Diseases of the Ear

Ear Diseases

• Congenital Ear Diseases• External Ear Trauma• Tumors of the Pinna and External Auditory Meatus• Otitis Externa• Local Conditions of the Tympanic Membrane• Middle Ear Effusions• Suppurative Otitis Media• Cholesteatoma • Complications of Suppurative Otitis Media

Ear Diseases

• Otosclerosis • Middle Ear Microsurgery• Facial Nerve Palsy

Congenital Ear Disease

• External Ear:• Anotia – absence of auricle.• Microtia – small sized or rudimentary pinna.• Macrotia – large sized auricle.• Accessory auricles – small, firm elevation of skin

often containing bar of elastic cartilage w/c occur most commonly just anterior of the tragus.

• Congenital fistula – failure of obliteration of the first bronchial cleft, usually found in front of the helix or tragus which may become a site of infection.

Congenital Ear Disease

• Middle Ear• Ossicular chain defects – often occur in association with atresia of the

EAM.• Treacher-Collins syndrome – consists of middle ear malformation

with abnormal facial bone development.• Inner Ear• Congenital defects of the inner ear usually result in severe

sensorineural deafness.• These disorders may have hereditary basis.• Damage to the inner ear can also be caused by events during

pregnancy and the perinatal period w/c include infections, particularly maternal rubella and syphilis, hemolytic disease of the newborn and fetal anoxia during birth.

External Ear Trauma

• Foreign bodies – most common in child and mentally retarded account for the majority of cases .

• Animate – insects.• Inanimate – organic and plastic materials.• Treatment • Insects – filling the canal with mineral oil kills the insect, giving

some immediate relief, and facilitates its removal with forceps.• Metal and glass beads (small objects) can be removed by irrigation.• Hygroscopic FB (e.g., a bean/vegetable) swells when water is added

to it (syringed with saline), complicating its removal and it should either be removed with small forceps or syringed.

• Removal of FB may require a GA in children.

External Ear Trauma

• Haematoma auris – it is a condition that results from trauma to the pinna.

• Extravasations of the blood occur between the cartilage and pericondrium.

• Predisposing factors:• Boxer• Foot ball player• Treatment:• Early drainage of the haematoma with pressure dressing to

prevent its recurrence• Antibiotics

External Ear Trauma

• Perichondritis – infection of the perichondrium of the pinna w/c may result from open trauma, that may be surgical, involving the cartilage of pinna or auditory meatus.

• Occasionally complicates a severe otitis externa.• C/P: Severe pain• Objective findings: • A generalized red, swollen and tender pinna.• Ear lobe is not involved• Treatment:• TTC 250 mg six-hourly (ten days)• Surgical drainage of any abscess• Pinna should be examined daily

Tumors of the Pinna and External Auditory Meatus

• Malignant tumors – • Basal cell carcinomas, squamous cell carcinomas and malignant

melanomas occur on the skin of the pinna.• Predisposing factors:• Exposure to sunlight over a long period of time• Clinical feature:• Initially small superficial lesions that progress to deep ulceration in

advanced cases.• Squamous cell carcinoma and malignant melanomas metastasize to

regional cervical lymph nodes.• Treatment:• Surgical excision • Radiotherapy


• Benign tumors – • Osteoma of the external auditory meatus.• Aetiology • Associated with repeated exposure to the external auditory meatus to

cold water as in swimming and diving.• Clinical features:• Solitary or multiple• Osteomas appear as smooth swellings on the wall of the bony meatus.• They are often asymptomatic, but if the lumen of the meatus is occluded,

retention of wax, otitis externa or hearing loss may occur.• Treatment • None – if asymptomatic• Surgical reduction – recurrent otitis externa


• Angioma.• Sebaceous cyst.• Papilloma usually arises at the orifice of the canal. It

is a simple wart and is treated by removal under a local anesthetic.

• Keloide may present a form of fibroma is stimulated by trauma of the skin.

• Fibroma, melanoma, exostosis, osteoma, adenoma.

Otitis Externa

• Definition – inflammation of the skin of the external auditory meatus.

• Classification • Circumscribed otitis externa (Furunculosis) – infection of hair

follicles in the cartilaginous canal by staphylococcus aures.• Diffuse otitis externa – inflammation of the skin of external

auditory canal.• Aetiology • Gram negative organisms (e.g., E. coli, P. aeruginosa, P.

vulgaris, S. aureus and fungi or Otomycosis (e.r., Aspergillus).

