Trauma
Lacerations: simple with or without involved cartilage; stellate from blunt trauma; partial or total avulsion
Treatment: Deep cleaning, debridement, surgical repair; may require stage or flap reconstruction; dressing, systemic antibiotics. Consider bolster to prevent hematoma.
Complications: Perichondritis, cartilage necrosis.
Hematoma—typically occur from blunt trauma
Treatment: incision and drainage with through-and-through sutures and bolster dressing
– Systemic antibiotics (consider fluoroquinolones)
Complications: fibrosis, cauliflower/wrestlers ear, perichondritis
Frostbite—exposure to subfreezing temperature and wind leading to disruption of endothelial layer with extravasation of erythrocytes, platelet aggregation, and sludging
Symptoms: pain, burning, discoloration; reduced pliability; loss of sensation.
Treatment: slow warming; antibiotics; anticoagulants; debridement of necrotic tissue after demarcation. No pressure or pressure dressing to the ear.
Bites—lobe of ear is most common site
Treatment: meticulous cleaning; systemic antibiotics; surgical repair and/or debridement
– Human bites have greater propensity for infection.
Keloids and hypertrophic scars—increased rates in African American and Histpanic population (up to 30%)
Treatment: steroid injection, surgical excision, pressure dressing, rarely radiation therapy
Carcinoma of the external ear
6% of skin cancers involve the ear
Lymphatic drainage—anterior auricular nodes: lateral pinna and anterior canal wall; postauricular nodes: superior and upper posterior pinna, posterior canal wall; superficial and deep cervical nodes: lobule and floor of external ear canal
Metastasis assocaited with depth of invasion
Staging:
Skin and pinna
– TX—Primary tumor cannot be assessed.
– T0—No evidence of primary tumor.
– Tis—Carcinoma in situ.
– T1—Tumor 2 cm or less.
– T2—Tumor larger than 2 cm but smaller than 5 cm.
– T3—Tumor larger than 5 cm.
– T4—Tumor invades deep extradermal structures (bone, muscle, cartilage).
University of Pittsburgh staging system for SCC involving the temporal bone
– T1—Tumor limited to external auditory canal without bone or soft tissue extension
– T2—Tumor with limited external auditory canal bony erosion or less than 0.5 cm soft tissue involvement
– T3—Tumor eroding full thickness bony external auditory canal with less than 0.5 cm soft tissue involvement, or tumor invovling the middle ear and/or mastoid
– T4—Tumor eroding the medial wall of middle ear or beyond, or less than 0.5 cm soft tissue involvement, or patient with facial nerve paresis or paralysis
Regional lymph nodes:
– NX—Regional lymph nodes cannot be assessed.
– N0—No regional lymph node metastasis.
– N1—Regional lymph node metastasis.
Basal cell carcinoma—most common malignancy of the ear (45%)
Symptoms: erythematous lesion with raised margins; silvery scales common, occurs on the pinna and in the external canal
Treatment: biopsy, topical agents, wide local excision; may require cartilage excision, skin graft, or local flaps
Squamous cell carcinoma
Symptoms: pain, bloody discharge, polyp with granular appearance, facial nerve paralysis, hearing loss
Treatment: biopsy, wide surgical excision, may require parotidectomy, sleeve resection of ear canal or temporal bone resection; postoperative radiation for advanced cases
Malignant melanoma—7% of head and neck sites involve the ear
Other tumors of the ear: adenoid cystic carcinoma, adenocarcinoma, adenoma, pleomorphic adenoma
Seborrheic dermatitis, psoriasis
Psoriasis affects 2% to 5% of the population. In 18% with systemic psoriasis, ear is affected. Scalp and postauricular sulcus affected often.
Eczema—external otitis, the most common dermatologic condition of the external canal, may be associated with dandruff.
Symptoms: itching; weeping; dry, scaly, fissured skin; crusting and flaking; recurrent external otitis; canal stenosis
Treatment: frequent cleaning to prevent accumulation, 1% hydrocortisone solution or lotion, betamethasone for acute treatment
Keratosis obturans
Rapid accumulation of keratin debris; wax casts; plugged external auditory canal; painless erosion and expansion of external canal; may be associated with drainage, foul odor, and secondary external otitis
Pathology: chronic inflammation and poor epithelial migration
Treatment: frequent cleaning; topical 1% hydrocortisone; betamethasone for acute treatment
Cholesteatoma of the ear canal
Keratin accumulation in the external canal associated with osteitis and bone necrosis; usually occurs on the floor of the external canal; commonly associated with pain and keratin invasion of bone
Treatment: frequent cleaning of the external auditory canal; topical steroids; may require surgical debridement of osteitic bone. May require canal wall down mastoidectomy if extensive bone erosion.
Osteoma
Pedunculated bone mass developing along tympanosquamous and tympanomastoid suture lines; occluding osteoma may require surgical removal.
Exostoses
Lamellar thickening of bone of external ear canal associated with cold air/water exposure, commonly involving the anterior and posterior canal wall. Exostoses may cause canal stenosis, cerumen impaction, retention of moisture and skin, and rarely hearing loss.
