1. A Practical Guide to Diseases
of the Ear
Simon Lloyd
Consultant ENT Surgeon
Manchester Royal Infirmary

2. Otitis externa Acute otitis media Chronic otitis media
without cholesteatoma
Chronic otitis media
with cholesteatoma
Otitis media with
effusion
Severe Otalgia Otalgia for a few days Otorrhoea
intermittently or for
more than 3 months
Otorrhoea
intermittently or for
more than 3 months
Hearing loss
Mild otorrhoea Fever Possibly conductive
hearing loss
Probably conductive
hearing loss
Speech delay
Occasionally conductive
hearing loss
Otorrhoea once otalgia
resolves
Usually a child
History of
swimming/holiday
Conductive hearing loss May have adenoidal
symptoms
Often a child
Differentiating Types of Otitis

3. Acute Otalgia with normal TM

4. Otitis externa
• Inflammation of ear canal skin
• Aetiology:
– Bacterial – Staph. aureus, Pseudomonas, Proteus
– Fungal – Aspergillus niger, Candida albicans
– Viral – Herpes simplex,Herpes zoster
– Reactive – Eczema, Psoriasis
• Predisposing factors:
– Bathing, humidity
– Trauma
– Canal stenosis
– Eczema

5. Symptoms & Signs - Bacterial
• Otalgia - severe
• Purulent otorrhoea
• Deafness
• Inflammation of ear
canal +/- pinna

6. Treatment
• Swab for sensitivities
• Aural toilet
• Splinting of ear canal
(Pope wick)
• Topical antibiotics eg.
Sofradex, Gentasone
• Keep dry

7. Malignant Otitis Externa
• Osteomylitis of temporal bone
• Immunocompromised patients eg. Diabetes
• Usually pseudomonas
• Extremely painful
• May be associated with cranial nerve palsy
• Have a high index of suspicion
• Treat aggressively with IV antibiotics for at
least 6 weeks

8. Symptoms & Signs - Fungal
• Itching
• Mild otalgia
• Fullness
• Greyish white debris
+/- fungal spores

9. Treatment
• Aural toilet
• Topical antifungal agents eg. Canestan

10. Furunculosis
• Staph. infection of
hair follicle causing
abscess formation
• Severe otalgia
• Requires I&D

11. Ramsey Hunt Syndrome
• Herpes zoster
• Geniculate ganglion of
facial nerve
• Vesicular rash of pinna
and ear canal (+/- mouth
and tongue)
• Facial nerve palsy
• Painful
• Vertigo
• Treatment
– Analgesia
– Antivirals eg. Acyclovir
– Protect the eye

12. First Branchial Cleft Anomalies
Pre-auricular sinus

13. First Branchial Cleft Anomalies
Pre-auricular sinus

14. First Branchial Cleft Anomalies
Pre-auricular sinus

15. First Branchial Cleft Anomalies
Accessory Auricle

16. Benign Skin Pathology

17. Benign Skin Pathology
Gouty
Tophi

18. Benign Skin Pathology
Seborrhoeic Keratosis
Gouty
Tophi

19. Benign Skin Pathology
Seborrhoeic Keratosis
Gouty
Tophi
Solar keratosis

20. Benign Skin Pathology

21. Benign Skin Pathology
Chondrodermatitis
helicis nodularis
chronica

22. Benign Skin Pathology
Chondrodermatitis
helicis nodularis
chronica
Darwin’s tubercle

23. Benign Skin Pathology
Chondrodermatitis
helicis nodularis
chronica
Keloid ScarringDarwin’s tubercle

24. Malignant Skin Pathology of The
Pinna

25. Malignant Skin Pathology of The
Pinna
Basal Cell Carcinoma

26. Malignant Skin Pathology of The
Pinna
Basal Cell Carcinoma
Squamous Cell Carcinoma

27. Middle Ear
• Otitis media
– Acute
– Chronic otitis media +/- cholesteatoma
– Otitis media with effusion
– Complications
• Tympanic membrane perforation
• Hearing loss
– Conductive

