A Pocket Guide to the Ear: A concise clinical text on the ear and its disorders
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Foreign body inhalation is the most common cause of accidental death in children less than one year of age. Go to BLS maneuvers if the child decompensates. Infants under 1 year of age — back blows : head-down, 5 back-blows between scapulae , 5 chest-thrusts sternum. Reassess, repeat as needed. The thumb side of one fist should be placed on the abdomen below the xiphoid process. The other hand should be placed over the fist, and 5 upward-inward thrusts should be performed.
This maneuver should be repeated if the airway remains obstructed. Alternatively, if patient is supine, open the airway, and if the object is readily visible, remove it. Abdominal thrusts: place the heel of one hand below the xiphoid, interlace fingers, and use sharp, forceful thrusts to dislodge. Be ready to perform CPR. After 30 chest compressions, open the airway. If you see a foreign body, remove it but do not perform blind finger sweeps because they may push obstructing objects further into the pharynx and may damage the oropharynx.
Attempt to give 2 breaths and continue with cycles of chest compressions and ventilations until the object is expelled. Other anatomically narrow sites include the level of the aortic arch and the lower esophageal sphincter. Coin en face — in the esophagus — lodged at the thoracic inlet.
This is an emergency: the electrolyte-rich mucosa conducts a focal current from the narrow negative terminal of the battery, rapidly causing burn, necrosis, and possibly perforation. Emergent removal is required. Button batteries that have passed into the stomach do not require emergent intervention — they can be followed closely.
If there is no obstruction, consider revaluation the next day — may wait up to 24 hours for passage. Infants: objects smaller than 2 cm wide and 3 cm long will likely pass the pylorus and ileocecal valve Children and adults: objects smaller than 2 cm wide and 5 cm long will likely pass the pylorus and ileocecal valve 9. Hair beads if the central hole is accessible may be manipulated out with the angled tip of a rigid curette. There is a large selection of disposable simple and lighted curettes on the market.
Various eponymous hooks are available for this purpose; one in popular use is the Day hook , which may be passed behind the foreign body. If it is completely lodged, use of a right-angle hook will likely only cause trauma to the canal. Alligator forceps are best for grasping soft objects like cotton or paper. Smooth, round or oval objects are not amenable to extraction with alligator forceps. When using them, be sure to get a firm, central grip on the object, to avoid tearing it into smaller, less manageable pieces. Pro tip: Look before you grip! Be careful to visualize the area you are gripping, to avoid pulling on and subsequently avulsing soft tissue in the ear canal.
Immediately apply the treated side to the object in the ear canal in a restrained patient. Apply the treated swab to the foreign body for seconds, to allow bonding. Slowly pull out the foreign body. Re-visualize the ear canal for other retained foreign bodies and abrasion or ear canal trauma. Did the cyanoacrylate drip? Did the swab stick to the ear canal? Both agents help to dissolve ear wax, the compound, or both.
Repeat if needed to debond the cyanoacrylate from the ear canal. Irrigation is the default for non-organic foreign bodies that are not amenable to other extraction techniques. Do not use if there is any organic material involved: the object will swell, causing much more pain, difficulty in extraction, and possibly setting up conditions for infection. Position the child either prone or supine, gently restrain as above. It may be more accessible to you, but you may never get the foreign body out. To use a butterfly needle : use a small gage 22 or 24 g butterfly set up, cut off the needle, connect the tubing to a 30 mL syringe filled with warm or room-temperature water.
Gently and slowly increase the pressure you exert as you irrigate. To use an IV or angiocatheter: use a moderate size 18 or 20 g IV, remove the needle and attach the plastic catheter to a 20 mL syringe, and irrigate as above.
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Cerumen is composed of sebaceous ad ceruminous secretions and desquamated skin. Genetic, environmental, and anatomical factors combine to trap a foreign body in the external canal. Use of a ceruminolytic such as docusate sodium may help to loosen and liberate the foreign body. In the case where loosening the ear wax may aid extraction and will not cause a slippery mess , consider filling the ear canal will docusate sodium Colace , having the child lie with the affected side up, waiting 15 minutes, and proceeding. This is especially helpful when planning for irrigation.
Rare earth magnets a misnomer, as their components are actually abundant such as neodymium can be useful in retrieving metallic foreign bodies e. Alternatively, you may purchase a strong neodymium bar magnet to lb hold to attach to an instrument such as an alligator forceps, pick-up forceps, or small hemostat a pacemaker magnet may also work.
The magnetic bar, placed in your palm at the base of the instrument, will conduct the charge depending on the instrument and allow you to retrieve many metallic objects. Most stainless steel has a minimum of Even if the metal is very weakly magnetic, the strong neodymium magnet may still be able to exert a pull on it and aid in extraction.
A relatively new method, described by Fundakowski et al. After treatment with oxymetolazone 0. Pull the loop toward you until you feel that it is sitting up against the button battery. Pull gently out. This technique is especially useful when the foreign body has created marked edema, either creating a vacuum effect or making it difficult for other instruments to pass.
Small-caliber devices 5, 6, or 8 F originally designed for use with intravascular or bladder catheterization may be used to extract foreign bodies from the ear or nose. Inspect the ear or nose for potential trauma and to anticipate bleeding after manipulation especially the nose. Insert the deflated catheter and gently pass the device past the foreign body. Inflate the balloon and slowly pull the balloon and foreign body out. Apex of cochlea. The Inner Ear 23 The organ of Corti is the key sensory area within the scala media.
Here, inner and outer hair cells are stimulated, via bending of their stereocilia, by sound waves. These waves are transmitted from the vibrating stapes foot- plate into perilymphatic fluid to displace the basilar membrane, on which the hair cells rest. This membrane is narrower near the oval window, where higher frequencies are perceived, and gradually widens toward the apex of the cochlea, where lower frequencies are perceived.
The hair cells send their impulses through nerve fibers in the spiral lamina to- ward the auditory nerve, converting mechanical energy into electrical en- ergy. Sound waves from the vibrating stapes footplate in the oval window en- ter the scala vestibuli at the posterolateral end of the basal turn to circulate through the cochlear fluids. The round window and its membrane, located beneath the oval window, also connect the middle and inner ear cavities by way of the scala tympani.
