Congenital Anomalies Otorrhea

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Congenital Anomalies Otorrhea Powered By Docstoc
					‫ا د هسعد السيسي‬
                      Congenital
Atresia
Etiology : failure of canalization of the
    external auditiry canal
It may be associated with anomalies of the
    auricle, middle ear or rarely inner ear
CP :
Unilateral or bilateral
The external canal is absent or
appears as a blind pit
Investigations
Radiological evaluation:
To assess the middle and inner ear
Audiological evaluation:
 Conductive deafness
                 Treatment

• Unilateral : postpone after puberty
• Bilateral : HA fitting at 1 year
• operation at one side (at 2-5 years) , the other
  after puberty
 Traumatic: Laceration

Self inflicted : by ear bud hair
    grip
Iatrogenic: ear wash or
    instrumentation
Clinically:
Earache, mild bloody otorrhea
Treatment:
Antibiotics
Avoid entry of water in the ear
    canal
 Traumatic: FB                    ‫جسن غريب في االذى‬

Type of patient:
Commonly children
Mentally retaded adult
Type of FB:
Animate FB:
Flies, larvae, fleas mosquito,,
Inanimate FB:
Non vegitable: bead, button,
    disc battery
Vegetable: bean and pea
FB




Symptoms
- History
- Hearing loss if the FB obstructs
   the canal
- Severe irritation and noise in
   the ear with animate FB
Signs:
The FB can be seen by otoscopy
FB


     Treatment:
     Animate FB:
     Kill by alcohol or oil  remove by ear wash or
          instruments
     Inanimate FB:
     - Non vegetable: remove by ear wash or                 So donn’t wash if:
          instruments BUT PLEASE DO NOT WASH
          IF THE FB IS DISC BATTERY                       -The FB is vegetable
                                                         -The FB is disc battery
     - Vegetable: Remove by instruments and
         avoid ear wash
     because it may swell by water and become
         more impacted

     General anesthesia may be needed in impacted
     FB and uncooperative children

     Complications:
     Injury of the external canal or drum by the FB or
          during removal
  Inflammatory conditions of
  the external auditory canal
• Bacterial:
 1- Diffuse OE
  2- Localised OE: frunculosis ‫دهل‬
  3- Malignant OE ( Necrotizing OE)
• Viral ( bullous- Herpes)
• Fungal: (Otomycosis)
• Non infective
   ( allergic OE, Seborrhoic OE)
 Inflammatory: Bacterial
 Diffuse otitis externa
Definition:
Diffuse inflammation of the skin
   lining of the extenal auditory
   canal

Pridisposing factors:
- Skin laceration:
  Self inflicted
  Iatrogenic:- Ear wash or instruments

- Skin maceration:
   Hot humid atmosphere
   Swimmer ear
   Discharge of chronic
   suppurative Otitis media
Symptoms:
 Earache:                         Because the skin is tightly
- Severe Why?                    adherent to the underlying
- Increase on moving the jaw Why?perichondrium & periostium
 Deafness when edema is severe  Because the external canal
   obstruct the canal
                                        Lies immediately behind
Signs                                  Temporomandibular joint
External exam:
Tenderness on moving the auricle or
   pressure on the tragus
Tender pre and postauricular LN
Otoscopic exam :
Redness, edema, tenderness of the
   skin of the external canal
Scanty discharge, serous or purulent

TREATMENT
•   METICULOUS CLEANING
•   PACK WITH ANTIBIOTIC
•   CULTURE
Inflammatory: Bacterial
Frunculosis

Definition
 Localized suppurative
inflammation of a hair follicle in
the skin of the external auditory
canal

