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Ear ache & Ear discharge

Dr T Balasubramanian

Anatomy

External ear

Middle ear

Internal ear

External ear

Pinna

External auditory canal

Lateral surface of ear drum

PINNA - ANATOMY

PINNA INNERVATION

Pinna Innervation

External auditory canal

Outer 1/3 cartilagenous

Inner 2/3 bony

About an inch long

Postero-superior wall 25 mm

Antero-inferior wall 31 mm

External canal - Innervation

Innervation of middle ear

Sensory supply to middle ear is via glossopharyngeal component of tympanic plexus

Jacobson's branch of glossopharyngeal nerve is the precise supply

Medial portion of ear drum is supplied via chorda tymopani

Inner ear innervation

Inner ear is supplied by vestibulocochlear nerve

This nerve doesnt have pain fibers, significant pathologies of inner ear can develop without painful symptoms

Vestibulocochlear nerves are sensitive to stretch. In Meniere's disease considerable enlargment of membranous labyrinth can cause stretching of these nerves leading on to a sense of fullness in the ear

Otalgia

Is defined as pain localised to the ear

It can either be primary / referred

Primary otalgia is caused by pathology localized to the ear

Referred otalgia is caused by disorders not related to the ear but to its nerve supply

Primary otalgia

External ear causes

Middle ear causes

Inner ear causes

External ear causes of otalgia

Also known as otitis externa

This is a very painful condition

Patient usually lose sleep

Tragal sign positive

Otitis externa classification

Acute diffuse otitis externa (commonly bacterial)

Acute localised otitis externa (Furuncle)

Chronic otitis externa

Eczematous otitis externa

Fungal otitis externa

Malignant otitis externa

Otitis externa Predisposing factors

Absence of cerumen

Removal of cerumen by ear buds

Frequent exposure to water

Anti infective role of cerumen

Protects external canal skin from moisture

It has antibacterial properties

Lowers the pH of external canal making the environment difficult for pathogens to colonize

Role of water in otitis externa

Macrerates skin lining of external canal

Increases the pH of external canal making the environment favorable for bacterial colonization

Furuncle

Tragal sign positive

Affects cartilagenous portion of external canal because of hair follicles

Staph aureus is the common infecting organism

Acute diffuse otitis externa

Also known as swimmer's ear

Skin of external canal is involved in a diffuse manner

Water exposure is the common cause

External canal is itchy

External canal diameter is reduced due to oedema

Conductive deafness (rare)

Chronic otitis externa

Unrelenting pruritus

Mild pain

External canal skin appears dry

Fungal infections commonly cause this problem

Dermatological condition like eczema

Managment

Treatment of infection

Removal of epithelial debris

IG paint dipped wick to reduce oedema

Anti-inflammatory drugs

Otomycosis

Malignant otitis externa

Misnormer

Common in elderly diabetics

Pseudomonas is the causative organism

External canal granulation

Facial paralysis

Erosion of temporal bone

Nocturnal otalgia

Malignant otitis externa (contd)

History of trivial trauma (ear bud use) +

Granulation begins at the bony cartilagenous junction

Discharge from external canal scanty

No fever / constitutional symptoms

Malignant otitis externa (Images)

Bullous myringitis

Also known as bullous otitis externa

Acute infection of ear drum and external auditory canal

There is intra epithelial fluid collection

Bullae may be present over the lateral surface of ear drum

Bullae may also be present in the external auditory canal

Otalgia with serous / bloody ear discharge common

Management of Bullous myringitis

Decompression of bullae if otalgia is intense

Topical / oral antibiotics

Steroids

Analgesics

Middle ear causes of otalgia

Acute otitis media (AOM)

Eustachean tube dysfunction

Otitis barotrauma

AOM

Ear drum could be seen bulging

Accumulation of fluid in the middle ear cavity

Preceded by URI

Common in children

Pain subsides when drum perforates

Ramsay Hunt Syndrome

Herpes zoster oticus

Otalgia +

Facial palsy (LMN)

Rash over ipsilateral pinna / external canal

Otalgia is due to irritation of 7th nerve due to Herpes virus infection

Ramsay Hunt syndrome (Contd)

Relapsing polychondritis

Involves cartilage of pinna and external auditory canal

Intense otalgia is seen

End stage is fibrosis

Sparing of lobule differentiates it from cellulitis

Neoplasms

Primary neoplasms of pinna / external canal

Neoplasms involving skull base

Malignancy involving ceruminous glands

Miscellaneous causes

Trauma

Hematoma

Seroma

Frost bite

Burns / Thermal injuries

Referred otalgia

TM joint disorders

Eagle syndrome

Gerd

Neuralgias

Neoplasms of oropharynx/oral cavity

Cervical arthritis

Ear discharge

Wax (Normal)

Pus

Mucous

Blood

CSF

Saliva

Purulent discharge

Acute suppurative otitis media

Chronic suppurative otitis media

Rupturing furuncle of external auditory canal

Sinister ear discharge

Scanty

Purulent

Discharge associated with excessive otalgia

Discharge associated with giddiness

Discharge associated with head ache

Discharge associated with tinnitus

Otoscopy

Complications of discharging ear

Deafness

Extracranial Intra temporal complication

Extra cranial complication

Intra cranial complication

Facial nerve paralysis

Lateral sinus thrombosis

Thank you

Management

Aural toilet

Culture

Topical antibiotics CSOM

Systemic antibiotics ASOM / AOM

Resistant cases / unsafe - surgery

Autor: drtbalugeetha 18.04.12