The scalae vestibuli and tympani communicate at the cochlear apex. Thus, the round window can actually receive sound waves and transmit them retrograde in some middle ear conditions where the stapes footplate is fixed and does not vibrate. The cavities of the scalae vestibuli and tympani contain high-sodium, low-potassium perilymph, which communicates with cerobrospinal fluid CSF via the cochlear aqueduct.
Endolymph, within the scala media, or cochlear duct, is high in potassium and low in sodium. Without going into great detail, there are other ducts and sacs depicted in Fig. The result is a sense of ear fullness, tinnitus, and hearing loss. Ver- tigo develops as well, from swelling of the vestibular endolymphatic cav- ities. Over 15 hair cells are arranged in three to four outer rows, and an inner single row, along the organ of Corti.
Whether this explains the predominance of high-frequency loss from noise over-expo- sure is controversial. The physiology of the inner ear is complex. Years of research and pub- lications have been devoted to the subject and are available elsewhere to the interested reader. They are located just deep and posterior to the end of the basal turn of the co- chlea Fig. These structures, like the cochlea, also contain hair cell sen- sors, but they receive stimulation from positional shifts rather than sound waves.
These dense little "weights" shift with position change, thus bending and stimulating the hair cells, sending electrical information into the brainstem via the vestibular portion of cranial nerve VIII. More posteriorly and superiorly, the semicircular canals— lateral, super- ior, and posterior— comprise the other portion of the vestibular system. They are oriented in three planes, each perpendicular to the other. These sense "rotational" head motion, or angular acceleration, interacting with the neck and eyes to maintain orientation during turning motions.
If they are artificially stimulated calorically by cold or warm water in the ear, clas- sic vertigo is produced, just as it would if the head rotated repeatedly and then suddenly stopped. Diseases of the labyrinth produce vertigo, such as with the endolymphatic swelling of Meniere's disease. Another common condition of recurrent vertigo, benign positional vertigo, is believed to re- sult from abnormal displacement of otolithic debris cause uncertain into the posterior semicircular canal.
More information about these disorders, including a discussion of nystagmus, will follow in Chapter 8. The vestibular nerve, receiving information from the balance organs, has a superior and inferior division. These divisions converge with the auditory nerve from the cochlea to form cranial nerve VIII. In the brain- stem, nerve fibers from the utricle and saccule, perceiving linear accelera- tion, interconnect mostly with nerves to the anti-gravity muscles of the back and limbs.
Fibers from the rotation-perceiving semicircular canals, on the other hand, have connections with the ocular muscles and the mus- cles of the neck.
Foreign Bodies in the Head and Neck
The IAC and its meatus are the site of the often-discussed "acoustic neuroma. A single source of blood supply to the inner ear is a nonanastamosing end artery, the internal auditory artery. Its smaller branches terminate in the stria vascularis, which supports the circulation and probably aids in the fluid balance of the organ of Corti. In the past, an occlusion of the internal auditory artery was often seen as the cause of the phenom- enon of "sudden sensorineural hearing loss. The Inner Ear 25 although vascular compromise of its branches does play a part in the dis- order.
The external auditory canal. Otolaryngol Clin North Am. Physiology of the auditory and vestibular systems. Shambaugh GE. Mechanics of hearing. In: Shambaugh GE, ed. Surgery of the Ear. Philadelphia: WB Saunders Co; In this and the following chapters we will progress anatomically from the outer ear inward. At the outset, let us emphasize that the ear is fairly compartmentalized with respect to most of its disorders.
That is to say, the outer, middle, and inner ear have their own individual problems, without much overlap between these anatomic compartments, although a number of exceptions exist. Unfortunately, some medical and lay persons with a limited knowledge of ears tend to lump the symptoms and diagnoses of ear disorders together in one large basket. The educated clinician, on the other hand, knows that certain ear symptoms, even without the benefit of an examination, point toward the involved portion of the ear.
Disorders of the external ear are likely to cause one or more of the following specific complaints: itching, pain, tenderness, swelling, blockage of hearing autophony , and drainage. Secretions in the canal may also cause noises during chewing or manip- ulation of the ear. The external ear includes the auricle and the external auditory canal EAC , but some disorders outside the external ear cause referred aural symptoms.
These will be discussed first, and we will then proceed from the auricle inward. Temporomandibular Joint Syndrome Temporomandibular joint TMJ syndrome or disorder was first known as Costen's syndrome, having been described in by an otolaryngo- logist, Dr. James B. With a cartilage disk intervening, the mandibular condyle slides down and forward as the jaw opens, and then back and upward as it closes.
A number of factors can subject the joint to wear and tear. Since it borders on the external ear canal and shares innervation with it via the auriculo- temporal branch of the trigeminal nerve, symptoms of joint inflammation or derangement are often referred to the ear. The disorder has a relative, myofascial pain syndrome. Temporomandibular Joint Syndrome 27 from tension and spasm in the muscles around the joint. The two disorders often coexist. TMJ syndrome is the cause of a large number of ear complaints. Symp- toms and findings vary greatly from patient to patient. The actual patho- logic changes range from nothing at all to mild arthritic change to extreme mechanical disruption of the joint.
Thus, there can be an anatomically nor- mal, but painful, joint or advanced degeneration of the disk and joint sur- faces, with severe clicking or even locking of the joint. The cause is most often clenching or grinding of the teeth bruxism , either unconsciously in sleep or as a habit when awake. However, dental or bite abnormalities, pre- vious trauma to the mandible, and other factors possibly even genetic may be responsible. Those afflicted have variable complaints. Some patients report a feeling of intermittent or chronic fullness in the ear, with a perceived need to "clear" it.
Others may complain of pain, sometimes sharp and momentary, especially when chewing, or sometimes dull and chronic. The pain or ache in the ear may also radiate in any direction, but most often inferiorly down the neck, possibly secondary to muscle spasm. A sense of hearing loss, tinnitus, or even vertigo may be present. The cause of these latter symptoms is unclear, although sensitizing of the ear by way of neurologic referral is a convenient explanation.