Otitis Externa

• Precipitate factors (PDF):• Impacted cerumen• Local trauma• Middle ear disease• Swimming• Skin conditions• Chemical irritants• Clinical picture:• Complains scratching• Otalgia (pain)• Otorrhoea – a foul-smelling discharge• Hearing loss

Otitis Externa

• Otoscopic examination:• Skin of EAM is edematous, inflamed and tender• EAM is filled with white debris• Objective findings: • Traction on the pinna and pressure on the tragus

increase the pain• Enlarged lymph node• Hypae may be seen in fungal infection

Otitis Externa

• Treatment:• Remove dry debris by dry mopping or suction aided• Take meatus swab for bacteriology• Local antibiotics drops (CAF, Gentamycin)• Systemic broad spectrum antibiotics• Analgesic• Nystatin (Fungal)

Otitis Externa

• Malignant otitis externa – a potentially fatal Pseudomonas infection of the external auditory meatus occurring in elderly diabetic patients with spread to the skull base.

• Predisposing factors• Diabetus mallitus• Clinical features• Severe Otalgia• Otorrhoea• Hearing loss with progression to CN palsies (IX, X, XI,

XII).• Paresis or paralysis of facial nerve

Otitis Externa

• Treatments:• Hospitalization of the patient• High dose of antibiotics specific for an extended length

of time• Aminoglycosides + Synthetic penicillin• Creatinine level should be obtained 3x a week• Periodic hearing tests.• Special attention to diabetic management.• Proper aural hygiene indicated.• Mastoidectomy

Local Conditions of the Tympanic Membrane

• Bullous myringitis – infection of the tympanic membrane.• Aetiology – influenza virus• Clinical features• Acute onset of severe pain (otalgia)• Hearing loss • Serosanguinous otorrhea• Otoscopic examination:• Hemorrhagic bullae• Treatment:• Analgesic• Local and systemic antibiotic for secondary bacterial infection• Puncture of the bullae (?)


• Tympanosclerosis – • Aetiology • Deposits of collagen beneath the mucosa of the TM and middle ear

following OM or middle ear surgery.• Clinical features• Mostly asymptomatic• Otoscopic examination • Deposits are visible as white chalk patches in the TM• Middle ear deposits may cause conductive deafness by ossicular fixation• Treatment • None – if asymptomatic• Ossiculoplasty


• Acute necrotizing otitis media – • Occurs 2ny to complication of measles and scarlet fever • Aetiology • Symptoms - Similar to the others but is more severe and rapid foul thin

purulent discharge• Otoscopic examination:• Central perforation• Total loss of tympanic membrane. • Friable granulation.• Aural discharge is thin purulent and foul.• Treatment:• Antibiotics• Reconstruction to restore function

Middle Ear Effusions

• Middle ear effusion – • It is a common pediatric problem particularly in the 4-7 age group.• It is often associated with Eustachian tube obstruction, either acute

during URTI or chronic as in childhood adenoid hypertrophy.• Aetiology • Allergic rhinitis• Adenoiditis or nasopharyngitis, Sinusitis• Posterior deviation of nasal septum• Stenosis or dysfunction of Eustachian tube• Tumor of the nasopharynx• Paralysis of palatal muscles• Cleft palate


• Clinical features• Hearing loss in childhood• Cracking sound heard on yawing and swallowing• Feeling of fullness of something occluding the ear• Autophonia• Tinnitus• Otoscopic examination: • Retraction of TM• Short process of the Malleus more prominent.• Dull TM with loss of light reflex.• Fluid level occasionally seen


• Tuning fork test – lateralized to more affected side (conductive type)

• Audiometric test – conductive hearing loss• Tympanogram – reduced middle ear pressure (type B)• Treatment:• Medical treatment• Removal of obstructing or chronically infected adenoid• Topical decongestant.• Anti allergic.• Surgical treatment• Myringotomy • Insertion of a ventilation tube into the affected TM

Suppurative Otitis Media

• Acute otitis media – • Acute infection of middle ear cleft is common in young children.• Usually occurs as part of an URTI• Sources of Infection:• Infection of the middle ear is usually 2ry to disease of the nasopharynx.• An enlarged and infected part of adenoid obs the Eustachian tube so that

the air in the middle ear absorbed and replaced by mucus w/c in turn becomes mucopurulent.

• Pus from the sinuses may flow into the post-nasal space to infect the Eustachian tube.