Organism Staph aureus

PP factors:
- scratching of ear canal
- DM
Symptoms:
Earache:
- Severe Why?
- Increase on moving the jaw Why?
 Deafness when edema is severe 
    obstruct the canal
Signs:
 External:
Tenderness on moving the auricle or
pressure on the tragus
Tender pre and postauricular LN
 Otoscopic:
It is difficult to examine the external canal
By Otoscope because there is localised
area of tenderness in the skin of the outer
Part of the external canal
No or scanty purulent otorrhea ( never
      mucoid as there is no mucous glands )
Investigations:
Blood glucose level especially in:
- Recurrent cases
- Bilateral cases
DD acute mastoiditis
Treatment
Antibiotics
Analgesic
Aural toilet: removal of ear discharge
Aural pack: by gauze strip soaked in
   glycrine icthyol:
Inflammatory: Bacterial
Malignant otitis externa
(Necrotizing otitis externa)
Def:                                                      Necrotizing external otitis
invasive potentially fatal of the external canal which extends
    to the base of the skull                              should be suspected when
Incidence: elderly uncontrolled diabetic patient          patients with diabetes
Organism: pseudomonas aeuruginosa
Symptoms:
                                                          mellitus (or another
Ear discharge and severe earache which does not respond   condition that compromises
    to analgesics                                         the immune system)
Signs
External examination:
                                                          complain of persistent
Tenderness on pulling the URICLE OR PRESSURE              external otitis that causes
ON THE TRAGUS                                             severe pain, especially at
TENDER PRE AND PSTAURICULAR ln                            night
Otoscopic examination:
Granulations at the floor of the external canal at the
attachment of bony and cartilagenous part
‫ًىره عالهت ىاهت جدا ليرا الوسض‬
Scanty, sanginous and purulent otorrhea
•   Investigations:
-   Blood glucose level
-   CT scan of the temporal
    bone& skull base
-   Radio-isotop scan ( Gallium
    &Tecnetium) to assess
    severity & prognosis
-   Biopsy
-   Culture &sensitivity
                                  •    Axial computed tomographic (CT) scan in a 65-year-old
                                      . Gallium citrate diabetes mellitus who had severe
                                        male patient with Ga 67 scintigraphy in a 74-
                                      year-old male patient with diabetes mellitus
                                       nocturnal otalgia for two months. This patient was
                                      and left-sided temporal bone osteitis. This
                                       referred because of facial nerve paralysis that
                                      patient was referred because of persistent (Floxin).
                                       developed despite oral treatment with ofloxacin
                                      otalgia and otorrhea after a prolonged right
                                       The CT scan shows bony destruction of the
                                       temporal bone. Note the antibiotics. As a result
                                      course of systemic oral missing posterior wall of the
                                       external auditory canal (short arrow). Mastoid air
                                      of ongoing infection, the left temporal bonecells
                                       are secondarily involved and are opacified (long arrow)
                                      shows enhanced uptake of 67Ga (arrow).
                                       compared with the well-aerated left side.
•   Complications:
•   Osteomyelitis of the temporal bone
    &skull base
-   Facial nerve paralysis at the
    stylomastoid foramen
-   Last 4 cranial nerves paralysis at
    the jagular foramen

- Treatment:
- Medical:
- Control of diabetes
- Antibiotics;
- Gentamycin (be aware of possibility
   of ototoxicity)
- Quinolones
- 3rd generation cephalosporins
- Local antibiotic ear drops
- Analgesics
- Aural toilet
- Surgical:
- Removal of granulations and
   debridement of necrotic tissue up
   to mastoidectomy
  Inflammatory:Viral:
  Herpes Zoster Oticus

Etiology: Herpes zoster virus
Clinically:
- Pain in and around the ear
- Vesicles on the auricle and
  external canal
- Ramsay-Hunt syndrome:
Vesicles+ facial nerve palsy+SNHL& Vertigo
TTT:
- Antiviral
- Corticosteroid if there is affection of
   VII nerve f VIII nerve
Fungal:Otomycosis
 Fungal infection of the skin of the
   exernal canal
 Etiology:
- organism:
- Aspirigillus Niger
- Candida albicans
Symptoms:
• Itching is usually the only symptom
• Pain if there is secondary infection
• Deafness if the external canal is
   obstructed
Signs:
- The external canal contains whitish
   mass withblack spotslike wet
   newspaper ‫هثل قطعت صغيسة هبللت هن ًزق جسائد‬

TTT:
- Aural toilet: removal of the fungal mass
  by suction or ear wash
- Antifungal: nystatin, or or salicylic acid
  (2%) as a keratolytic in alcohol as
  fungicidal
Neoplasm: Benign
Exostosis
Incidence
The commonest tumor of the external
    canal
More common in swimmers