The patient is often convinced there is an ear blockage or infection, but may occasionally point directly to the TMJ as the source of the discomfort. Although the mandible works as a single unit, the symptoms are often worse on one side or completely unilateral. Careful questioning by the examiner may uncover more historical in- formation, which might be valuable in formulating the cause of the pro- blem. Here are some examples: 1. The symptoms are worse overnight or on awakening. A spouse, or even the patient, notes audible or visible bruxism during sleep.
Bruxism occurs while the patient is awake. The patient chews gum or other objects e. The patient has been subjected to undue tension and stress lately. A number of posterior molars have been extracted in the past. Chewing food hurts. Physical findings should support your suspicions. Place a finger over the TMJ on both sides, or actually in the external canal, pressing gently forward on the joints.
Have the patient open and close the mouth, and ask if either joint is tender. If so, you can feel strongly about the diagnosis. You may even feel or hear crepitance a crackling sensation or clicking if the disk is damaged. Look for gross bite misalignment or multiple missing molars, findings that can cause stress on the joint. Of course, the ears themselves should be examined and they should show no evidence of real disease. TMJ syndrome and eustachian tube dys- function have similar symptoms and are often confused. In a typical sce- nario, the practitioner listens to the patient's symptoms, sees a scarred but functionally normal tympanic membrane TM , and puts these findings together to conclude that there is a middle ear problem.
Some patients are thus treated for long periods with antihistamines, decongestants, ster- oid nasal sprays, and even antibiotics. To avoid this error, an accurate ear examination is necessary, with good assessment of hearing and TM mo- bility. One equivocation, though, is that eustachian tube and TMJ disorders may coexist in the same patient! Here is where good diagnostic capability with ears makes all the difference.
Once middle ear or other problems are ruled out and TMJ syndrome is diagnosed, treatment begins with a caring and interactive discussion. A patient's insights and acceptance are needed to pursue remedies. Often, muscle tension and spasm aggravate the joint pain. Stress reduction, if pos- sible, with conscious avoidance of bruxism while awake, will help.
Gum chewing should be avoided, as well as very chewy foods. Anti-inflamma- tory medications are a great help. Rehabilitative jaw exercises can be re- commended. Referral to a dentist or dental subspecialist should be an early considera- tion. Oral appliances called night guards can be made.
They are worn at night and serve to separate the posterior upper and lower teeth, relieving stress on the joint. Joint surgery is available for extreme cases. The treat- ment of this disorder is more in the realm of the dental specialist than the general physician or otolaryngologist, but correct diagnosis is imperative. A patient may present with the jaw locked open, holding a towel to catch saliva. This usually occurs after a wide opening of the mouth, such as with yawning.
Individuals with significant disk derangement or laxity in the joint are prone to it. The treatment is manual reduction of the dislocation by rotating the mandible with the thumbs pressing downward on the mandibular molars inside the mouth. This will often require someone with experience in this procedure, such as an oral surgeon or ENT specia- list.
Muscle relaxants are often necessary before the reduction. Neuralgias Involving the Ear 29 Summary The key point to make about TMJ syndrome is that it is the most com- mon cause of multiple ear symptoms in patients with normal ears, and that it is often misdiagnosed as a eustachian tube or middle ear disor- der. The patient usually presents with unilateral or bilateral fullness in or near the ear, and ache may be present. Thorough evaluation of the TM, its mobility, and hearing can rule out ear disease. A positive history of bruxism, coupled with findings of joint tenderness or crepitance, supports the diagnosis.
Patient counseling and anti-inflammatory med- icines, along with possible dental consultation and nighttime appliance fitting, are the mainstays of treatment. The primary practitioner can diagnose and initiate treatment for TMJ syndrome, with elective refer- ral to an ENT or dental specialist for confirmation of the diagnosis and further options. Neuralgias Involving the Ear Webster defines "neuralgia" as a severe pain along the course of a nerve or in its distribution.
Obviously, this is a concise and accurate description. In diagnosing neuralgia, there are few physical findings to support one's im- pression. Clinical suspicion is aroused mostly by the patient's history— the description of the type of pain and its location.
Typically, neuralgia pains are severe and lancinating, lasting only a few seconds to a half-minute, and are variable in frequency. Often, there is tenderness to light touch. The duration of the disorder is also variable. Some neuralgias are short-lived, accompanying a viral illness, and others are chronic and disabling, lasting months to years. Notably, almost all are unilateral. The cause of most neuralgias is uncertain, although viral or postviral neuropathy may play a role. It has recently come to light that sometimes direct nerve compression is involved.
Trigeminal neuralgia, for example, has been cured by surgically alleviating a vessel's compression of the nerve root near the brainstem. In addition, ablation procedures, by nerve section or toxic injection, have been done successfully for years. These surgical successes certainly support an anatomic basis for the disorder. Thus, several neuralgia syndromes include ear pain.
Diagnosis of the following neuralgias is often by exclusion— one must rule out other reasons for the pain. However, the severity of the pain, sensitivity in the area of nerve distribution, and unilaterality are all contributing considera- tions. It involves one or more of the three divisions of cranial nerve V, usually the lower two. The lancinating pains are typically triggered by light touch, or even the wind! The pain distribution may include the ear, pre- sumably via the auriculotemporal branch.
Occipital neuralgia occurs in the distribution of this branch of C3 in the posterior scalp and mastoid re- gions. Often the patient even complains of "hair" tenderness in these areas. Extremely rarely, glossopharyngeal neuralgia, arising from cranial nerve IX, is experienced as pain in the posterior oropharynx, tonsil, or base of tongue, with radiation to the ear via Jacobson's nerve. Also rare, sphenopalatine neuralgia arises from the ganglion of the same name in the fossa behind the maxillary sinus, with nerve relays from V and VII.
It manifests itself as a unilateral pain in the maxillary, orbital, and temporal regions, with ear pain as well. Treatment for all these disorders depends on the chronicity of the symp- toms and the certainty of the diagnosis. Acutely, one should consider the usual pain medications, if all other causes are ruled out.