• Aetiology • Hemophilus influenzae• Pneumococcus


• The most common forms:• Acute viral Otitis media.• Acute bacterial otitis media.• Acute necrotizing otitis media.• Symptoms:• Hearing loss• Fever• Sense of fullness • Pressure • Tinnitus• Otalgia • Discharge


• Otoscopic examination:• Stage I – the margin of the ear drum and the handle of the

Malleus are red, the whole tympanic membrane rapidly becomes red.

• Stage II – tympanic membrane bulging• Stage III – rupture may occur leading to mucopurulent.• Treatment:• Oral antibiotics (amoxicillin, cotrimexazole or erythromycin and

adequate analgesic).• In infants the Eustachian tube is relatively wide and straight,

milk or vomit can enter the middle ear if the child fed and vomit lying down.


• Complications:• Failure to resolve with antibiotics my have been taken

<10 days• Spread of infection to the adjacent structure causing• Acute Mastoiditis.• FN paralysis.• Intra-cranial complication.• Lateral sinus thrombosis.


• Acute mastoiditis – • May complicate acute otitis media.• Infection of the mastoid air cell system occurs.• Aetiology • Clinical features• Worsening of otalgia with tenderness over the mastoid antrum• Otoscopic examination• Narrowing of EAM by edema of posteior-superior wall.• Ear is pushed forward by subperiosteal abscess• Mastoid x-ray – opacity of mastoid air cells• Treatment • Parenteral antibiotic therapy• Surgical drainage via cortical mastoidectomy


• Chronic Ear Disease – • Forms of chronic ear disease: • Simple chronic otitis media (Benign) • Serious chronic suppurative OM dangerous (cholesteatoma).• Chronic otitis media – chronic inflammation of the middle ear cleft

w/c is usually associated with a perforation of the TM, or is a chronic inflammatory process involving the middle ear cleft producing irreversible pathological changes.

• Perforations usually result from previous episodes of acute OM when the membrane fails to heal following rupture.

• Two types:• Tubotymanic type (Simple chronic otitis media).• Attico-antral type (serious chronic otitis media).


• Pathological classification:

– Persistent mucosal disease– Cholesterol granuloma

• Persistent mucosal disease – infection reaches the middle ear either through a perforation of tympanic membrane or through the Eustachian tube.

• Repeated infection of middle ear leads to hyperplasia of its mucosa. • These hyperplasic mucosal proliferations trap the infection which is

responsible for its chronicity or polyp formation.• Cholesterol granuloma – due to dysfunction of the Eustachian tube it may

block the posterior position of the tympani thus creating vacuum which leads to extravasations of blood into the middle ear.

• This provokes a FB reaction resulting in the formation of cholesterol granuloma.


• Clinical classification:• Tubal type – the underlying cause of infection lies

either in the nose, sinuses or the nasopharynx. • Usually seen in children from the low socioeconomic

strata and often involves both ears.• Tympanic type – the infection reaches the middle ear

through a defect in the tympanic membrane (persistent perforation syndromes) usually seen in adults and involves one ear only.


• Clinical features:• Tubal type – Profuse, bilateral mucopurulent discharge.• Otoscopic examination:• The ear is seen full of mucopurulent discharge.• Anterior perforation of the eardrum.• Risk factors:• Deviated nasal septum and running nose. • Features of sinusitis or adenoid may been seen.• Audiogram – Mild to moderate hearing loss.• Tympanic type – Usually seen in adults and repeated infection of the ear.• Otoscopic examination: • Scanty discharge is seen in the ear.


• Investigations:• Tuning fork test.• Culture sensitivity test of the discharge. • X-Ray of mastoid.• PNS X-Ray.• Treatment:• Treatment of underlying cause• Aural toilet- cleaning the ear with sterile cotton tipped probe• Culture sensitivity – to select proper antibiotics.• Local antibiotics• Systemic antibiotics.


• Surgical management:• Adenoidectomy, septoplasty, antrum wash—is may

required in some cases. • Aural polypectomy should be done under GA using

microscope• Myringoplasty:• Prerequisites• The ear should be dry for at least for 6 -8 weeks.• The Eustachian tube should be patent• No focus of infection.


• Attico-antral disease – • It involves the attic, antrum and the posterior tympanum. • It is bone invading disease, therefore exposes the adjacent

structure with resultant complication and hence it is termed dangerous or unsafe variety.

