External Ear Disease

3.1 Inflammatory Disorders of the Auricle

• Cellulitis of auricle: regional neck nodes may be inflamed; usually gram +ve cocci (not Pseudomonas)

• Allergic dermatitis: no history of trauma, peau d’orange/shiny appearances may occur; c/o itching; sensitization may occur with repeated exposure

• Auricular erysipelas: superficial cellulitis caused by group A Streptococcus; often preceded by trauma; may lead to systemic toxicity, contagious

• Infectious (peri)chondritis (Fig. 3.1): Pseudomonas, Staphylococcus aureus, and Streptococcus; aggressive Rx required; clinically sparing of lobule

• Relapsing polychondritis: recurring inflammation of cartilage throughout body (e.g., nose, larynx); autoimmune response to type II collagen; 85 to 90% of these patients get auricular cartilage involvement; recurrent episodes may cause “cauliflower” ear; systemic corticosteroids for acute episodes

• Eczema, psoriasis

3.2 Inflammatory Disorders of the External Auditory Meatus

• Furuncle: small abscess in a hair follicle; if ready to rupture, gently open with tip of sterile needle

• Acute otitis externa:

Pseudomonas infection most common; also S. aureus, Candida, Aspergillus

Risk factors: prolonged water exposure, repeated trauma (e.g., cotton buds), eczema/psoriasis, middle ear discharge

Painful (especially on tragal movement): narcotic painkillers may be required

Rx: aural toilet, Pope wick and antibiotic/steroid drops, water exclusion

May spread to cause facial cellulitis, requiring systemic antibiotics

Otomycosis: fungal infection often follows prolonged treatment with topical antibiotics

• Malignant (necrotizing) otitis externa:

Otitis externa becoming an invasive infection, leading to osteomyelitis (tympanic plate to skull base)

Pseudomonas aeruginosa usual infecting organism

Diabetic patients and immunocompromised most affected, often elderly

Unresolving infection with deep otalgia and granulations noted at cartilage/bone junction of external ear canal—here the clefts of Santorini provide the pathway for the spread of infection

Cranial nerve (CN) palsies (7–12) and death (intracranial infection) can occur in severe cases

Rx: rigorous diabetic control, long-term intravenous (IV) antibiotic, topical ciprofloxacin drops; possible role for hyperbaric oxygen

• Chronic otitis externa: chronic itching with skin often shiny, scaling and devoid of wax; cultures can be non-specific or misleading; treat secondary infection and use topical steroids

• Post-inflammatory stenosis of EAM (external auditory meatus) subepithelial fibrosis with progressive narrowing of EAM; early management includes local steroids; once scar is mature, consider tissue excision and split-thickness grafting but risk of recurrence

3.3 Inflammatory Disorders of the Tympanic Membrane

• Myringitis bullosa hemorrhagica:

Painful infection of tympanic membrane (TM), uncertain causative organism

Mostly in autumn, benign and self-limiting

Blisters of varying size on TM/EAM—filled with serous/hemorrhagic fluid

Analgesia (± antibiotic/steroid drops)

• Granular myringitis:

Separate or confluent granulations on surface of TM

Topical drops and superficial curettage

Some progress to inflammatory obliteration of deep EAM

3.4 Non-inflammatory Lesions of the External Ear

Chondrodermatitis nodularis chronica helicis (Winkler nodule)

• Benign, usually on rim of helix/antihelix

• Red, raised, and tender nodule with central depression/crater

• Tenderness affects sleeping position

• Full-thickness excision; topical steroids may help while waiting for surgery

3.4.1 Other Pinna Lesions

• Gouty tophi: yellow/pink nodules on helix; control of gout required

• Keratoacanthoma: benign tumour of hair follicles most common anterior to tragus; rapidly growing and painless—biopsy to distinguish from neoplastic lesions

• Hypertrophic scars remain confined to site of injury

• Keloid scars invade adjacent normal tissue, commonly lobule from earrings; topical injection of steroids (± excision)