More chronically, carbamazepine Tegretol is effective, although the side effects of drowsi- ness and rare severe reactions bone marrow depression warrant great caution. Monitoring the complete blood count, before and during use, is indicated. Oxcarbamazepine Trileptal is a newer compound without the above side effects, although neuralgia is not yet listed in its indications. Summary Most importantly, neuralgias are severe pains, often lancinating and ac- companied by tenderness to light touch.
They may be acute or chronic, and an exact cause is seldom known. To make the diagnosis, all other causes of the pain should be ruled out. We must emphasize here again that when unexplained ear pain is a symptom, malignant tumors else- where in the respiratory tract, especially in the pharynx and larynx, may cause referred ear pain.
These should be ruled out by a full ENT exam- ination, if at all suspected. Traditionally, Tegretol is a popular treatment, to be prescribed with care. Trileptal is proving to be a safe and effective replacement. The primary practitioner can diagnose and treat these disorders, with referral to an ENT specialist or neurologist if there is any doubt. Hematoma of the Auricle 31 Hematoma of the Auricle This problem occurs most often in young athletes, particularly wrestlers or football players who practice without their headgear.
However, any severe blunt trauma to the auricle can cause a hematoma at any age. The vascular anastamoses of the auricle make subperichondrial accumula- tion of blood, with recurrences and lack of reabsorption, a likelihood. Usually, the hematoma occurs on the superolateral surface, centered over the scapha and upper concha Fig. If left untreated, fibrosis and even calcification can develop in time, causing the classic "cauliflower ear" deformity. Incision and drainage should be done aseptically to avoid the dreaded complication of perichondritis, which will be discussed next.
Antipseudo- monal antibiotics should be prescribed. Evacuation of the hematoma may be carried out by making an incision, or two parallel incisions, and insert- ing a rubber drain. Pressure dressings are applied and the drain removed several days later. A follow-up visit to rule out recurrence should also be made. Another method of treatment is aseptic needle aspiration, using an gauge needle after numbing the skin with a tiny-needle lidocaine injec- tion.
After aspiration, a cotton wad soaked with collodion is form-fitted over the area and held in place until it dries. Over it, an additional small Fig. The patient is in- structed to hold it there firmly for 20 minutes or so and to keep the dres- sing on for a few days. With either technique, there may be recurrences that need repeat drainage procedures, but success usually eventuates with careful treatment, observation, and avoidance of the activity that brought on the hematoma.
The primary practitioner or emergency physician, if comfortable, may perform the second of these two procedures on an initial encounter, but ENT follow-up is recommended as recurrences are likely. Perichondritis of the Auricle This devastating infection occurs most often as a result of trauma, with penetration of the skin and a contaminated wound.
Another possible cause is iatrogenic injury, i. The auricle becomes hot, red, swollen, and tender after the contaminating injury Fig. When perichondritis is suspected, aggressive treatment is necessary. The organism is usually Pseudomonas aeruginosa, although Staphylococcus aureus may be involved. If there is evidence of fluctuance from pus, drai- nage should be carried out, of course with a culture. Appropriate antibio- tics antipseudomonal, if not cultured otherwise should be administered, Fig. Ear, Nose, and Throat Dis- eases.
Congenital Disorders of the External Ear 33 Fig. The quinolones, as well as the aminoglycosides, such as tobramycin, are effective against Pseudomonas and staph. A severe infection, which begins and stays localized under the perichondrium, often results in necrosis of the cartilage and eventual fibrosis with a permanent severe auricular deformity Fig. A condition simulating perichondritis can be encountered— the allergic insect bite reaction.
Typically, the patient is seen during the summer months with rapid onset of a swollen, warm, itching, pink auricle. The cul- prits are often gnats, and an obvious insect bite is not necessarily seen. The absence of gross skin injury and predominance of itching, rather than pain, favors this diagnosis rather than perichondritis. In these cases, antihista- mines and topical steroids are the indicated treatments. If there is any doubt about the diagnosis, precautionary antipseudomonal antibiotics should be used.
If the primary physician suspects full-blown perichondritis with its char- acterisitc red, swollen, tender auricle, hospitalization for IV antibiotics and early ENT consultation are indicated. Congenital Disorders of the External Ear Microtia The scope of this text will not include embryology nor a detailed discussion of all of the types of external ear deformities that can occur.
The most severe deformity is microtia, which is immediately noticeable at birth. Less severe deformities of the auricle may also be encountered. These external defects are often accompanied by stenosis or atresia of the external canal, as well as by middle ear anomalies. Occa- sionally, they accompany syndromes with other craniofacial defects. With complete occlusion of the canal, the conductive hearing loss is very large, on the order of dB HL. Sometimes the other ear is normal and there is no urgency for treatment of the deformed ear, although a hearing aid should be placed at a young age for the sake of good bilateral hearing.
A child with deformities of both ears should have a hearing aid placed as soon after birth as possible to gain speech input. The specialist should get involved early. CT scans will show the extent of the defect, and surgery can be done on the more cor- rectable ear before the school years. The procedure is extremely specia- lized, with risk for complications and failure. Regarding the cosmetic de- formity of the auricle, multiple procedures, or simply a prosthesis, may be indicated. Obviously, referral to a "super-specialist," who deals with such cases often, is recommended.
This Fig. Clinical Otology. Noncongenital Cysts and Keloids of the Auricle 35 usually presents as a small fistula in the skin anterior to the helix at the upper tragus. A number of people have only a punctum here as an embryo- nic remnant with no clinical problems. However, the associated sinus tract can develop a dilated cyst with repeated infection and abscess formation. An acute abscess should be treated by drainage through an incision as close to the punctum as possible.
In problem cases, surgical excision, with com- plete removal of the tract, is the answer. Care must be taken to avoid the upper branches of the facial nerve. First Branchial Cleft Cyst These cysts occur just beneath the lobule of the auricle and may be mis- taken for parotid gland tumors. They often have a sinus tract and tiny fis- tula that empties into the floor of the EAC. Thus, when infected, they may present with swelling below the ear and drainage into the canal.
