon and 6yrs
• Etiology:
– S.pneumonia, H.inf. and M.catarrhalis.
• Recurrent AOM: SUSPECT IMMUNE DEFICENCY.
*Recurrent AOM: 3 episoides /6mon or 4 episoides/ year

23. Predisposing factors
• ET obstruction or dysfunction-
• Defect in mucociliary clearance-
• Immuno deficiency state-

24. Clinical manifestation
• Fever, otalgia and decreased hearing.
• Ear discharge if TM is perforated.
• Otoscopy: deep erythematous and bulged TM.
• MX -A 10 day course of amoxicillin.
-Analgesic and antipyretics.
-Myringotomy
-Watch full waiting-????

25. AOM.

26. Complications
• Intra-temporal - Mastoiditis
- Facial nerve palsy
- Petrositis
- Suppurative labyrinthitis
• Intra-cranial - Meningitis
- Epidural and subdural abscess
- Brain abscess
- Inflammatory sinus thrombosis

27. OME
• It is an accumulation of serous fluid in the middle ear.
• RFs: RFs to AOM.
• Commenest cause of CHL in children.
• CFs: Hearing loss, pain and sensation of fullness.
• Otoscopy - dull immobile bulged TM.
- Retracted TM
- Air fluid level
• Tympanogram –flat (type B).

29. Management
• Identification and treatment of the underlying cause is
important.
• Conservative treatment for 3 months.
• Surgery if the conservative option fails-
-Grommet insertion

30. Chronic Suppurative Otitis Media
 Is a chronic inflammation of the mucosa & sub mucosa of
ME e discharge via perforated TM.
 Impact on TM & ossicles.
 Can be active or inactive.
 Staph aures and pseudomonas arguinosa are the
commenest etiologic agents.

31. Pathogenesis of CSOM
 AOM e perforation & failure to heal.
 OME.
 Ventilation Tube.
 Traumatic perforation
 Polyp, granulation tissue.
 Pain is not a feature.

32. Symptoms and Signs:
- Ear discharge
- Decreased hearing
- Perforated membrane
- Granulation tissue and/ Polyp

33. Management
1. Non-surgical-
 Aural toilet
 Topical Abcs.
 Systemic Abcs.
2. Surgical measures - tympanoplasty.

34. Facial nerve paralysis
 Causes:
• Bell’s palsy(50%)
• Trauma(20%)
• RH syndrome
• Otitis media …
Palsy is not Bell’s if any of the following occur
• Signs of tumor/ vesicle
• Temporal bone infection/trauma
• Multiple CN involvement/ palsy at birth
• Signs of CNS lesion
• Acute infectious mononucleosis

35. Bell’s palsy
• Rapid onset, minimal associated symptoms & spontaneous
recovery
• Improvement in 3 weeks in 85% of cases
• The longer the delay, the greater the sequale
• Recent evidences suggest it is Herpes simplex mononeuritis
Treatment
• Steroids
• Acyclovir
• Surgical decompression
• Eye care

36. Choleasteatoma
• A cyst composed of keratinizing squamous epithelium in an
abnormal place (e.g. middle ear, mastoid, temporal bone)
• Variants:
– Congenital-
– Acquired (more common)-
• Generally occurs as a consequence of otitis media and
chronic Eustachian tube dysfunction
• Frequently associated with retraction pockets in the pars
flaccida and marginal perforations of the tympanic
membrane
• The associated chronic inflammatory process causes
progressive destruction of surrounding bony structures

37. Clinical Features
• Symptoms:
– History of otitis media (especially if unilateral), ventilation
tubes, ear surgery
– Progressive hearing loss (predominantly conductive
although may get sensory neural hearing loss in late stage)
– Otalgia, aural fullness, fever
• Signs:
– Retraction pocket in TM, may contain keratin debris
– TM perforation
– Granulation tissue, polyp visible on otoscopy
– Malodorous, unilateral otorrhea

38. Complications
• Ossicular erosion: conductive hearing loss
• Facial paralysis
• Meningitis
• Sensorineural hearing loss from inner ear erosion
• Sigmoid sinus thrombosis
• Dizziness from inner ear erosion or labyrinthitis
• Intracranial abscess (subdural, epidural, cerebellar)
• Temporal bone infection: mastoiditis, petrositis

39. Investigations
• Audiogram and CT scan
Treatment
• There is no conservative therapy for cholesteatoma
• Surgical: mastoidectomy ± tympanoplasty

40. Otoscelerosis
• Fusion of stapes footplate to oval window so that it cannot
vibrate.
• Otosclerosis is the second most common cause of CHL in 15 to
50 year olds (after cerumen impaction).
Ethology-
 Autosomal dominant, variable penetrance approximately
40%
 Female > male, progresses during pregnancy (hormone
responsive)

41. Clinical Features
• progressive conductive hearing loss first noticed in teens and
20’s (may progress to sensorineural hearing loss if cochlea
involved)
• ± pulsatile tinnitus
• tympanic membrane normal ± pink blush (Schwartz’s sign)
associated with the neovascularization of otosclerotic bone
• characteristic dip at 2,000 Hz (Cahart's notch) on audiogram
Treatment-
• Monitor with serial audiograms if coping with loss
• hearing aid
• Vitamin D, NaF
• stapedectomy or stapedotomy (with laser or drill) with
prosthesis is definitive treatment

42. GLOMUS TUMOR
• Glomus bodies are part of the diffuse neuroendocrine
system.
• Paragangliomas of the temporal bone arise from
nonchromaffin paraganglia, or glomus bodies, which are part
of a diffuse neuroendocrine system.
• Glomus jugulare tumors arise within the jugular fossa, and
glomus tympanicum tumors arise along the course of the
tympanic branch of cranial nerve IX (Jacobson nerve) and
along the course of the auricular branch of cranial nerve X
(Arnold nerve).

43. • are the most common true neoplasm of the middle ear and
are considered the most common pathologic condition
involving the jugular foramen
• occur most frequently in whites and predominate on the left
side.
• Females : males = 6:1
• CFs are related to tumor extent and vascularity.
• are generally slow-growing neoplasms
• conductive hearing loss and pulsatile tinnitus is the most
common presenting symptom

44. Glomus tumor

45. Diseases of the inner ear

46. Presbycusis
Definition:
• sensorineural hearing loss associated with aging (5th and 6th
decades)
• Presbycusis is the most common cause of sensorineural
hearing loss.
Etiology:
• hair cell degeneration
• age related degeneration of basilar membrane
• cochlear neuron damage
• ischemia of inner ear

47. Clinical Features:
• progressive, gradual bilateral hearing loss initially at high
frequencies, then middle frequencies
• loss of discrimination of speech especially with background noise
present – patients describe people as mumbling
• Recruitment phenomenon: inability to tolerate loud sounds
• tinnitus
• Recruitment Phenomenon results in a large rise in sensitivity to
loud noises with relatively small changes in sound intensity.
Treatment:
• hearing aid if patient has difficulty functioning, hearing loss > 30-
35 dB
• ± lip reading, auditory training, auditory aids (doorbell and phone
lights)

48. Sudden SNHL