• The main pathological feature is the formation of cholesteatoma.

• Cholesteatoma – it is a sac of keratinized desquamated epithelium in the middle ear cleft, resting on a fibrous tissue layer called the matrix.


• Cholesteatoma – a ball of keratinized stratified squamous epithelium in the middle ear cleft or mastoid w/c enlarges and can destroy or erode local structures.

• It is a feature of unsafe type of chronic middle ear disease.

• Aetiology • Metaplasia theory• Immigration


• Types of cholesteatoma:• Congenital – it is thought to be embryonic in origin. • It is believed that during development epithelial cell crest get

trapped in the parietal bone or elsewhere in the skull.• Acquired – • Primary acquired Cho - occurs in the attic or in the posterior

of tympanic cavity where there has not been any predisposing COM.

• Secondary acquired Cho - in this variety the cholesteatoma develops in the ears from the active chronic disease with defect in the tympanic membrane


• Metaplasia – because of repeated infection. This theory does not find mach favor.

• Immigration – immigration of squamous epithelium from the deep meatal wall and tympanic membranes. Recurrent acute middle ear infection in child hood acts as a stimulus for the process of cholesteatoma formation. Inadequate ventilation in the attic because of infantile diets.

• Clinical feature:• Purulent discharge foul smelling and scanty in amount. • Progressive hearing loss and may be associated with tinnitus • The development of earache, vertigo, vomiting and headache

signify the onset of complication.


• Otoscopic examination:• Attic perforation, posterior, superior & marginal

perforation • Granulation which is reddish in color epithelial lams

of cholesteatoma. • Fistula sign may be positive.


• Investigations:

• Hearing assessment usually reveals conductive hearing. • Bacteriology - reveals mixed groups of organisms like, B

proteus, Pseudomonas and Pseudomonas, anaerobic bacteria • Radiology – the mastoid reveals hypo-cellular or cellular,

bone destruction i.e., cavity formation.• Treatment:• Attico antral disease • To make safe the ear by eradicating cholesteatma and to

prevent its recurrence• Reconstructive surgery


• Complication of CSOM:• Meningeal complications:• Extradural abscess• Peri sinus abscess• Venus sinus thrombosis• Meningitis • Subdural abscess. • Meningeal


• Non-meningeal complications:• Mastoditis• Porosities• Facial nerve paralysis• Labyrinth • Retropharyngeal abscess.

• Otosclerosis – a disease primarily of the bone of the otic capsule w/c causes a conductive hearing loss, usually because of stapes fixation, or it is a disease of the bony labyrinth which produce effects on the middle and inner ear functioning – ankylosis of the foot plate of stapes

• A sensorineural deafness may occur in later stages.• Etiology • Uknown

• Theories• Hereditary – Family Hx about 70% of the case and

evidence goes in favor of autosomal dominant inheritances.

• Racial distribution – Common in India, White and rare in Negroes, Chinese and Japanese.

• Age of on set – 15 - 35 years in - 90%.• Sex – More common in females.• Sites – Fossula ante-fenstrum (2-3 mm area in front

of the oval window).

• Fossula post-fenstrum, round window, foot plate of stapes, Infra cochlear region and below the I.A.C.

• Histopathology – the normal endocondrial bone of the bony labyrinth is replaced by new bone which is spongy more cellular and more vascular.

• Clinical Otoesclerosis:• Stapedius Otoesclerosis - produce Anqylosis of the steps

causing conductive hearing loss.• Cochlear oto - affect membranous labyrinth producing

SNHL• Mixed oto-fixation of the steps + labyrinth.

• Symptoms:• Progressive hearing loss bilateral in 80% symmetrical in

degree• Tinnitus.• Otoscopic examination:• Otosclerosis focus (thickened and vascular contrasting with

the bluish appearing). • Paracusis willisi – the ability to hear speech in noisy

surrounding.• Audiogram – Carhats notch There is a dip of the bone

conduction curve (5 dB lose at 4000 Hz).

• Differential Diagnosis:• Middle ear effusion• Adhesive O.M• Ossicular chain disruption• Congenital Ossicular fixation• Vander Hoeve’s Syndromes• Blue sclera with Osteogenesis imperfecta• Pathological fracture in long bone – Schwartz sign absent and

acoustic reflex cannot be elicited.• Paget disease (osteolytic and osteoblastic) – Softening of the bones• Treatment – Stapedectomy

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Diseases of the Ear