28. Acute Otitis Media
• Definition
– Inflammation of the middle ear cleft
• Demographics
– Mostly children (age 3-7)
• Aetiology
– Viral (majority)
– Bacterial (1y or 2y) - Strep. Pneumoniae, H. influenzae,
Bramhamella catarrhalis)
• Risk Factors
– Poor sanitation/ hygiene and parental smoking
– Exposure to other children
– Eustachian Tube Dysfunction
– ? allergy

29. Natural History
Infection via ET tube (Fever)
Mucosal oedema
Hyperaemia of tympanic membrane &
purulent middle effusion
Bulging tympanic membrane (Pain)
Pressure necrosis of tympanic
membrane resulting in perforation
Mucopurulent discharge

30. Acute Otitis Media

31. Acute Otitis Media
• Treatment
– Expectant
– Paracetamol/NSAIDS
– Oral amoxycillin
– +/- myringotomy
• Complications
– Acute
• Mastoiditis
• Facial palsy
• Labyrinthitis
• Meningitis
• Intracranial abscess
• Lateral sinus thrombosis
- Long term
• Tympanosclerosis
• Tympanic membrane perforation
• Ossicular damage

32. Acute Mastoiditis
• History of acute otitis
media
• Infection spreads to
mastoid
• Post-auricular abscess
• Treatment
– Grommet
– Cortical mastoidectomy

33. Mastoiditis Treatment

34. Intracerebral Abscess
Ring
enhancement
with contract
enhanced CT

35. Lateral Sinus Thrombosis
Filling defect
on MRA

36. Tympanic Membrane Perforation
• Causes
– Trauma
– Otitis media
– Iatrogenic eg. Grommets
• Symptoms
– None
– Recurrent otorrhoea
– Hearing loss

37. Tympanic Membrane Perforation
• Treatment
– None
– Myringoplasty
– +/- ossiculoplasty
Graft is placed under
perforation to allow
epithelium to regrow
Myringoplasty

38. Chronic Otitis Media
• Without cholesteatoma
– Tympanic membrane perforation
– Chronic middle ear infection
– May resolve with topical or oral
antibiotics
– If no resolution – myringoplasty
+/- cortical mastoidectomy
• Otorrohoea for more than 3 months
• May occur with or without cholesteatoma

39. Chronic Otitis Media
• With cholesteatoma
• Eustachian tube dysfunction results in tympanic membrane retraction
(attic)
• Accumulation of keratin in retraction pocket
• Gradual enlargement and adjacent bony destruction
• Complications as for AOM above

40. Cholesteatoma

41. Chronic Otitis Media with
Cholesteatoma

42. Chronic Otitis Media with
Cholesteatoma
• Treatment is surgical
• Aims of surgery
− Remove all disease
− Dry ear
− +/- Restore hearing
• Types of operation
– Modified radical mastoidectomy
– Canal wall up mastoidectomy

43. Chronic Otitis Media with
Cholesteatoma
Post-auricular incision Mastoid air cells
drilled away
Posterior ear canal
removed to leave
mastoid cavity

44. Inner Ear

45. Sudden Hearing Loss
• Normal TM with sudden hearing loss
• Aetiology unknown
• Viral
• Vascular
• Rarely acoustic neuroma, perilymph leak
• May be unsteady or vertiginous

46. Cochlea Drug Delivery

47. Sudden Hearing Loss
Management
• Refer urgently
• Treatment options
• Oral steroid
• Antiviral
• No evidence for efficacy
• Carbogen
• No evidence for efficacy
• Intratympanic steroid
• Reasonable evidence for efficacy

48. Hyperostosis
• Exostosis
– Multiple bony swellings in
deep canal
– Cold water
– Asymptomatic
– No treatment unless large
• Osteoma
– Single benign bony tumour
outer bony meatus
– No treatment unless large

49. Perichondritis
• Inflammation of
perichondrium
• Aetiology:
– Ear piercing
– Laceration
– Surgery
– CT disease
• Treatment:
– Antibiotics
– I & D (if abscess)
• Sequelae:
– Cauliflower ear