Symptoms:
Usually asymptomatic
Hearing loss if the external canal is
obstructed by large exostosis or
wax
Signs:
Bilateral smooth bony swelling
TTT:
- If obstructing the canal excision
 Neoplasm: Malignant
 Squamous cell carcinoma
• Incidence
- Rare
- More common in elderly males
• CP:
Otological:
- Deep seated earache
- Bloody stained otorrhea
- Fleshy friable mass in the external canal
- Progressive hearing loss, initially CD then
   SNHL
Neurological:
paralysis of VII& last 4 cranial nerves
Cervical:
- Enlarged preauricular, postauricular and
   upper deep cervical LN
Investigations:
- CT scan and MRI to assess
  tumor extension and lymph
  nodes involvement
- Biopsy
- Metastatic work up
Treatment:
Surgical resection of the temporal
   bone +
postoperative radiotherapy +
   Radical neck dissection
 prosthesis ‫انظس الشسيحت القادهت لتسي‬
    ‫نوٌذج لوسيط تن اجساء ىره الجساحت لو‬




       Chest X ray       Abdominal        Bone scan CT scan
                         ultrasound                 Of brain
• From;
  http://www.caritas.ab.ca/ther_new/respcare/hbo/case
  5.html

• This 68 year old man was diagnosed with
  squamous cell carcinoma of the left external
  auditory miatus. The temporal bone resection
  resulted in loss of the left ear. Following the
  resection, the patient was treated with therapeutic
  radiation


• Craniofacial oseointegrated implants were used to
  retain an auricular prosthesis


• A close-up view of the auricular prosthesis
  retained on the craniofacial osseointegrated
  implants.
              WAX Accumulation

Def:
Abnormal accumulation of wax
in the external auditory canal
 Etiology:
• Failure of the natural cleaning as a
    result of :
- Narrow external canal
- Attempts of the patient to clean
    his ear push the wax medially
- TMJ dysfunction
               What is WAX?
                ‫هبهى الصوالخ؟‬
• Wax is a mixture of secretions of ceruminous and
  sebaceous glands with desquamated skin cells

• It is expelled outside the canal in the form of flakes
  BY movement of the TMJ during talking and eating
Function
• Protects the skin by :
- Acidic reaction
- Lyzozyme activity
Symptoms:
Hearing loss and tinnitus when the
    wax obstructs the canal
‫تحدث كثيسا بعد االستحوام أً نزًل البحس حيج ينتفد‬
    ‫الصوالخ بالواء‬

Signs:
brownish mass in the exernal canal
Treatment:
Remval by:
- Ear wash: if the wax is hard it
  should be softened by glycrine
  bicarbonate before ear wash
- Instruments
                   Rupture of the
                 Tympanic membrane
Incidence : uncommon why?
The drum is protected by the tortuous
   course of the external canal
Etiology :
Indirect Trauma:
- Hand slap (the commonest)
- Explosion
- Otitic barotrauma

Direct Trauma:
 -FB
 -Self inflicted
- Iatrogenic ( ear wash or instruments)
- Longitudinal temporal bone fracture
Symptoms:
- History of trauma
- Earache at the time of
   rupture
- No or mild bloody otorrhea
- Air comes from the ear on
   nose blowing
- Hearing loss
Signs:
- Central perforation( in the
   pars tensa)
- Any size
- Any shape
- Ragged edges
- Surrounded by blood clots
Treatment
Conservative:
Antibiotic
Avoid :
- Nose blowing
- Ear wash
- Entry of water into the ear
  ‫بىضع قطعة شبش عليهب فبزليي في‬
  ‫األذى عند غسل الرأس أو االستحوبم‬
- Ear drops
Surgical:
- Myringoplasty ‫لى لن يحدث‬
  ‫التئبم بعد ثالثة اشهر‬
- Elderly diabetic patient presents with persistent otitis externa
inspite of proper treatment  suspect Malignant Otitis Externa
(Necrotizing OE)
- It is normal to have some wax in the middle ear
- Wax causes deafness when it obstructs the external canal
- You should check for blood sugar in:
- Recurrent or bilateral frunculosis
- In eldrly patient with persistent otitis externa

				
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