Treatment: canaloplasty and possible skin graft.
Foreign bodies
Insects, nuts, beans, gum, putty, beads, toys, etc. Avoid irrigation—vegetable matter will expand; blind instrumentation may cause bleeding or swelling of the ear canal and may impale the foreign material through the eardrum.
Treatment: local anesthetic block, microscopic examination, and instrumentation for removal of foreign body; mineral oil or antibiotic solution may facilitate removal. Depending on status of canal after removal, topical antibiotic may be required.
Trauma
Temporal bone fractures, basilar skull fractures
Epidemiology: Most common cause is motor vehicle accidents followed by assault.
– 70% occur in second to fourth decades of life with a male/female ratio of 3:1.
Classification: Traditionally classified as transverse, longitudinal, and mixed based on orientation of fracture line to the petrous ridge axis.
– Modern classification is based on whether the fracture involves or spares the otic capsule.
Created due to poor correlation between temporal bone sequelae and traditional fracture classification. For example, transverse fractures originally thought to be associated with sensorineural hearing loss (SNHL) but modern data show longitudinal fractures are three times more likely to have associated SNHL.
Only 5.8% of temporal bone fractures involve the otic capsule.
Diagnosis:
– Otoscopic evaluation often reveals hemotympanum, which is the most common cause of initial conductive hearing loss.
If present, audiometric evaluation should be repeated in 6 to 8 weeks to allow resolution.
– Ability to perform bedside tuning fork examination is dependent on the level of patient consciousness.
– CT temporal bone to evaluate fracture location, ossicular integrity, and otic capsule involvement.
– Ultimately audiometry is required for diagnosis.
Conductive hearing loss can occur from hemotympanum, tympanic membrane (TM) perforation, and ossicular discontinuity. Incudostapedial joint subluxation followed by incus dislocation and stapes crura fracture are most common ossicular disruptions.
SNHL is most severe with otic capsule involvement. Non-otic capsule fractures involving SNHL have been suggested to occur from intralabyrinthine hemorrhage and membranous labyrinth injury.
Hearing loss pattern is often mixed.
Middle ear trauma
Foreign body can puncture TM resulting in a wide variety of injuries.
– Simple TM perforation without ossicular injury leads to temporary CHL; these typically heal without surgical intervention.
– Ossicular injury can occur from incudostapedial joint subluxation, incus dislocation, and stapes subluxation.
Middle ear exploration is warranted after recovery from any vestibular insults (see later).
On pneumatic otoscopy TM may be hypermobile.
– Penetrating trauma can also enter the vestibule through the oval window.
When acute vestibular complaints occur with hearing loss, should be considered. This can also occur with stapes subluxation.
Treated with bedrest, minimization of straining (stool softeners), and anti-vertiginous agents. Surgery is avoided if possible during the healing phase.
Audiometric evaluation is required to determine type and severity of hearing loss.
CT is often imaging modality of choice to determine the integrity of the ossicles and labyrinth.
Congenital cholesteatoma—develops from rests of embryonic epithelial cells in middle ear
Occur in anterosuperior quadrant of mesotympanum and TM or adjacent to malleus and posterior mesotympanum
Presentation: 2 to 6 years of age—white mass beneath drum, usually adjacent to malleus
Imaging: CT to evaluate extent of disease
Treatment: surgical removal
Otosclerosis
Epidemiology: Caucasians 8% to 12%, clinical disease 0.5% to 2%; African American population 1%, clinical disease 0.1%.
Female:male ratio 2:1.
Genetics: approximately 50% have positive family history; 70% autosomal dominant with 25% to 40% penetrance
Pathology:
Early phase—vascular, spongy bone progressing to fibrosis
Late phase—new bone replaced with sclerotic bone
Anterior oval window (fissulae ante fenestrum): most common location, 70% to 90%. Round window: 30% to 70%; cochlear: 14%; extensive involvement: 10% to 12%
Measles virus associated with otosclerotic foci
Symptoms: progressive conductive or mixed hearing loss; typical presentation age of 30 to 50; associated with pregnancy in 30% to 63%; paracusis of willis (hearing better in noise), 36% to 85%; tinnitus, 75% to 100%; imbalance, 22%; vertigo, 26%; Schwartze sign (promontory hyperemia), 10%
Audiometry: Progressive, low frequency, conductive or mixed hearing loss; maximum conductive component, 60 dB; Carhart notch is depressed bone threshold at 2000 Hz; word discrimination often 70% or better.
Acoustic reflex: No reflex suggests fixed stapes.
Biphasic reflex (on–off): Occurs in 94% with symptoms of less than 5 years and in 9% greater than 10 years. (40% of normals have biphasic acoustic reflexes.)
If normal reflex consider other possible etiologies (superior semicircular canal dehiscence syndrome)
Tuning forks: Weber lateralizes to affected ear; Rinne is negative—bone greater than air, masking the opposite ear with unilateral hearing loss. Applying the tuning forks to the teeth rather than the forehead will increase the sensitivity 5 to 10 dB.
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