Even though these are "benign cysts," a skilled specialist should do the surgery. The tract is closely associated with the facial nerve, which may be injured as a surgical complication. Noncongenital Cysts and Keloids of the Auricle Epidermal Cysts Two cystic conditions may be encountered externally, each in a different location. Epidermal inclusion cysts, traditionally known as sebaceous cysts, are usually located low in the postauricular crease. They represent backed-up oil glands and occur in individuals with oily skin and acne. These patients tend to have them behind both auricles and in other facial areas as well.
Their usual content is cheesy sebum, but at times they may swell up and abscess, often infected with staph. If they are infected, the treatment is an antistaphylococcal antibiotic. Often the infection will resolve, but incision and drainage may be necessary. Troublesome recur- rences can be surgically excised, when not infected, taking care to remove the entire cyst lining. Even then, they may reappear. Epidermal cysts of the lobule can occur within the epithelialized tract of an ear-piercing site.
They present with swelling, weeping, and repeated infection. If conservative treatment with antibiotics and cleansing fails, surgical excision, with removal of the entire epithelialized lining, may be necessary. The defects in the lateral and medial skin of the lobe are su- tured and the patient is doomed to use conventional earrings here and find another site for body piercing.
These can be an extremely difficult problem, with growth to incredible size. They can recur even when excised completely. Triple therapy— exci- sion, postoperative steroid injections, and irradiation— may be necessary. Skin Disorders of the External Meatus The three major "dermatoses" of the external ear are seborrheic derma- titis, eczema, and psoriasis. They have some overlapping characteristics and often affect the same areas, namely, the external canal, its meatus, and the concha.
Sometimes adjacent regions, such as the lobule and postauri- cular areas, are affected. They seldom extend deeper than the outer one- third of the canal. Dermatologists refer to all three as the papulosquamous disorders. Patients afflicted with these disorders complain of itching and weeping of the external canal. Occasionally, there is pain if inflammation or superinfection is present. Seborrheic Dermatitis This is the most prevalent of the three dermatoses affecting the external ear. It presents as a diffuse scaliness, with a pink or orange discoloration of the skin, in and around the external meatus.
Often the involved skin is greasy, but other times it is simply dry and flaky. The lesion may be seen behind the auricle as well, along with other locations on the face, especially on the forehead between the eyes and lateral to the nose. It oc- curs more often in the older adult population. Dandruff seborrheic der- matitis of the scalp often accompanies it.
Treatment centers around mild topical steroids, as well as selenium sulfide shampoo. When the latter is applied to the scalp for the dandruff, it may be applied to the ears as well. Sometimes yeast accompanies it, which responds to topical ketoconazole cream or shampoo. Eczematoid Dermatitis Eczema of the meatus and surrounding structures may affect any age group.
It may be "familial atopic dermatitis," "acquired-irritant," or "aller- gic" eczema. The lesions usually start as small blisters, which itch intensely and are scratched away, leaving skin that becomes "lichenified" with ex- aggerated striations and scales. Weeping of sticky clear fluid is often pre- sent.
Allergy to topical irritants, such as fabrics, soap, hair coloring, or hair spray, as well as other environmental allergens, may be causative. Neomy- cin allergy from eardrops can cause an acute eczema Fig. Noncongenital Cysts and Keloids of the Auricle 37 Fig. New York: Thieme; a condition you may be already treating! In addition, food allergy has been implicated— eggs, milk, cheese, chocolate, and nuts head the list.
Unfortunately, many times there is no identifiable allergen. Bacterial superinfection, especially with staph, may complicate the picture. A cul- ture will help if infection is suspected. Treatment also hinges on topical steroids, oral or topical antihistamines for the itching, antibiotics if indi- cated by culture, and of course, avoidance of the allergen, if known. Psoriasis This affliction of the external ear has some similarities to seborrheic der- matitis but tends to be more localized and patchy. It is also thicker, with a superficial white "micaceous" scale.
Underneath, the skin is often deep red and tends to bleed if the scales are peeled off. Patients with psoriasis of the ears usually have the lesions elsewhere and have probably already been diagnosed. The other favorite body sites for the lesions are the extensor surfaces of the extremities. Warm water soaks, which soften the scales, are an easy remedy for accessible lesions, as well as the topical steroids or vitamin D ointment.
Dermatologists are more qualified to treat this and should be involved. Topical steroids are a mainstay of treatment in these scaly skin disorders. Dermatologists often advise the use of weak steroid preparations to avoid thinning or ulceration of the skin. A culture for both bacteria and fungus might grow out a pathogen, which may be treated. The primary practitioner can recognize and treat these dis- orders. ENT or dermatology referral can be made for persistent cases, especially if psoriasis is suspected.
Otitis Externa We will now discuss several forms of external otitis. At this point, it is important to introduce two key clinical concepts. The first is that with an acute earache the presence of tenderness helps to distinguish between otitis externa and otitis media. If you are called on the phone at an in- convenient time by a mother whose child is screaming with an earache, ask her to pull backward on the auricle or press on the tragus.
This will hurt if the problem is external, but will not if only the middle ear is in- fected. At least you can get a feel for the cause, and perhaps the treatment. This leads to the second point. The bacterial organisms causing Otitis ex- terna are usually Pseudomonas, Staphylococcus, Proteus, Enterobacter, or other Gram-negatives.
On the other hand, the bacterial offenders for acute otitis media are usually Pneumococcus, Haemophilus influenza, and Morax- ella catarrhalis, the ones that are often seen in acute sinusitis or other bacterial respiratory infections. This generalization is quite reliable and implies a different treatment for each entity. Acute Diffuse Otitis Externa This condition, a well-known painful infection of the canal, is otherwise known as swimmer's ear.
Water immersion is not always the cause, but the disease occurs most often in warm, humid conditions. Moisture in the ear, even from perspiration, plays a causative role. Local trauma to the canal is also a precipitating factor. Abrading a wet, macerated canal with a cotton swab to clean it or scratch an itch is often the initiating insult, implanting bacteria under the epithelium. The darkness of the canal, its warmth, high pH, and moisture all promote microbial growth. Pseudo- monas causes this acute infection almost exclusively, although staph and others may rarely be involved.
The bacteria go on to infiltrate, growing beneath the epithelium; then more itching ensues, progressing to sore- ness. Otitis Externa 39 In the full-blown florid stage, the patient presents with a swollen, drain- ing, tender canal. Touching the tragus or pulling the auricle backward elicits severe pain.
Swelling narrows the lumen of the canal, sometimes to a pinpoint. In addition, the infection may spread through the fissures in the anterior cartilage to the parotid gland and adjacent skin, causing parotid cellulitis and localized adenopathy. Treatment of this condition has traditionally centered on topical therapy with eardrops, namely, combinations of neomycin, polymyxin, and hy- drocortisone Cortisporin, or its generic substitute. In recent years, addi- tional tools have become available.
Often, the canal is so swollen shut that drops will not penetrate. The new Pope ear wicks are easily inserted with- out too much trouble and are then soaked with the topical preparation. They soften and expand when moistened and stay in place so that the med- ication can work "around the clock. Quinolone eardrop preparations containing Floxin or Cipro have now become available, although the traditional Cortisporin is still effective. In addition, the Pseudomonas-killing quinolones may be administered or- ally in severe cases if the patient is old enough.
Analgesics should not be forgotten— this infection, when severe, ranks with kidney stones and acute gout for pain intensity. The patient should keep the head elevated at home and expect two or three more days of hard times, even with good treat- ment. Anecdotally, I have seen a number of patients in the past with this dis- ease who had been treated for days with only oral amoxicillin or cepha- losporins. It should be emphasized that Pseudomonas is the vastly predo- minating pathogen and that it will not respond to these antibiotics. Acute Localized Otitis Externa This disorder, a different disease from the diffuse type, also presents with a very painful ear.
It is otherwise known as a furuncle of the canal. The in- fection is localized in an obstructed sebaceous gland or hair follicle out near the meatus. A tender red, raised pustule is readily seen occluding the meatus Fig. When bulging and soft, incision and drainage at the most fluctuant point with a 11 blade will benefit. Stuttgart: Thieme; Malignant Otitis Externa Malignant otitis externa is also known as necrotizing otitis externa or skull base osteomyelitis in its full-blown form. Obviously, the second name is the gentlest one, but the other two imply its ominous characteristics. This type of infection is typically seen in elderly diabetics or immunocompromised patients.
It can spread from the external canal to cause osteomyelitis in the temporal bone with potentially fatal complications. Characterisically, the patient presents with an external earache similar to other forms of ex- ternal otitis. However, examination of the ear shows something different. The canal may be swollen and tender, but a small area of red granulation tissue is seen posteroinferiorly in the canal at the junction of cartilage with bone, one-third inward.
This finding, plus the type of patient described, points to the diagnosis. When suspected, ENT consultation for aggressive treatment should en- sue. The organism is almost always Pseudomonas, but a culture should be done. Biopsy of the granulation can rule out neoplasm. Treatments include appropriate topical and systemic antibiotics and aggressive debridement. Conventional CT scans and bone scans can image the areas of involvement. Even with appropriate aggressive treatment, de- vastating bone infection and death can occur. Otitis Externa 41 Summary of Acute External Infections Acute diffuse otitis externa "swimmer's ear" is much more common than the localized furuncle, and should be recognized by its diffuse swelling and tenderness.
Some clinicians err in prescribing oral antibio- tics that will not work on Pseudomonas, the vastly predominating or- ganism. Topical antibiotic drops, with wick insertion if the canal is swollen shut, are the mainstay of treatment. Oral quinolones, if the pa- tient is old enough, may be used in severe cases.
A culture should be done if there is any doubt about what you are dealing with, and pain medication should not be forgotten. An obvious localized furuncle has staph as its cause. Treatment with topical drops and antistaphylo- coccal oral antibiotics is indicated. The primary practitioner can diagnose and treat these infections, even with the insertion of a wick if the canal is swollen.
However, granulation tissue in the canal of an elderly or diabetic patient portends malignant otitis externa and warrants early ENT consultation.
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Mycotic Otitis Externa This disorder is also known as fungal otitis externa or chronic diffuse otitis externa. It differs from the previously mentioned infections in that it is not quite so painful, but more indolent, yet persistent. The usual complaints are of blockage, thick drainage, dull pain, and itching.
These infections oc- cur more often than most clinicians expect, and they are often treated in- appropriately with antibiotic drops. The most notable finding on ear ex- amination is the presence of "matter"— thick moist debris— in the canal Fig. Other species of Aspergillus appear tan or yellow-orange and also locate themselves deeply.
Aspergillus is more apt to cause pain than itching. When the canal is cleared of the exudate, the un- derlying skin is red and raw. This organism is a mold that may be picked up from the environment, wherever molds may grow.
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Candida albicans and other Candida species are also frequent pathogens. Their exudates tend to be flocculent and white or creamy in appearance, and itching is a notable complaint, in addition to blockage. It is often seen in antibiotic-treated or immunocompromised including diabetic indivi- duals. Other fungi, such as actimomyces and phycomycetes, may also rarely occur. One diagnostic point— the fungi mentioned have a mild musty odor, or none at all, whereas Pseudomonas has a characteristic sweet, musty smell, and Staph, aureus and Proteus are downright putrid.
In any external infec- tion, a culture for both bacteria and fungi should be done if there is doubt about the organism. Sometimes bacteria and fungi coexist, especially Pseu- domonas with Aspergillus. Treatment of these fungal infections keys on complete removal, so that no spores are present for regrowth. If there is no perforation of the TM, gentle irrigation and suction may be the best way to clear the canal. Cau- tion: irrigating an infected ear is not usually recommended, but with fun- gal infections it has not caused problems in my experience, as long as the canal is suctioned dry.
The ear can then be insufflated with a large amount of nystatin Mycostatin powder, which comes in containers that facilitate this. Clotrimazole Lotrimin drops are another recommended therapy. Antibiotics or steroids do not help and may even promote growth, espe- cially with Candida. In fact, fungal otitis may be a complication of over- treatment with Cortisporin-type preparations.
Oral antifungals, such as fluconazole Diflucan can be considered in refractory cases. Other Chronic External Ear Disorders 43 Summary Mycotic otitis externa, synonymous with chronic diffuse otitis externa, is characterized by milder pain than the acute infections. Patients com- plain of chronic moisture, blockage, thick drainage, itching, and mild discomfort. A characteristic finding is the presence of thick matter in the canal, without severe swelling or tenderness.
Aspergillus and Can- dida are the usual culprits, but a culture for all organisms should be done if there is any doubt. Successful treatment hinges on complete removal of the debris, followed by the topicals mentioned in the text. The primary practitioner can make the diagnosis, but usually referral to ENT is needed for thorough cleansing. Even then, there is a tendency for recurrence and persistence, and repeat cleanings and topical applica- tions may be necessary. Oral systemic antifungals, such as Diflucan, might also be considered in refractory cases.
Other Chronic External Ear Disorders Some patients suffer from another disorder, chronic stenosing otitis ex- terna.
These individuals have repeated infections; sometimes cultures are positive for bacteria or fungi, and sometimes there is no identifiable patho- gen. The dermatoses may be involved. The external canal itches, drains re- peatedly, and becomes chronically swollen, with progressively severe nar- rowing of the lumen. Severe cases may eventually need surgery to widen the canal.
Canalplasty with skin grafting, or even limited mastoidectomy, can be performed to open the canal and regain the hearing. Other individuals have problems with ongoing or recurrent acute otitis externa without the complication of stenosis. These patients often create their own problems and should be cautioned regarding the cause and pre- vention of external otitis. Many individuals feel the need to dowse their ears daily with water in the shower, and then vigorously clean with appli- cators. The old adage about "nothing smaller in the ear than your elbow" is not bad advice.
whats in that cats ear Manual
Gentle removal of cosmetically visible cerumen in the mea- tus is all that should be done. Prophylaxis for external otitis in swimmers, however, is a valid consid- eration. The steroids are effective for itching, but may aggravate fungal infections. Cerumen Accumulations and Keratoses Cerumen exists for several reasons. It protects the skin of the EAC from water penetration; its low pH discourages microbial growth; and it traps foreign material, carrying it outward by migration.
In normal individuals, the skin of the entire canal migrates very slowly and steadily from the inside outward. Studies with ink dots have shown that epithelial migration actually starts near the center of the TM and pro- ceeds all the way out, at a rate of about 2 mm a month! In the outer third, cerumen migrates together with the epithelium and eventually sloughs, carrying foreign material with it. Appar- ently, migration of the skin and its sloughing pattern are abnormal— the epithelium and cerumen tend to roll up in a ball. This is readily appreciated when cleaning ears in the office— many times one will see desquamating segments of epithelium that still cling to the midcanal after most of the cerumen has been removed.
Irrigation, as described in Chapter 2, is the simplest way for most clin- icians to clean problem ears. Wax softeners may help the process. Patients with recurrent accumulations often ask what they can do to clean their own ears and avoid periodic office visits which may be needed as much as two or three times a year in some individuals. First, these pa- tients should be advised not to use cotton swabs in their ears, as they will often aggravate a buildup by blindly packing it in. Wax softeners like Deb- rox or Ceruminex are often helpful for the impaction-prone individual, to be used in each ear once or twice a week.
Self-irrigating kits are available at pharmacies as well. These aids may help some patients, but failure of re- moval or infection may be complications. A rarer buildup in the ear is keratosis obturans. This is a mass of squa- mous epithelium accumulating in large whorls that are difficult to remove. It can erode through the skin of the bony canal and then erode bone itself, causing pain and draining infections.
It is tenacious, and removal often re- quires the "headlight and two-hands" approach, using hooks, curettes, and alligator forceps. Thus, an ENT referral might be necessary. Trauma and Foreign Bodies 45 with this problem should be seen at frequent intervals, perhaps every six months, for cleaning. Chronic, untreated cases of this disorder may show up with huge excavations into the bone of the canal wall, usually inferiorly or posteriorly. A related entity is cholesteatoma of the external canal. This entity dif- fers in that the epithelial accumulation tends to be deeper, near the TM. It is seen more often in older individuals and is usually unilateral.
Discussing cerumen problems raises an important point. Occasionally a clinician will see a patient usually a child with a fever and an earache and will not be able to see the drum due to cerumen or other debris. If this cannot be removed at the time, it is reasonable to go ahead and treat em- pirically for an ear infection.
However, if the problem recurs, and the block- age cannot be removed, ENT referral is indicated. Trauma and Foreign Bodies Abrasions and Lacerations of the External Canal This type of trauma to the external canal is most often self-inflicted by an individual with a cotton applicator or a hairpin while attempting to remove wax. The patient may feel pain or notice blood welling up, and thus present to the office. The examiner sees an ear full of blood and the question arises, "Is there a perforation of the drum? In these cases, it is best to leave things alone and treat the patient for a week with antibiotic drops to pre- vent infection and loosen the blood.
Avoidance of water in the ear should be advised. A follow-up visit will then give more information. Most of the time, only an abrasion or laceration of the canal is present— these bleed very easily, but usually heal with no complications. It is important to see the patient in follow-up until things are completely healed, however. The cotton-tip swab may have abraded a small carcinoma of the canal to cause the bleeding!
If a perforation has occured, continued water avoidance and initial observation are indicated. Perforations are discussed more fully in Chapter 5. Incidentally, this raises the question of whether neomycin-polymyxin eardrops should be used if a tympanic perforation is present. Much has been said in recent years about their potential ototoxicity. Be advised that most otolaryngologists have been using these drops routinely for years, even in middle ear surgery. However, now that other nontoxic antipseudomonal drops such as Cipro and Floxin are available, these can be used to play it safe, keeping in mind the much greater cost.
A bloody traumatized canal can be initially evaluated and treated with antibiotic drops by the primary physician. ENT follow-up within a few days would be appropriate. Foreign Bodies Objects lodged in the canal occur most often in young children, mentally handicapped adults, or temporarily mentally handicapped adults. If the foreign bodies are soft, such as the end of a cotton swab or furniture stuffing, removal with alligator forceps is usually not difficult. More often, however, they are solid round or oval objects, such as beads. These are more difficult.
Do not attempt instrumental removal unless you feel you can "get around behind" the object to pull it out Figs. Many times, a well-meaning attempt with a suction tip or forceps will lodge the object deeper in, beyond the bony hump of the anterior canal wall. A general anesthetic may then be necessary for removal, especially with an unco- operative young child. With cooperative patients, the best instrument for removal of solid objects, is the Day hook, a straight, thin, metal probe with a right-angle turn of about 2 mm on the end.
Also, irrigation, as with ceru- men impactions, may be successful in some cases. Special mention must be made of insects. Live ones in the ear can be terrifying to the patient because the fluttering and crawling is relatively loud, and skin of the bony canal is very sensitive to light touch. Mineral oil, wax softener, or dish detergent, all being mild and viscous, can be in- Figs. An attempt to remove a foreign body with simple forceps a usually displaces the object deeper and may cause middle ear damage. Using a hook b is the effective way. Trauma and Foreign Bodies Ail stilled in the canal to kill the insect quickly.
Then, removal can be done with alligator forceps or possibly irrigation. A few days of antibiotic drops are then a good idea.
Primary and emergency physicians should exercise great discretion when removing foreign bodies. If there is any doubt about one's ability to extract a foreign body, an ENT specialist should be consulted. The inert ones may wait a day or two. Live insects should be killed immediately, as described above.
Auricular Trauma Sharp and blunt trauma to the external ear might result in contusions, hematomas, lacerations, or even disruption of the cartilaginous frame- work. Appropriate surgical intervention is certainly indicated, and anti- biotic coverage for Pseudomonas and staph is recommended to prevent perichondritis.
Hematoma and perichondritis have been discussed earlier in this chapter. Temporal Bone Fracture Also termed basal skull fracture, this injury occurs with severe head trau- ma and characteristically presents with blood oozing from the external meatus. Hearing loss, vertigo, and facial paralysis may be present. Patients with this type of trauma are usually severely injured in other ways as well, and are hospitalized by the neurosurgeon after presenting to the emer- gency room.
Occasionally however, a stoic individual will not seek acute care. Sometimes, a cerebrospinal fluid CSF leak is present, with steady dripping of clear fluid from the ear. Initial treatment is bed rest, with the head elevated, and observation. Prophylactic antibiotics should be given, even if there is no apparent CSF leak. CT imaging will identify the fracture. Two types— longitudinal and transverse fractures— may occur, each with a different pattern of da- mage. A more detailed discussion can be found elsewhere.
Permanent hearing and vestibular damage can result. Frostbite of the Auricle This type of damage from prolonged exposure to cold is likely to affect the ear first. The auricle is quite vulnerable due to its exposed location, super- ficial blood supply near the skin's surface, and lack of sensitivity. At first, the involved skin is pale and numb. As warming occurs, the affected areas become hyperemic and painful and may even blister. Direct heat, massage, or snow application is not recommended, as it will simply aggra- vate tissue trauma.
Even- tual necrosis and loss of tissue may occur, but even then, delineation by sloughing gives a better result than premature surgery, unless gross in- fection is present. Regarding the last three categories of trauma, the physician involved de- pends on the severity of the injury. Obviously, temporal bone fractures and severe frostbite require ENT consultation in a timely fashion, whereas min- or auricular trauma can be repaired by the capable family or ER physician, taking care to prescribe antibiotics to prevent perichondritis.
Tumors of the External Ear Bony Tumors The most frequently seen tumors of the EAC, at least in northern climates, are the bony ones— exostoses and osteomas. Exostoses are sessile rounded bony projections in the inner two-thirds, often seen on the floor of the canal anteriorly and posteriorly, although they may be based superiorly as well. The inferior ones tend to be more external, flatter, and broader, whereas the superior ones are often deeper, smaller, and more rounded Fig. Their epithelial covering is normally smooth and unremarkable in appearance.
The cause is usually cold-water swimming over several years. Tumors of the External Ear 49 Many individuals are not aware of their exostoses, and one can impress these patients by taking a look in their ears and discussing their swimming history. Very gentle palpation with an instrument will confirm that these projections are in fact bony and not soft-tissue lesions.
Often they present no problem, but larger ones may trap cerumen or debris and cause chronic infection or hearing loss. Osteomas are histologically different from exostoses and appear more completely rounded— almost pedunculated. Either entity can be surgically removed if there are problems with obstruction, but the surgery itself can lead to complications.
Facial nerve injury has resulted in seemingly simple cases. Squamous Papillomas These lesions are not extremely rare. Usually occurring in ears with recur- rent external otitis, they are often located at or near the meatus and re- semble warts seen elsewhere. They are associated with human papilloma- virus HPV and tend to recur when excised. Cauterization of the base, after excision, may improve the chance for success. Other Neoplasms Numerous other tumors can arise on the auricle or in the canal and they are mentioned only briefly.
The point to make is that any questionable lesion deserves a biopsy. A benign-appearing granulation in the canal may actu- ally be a squamous cell carcinoma. The auricle, with its sun-exposed sur- face, can be the site of basal cell carcinomas, squamous cell carcinomas, and malignant melanomas.
These malignant epidermal tumors, along with adenoid cystic carcinoma and rhabdomyosarcomas, can occur inside the canal, although much less frequently than on the auricle. Angiomas, ceruminomas, adenomas, nevi, and myxomas are rare tumors of the exter- nal ear. The temporal bone may be the site of fibrous dysplasia or eosino- philic granuloma histiocytosis X. Congenital malformations of the ear. Austin DF. Diseases of the external ear. Ballenger JJ. Headache and neuralgia of the face. The Practitioner's Illustrated Dermatology.