Download Congenital Anomalies

‫ا د مسعد 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
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
‫جسم غريب في االذن‬
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
instruments BUT PLEASE DO NOT WASH
IF 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
So donn’t wash if:
-The FB is vegetable
-The FB is disc battery
Inflammatory conditions of
the external auditory canal
• Bacterial:
1- Diffuse OE
2- Localised OE: frunculosis ‫دمل‬
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:
Because the skin is tightly
Earache:
adherent to the underlying
- Severe Why?
- Increase on moving the jaw Why?perichondrium & periostium
Deafness when edema is severe  Because the external canal
obstruct the canal
Lies immediately behind
Signs
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
Temporomandibular joint
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
should be suspected when
to the base of the skull
Incidence: elderly uncontrolled diabetic patient
patients with diabetes
Organism: pseudomonas aeuruginosa
mellitus (or another
Symptoms:
condition that compromises
Ear discharge and severe earache which does not respond
to analgesics
the immune system)
Signs
complain of persistent
External examination:
external otitis that causes
Tenderness on pulling the URICLE OR PRESSURE
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
‫وهذه عالمة هامة جدا لهذا المرض‬
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
. male
Gallium
citrate
Ga 67 scintigraphy
74patient
with diabetes
mellitus who in
hada severe
year-old
patient
diabetes
mellitus
nocturnalmale
otalgia
for twowith
months.
This patient
was
and
left-sided
temporal
referred
because
of facial bone
nerve osteitis.
paralysis This
that
developed
oralbecause
treatmentof
with
ofloxacin (Floxin).
patient
wasdespite
referred
persistent
The
CT
scan
shows
bony
destruction
of
the right
otalgia and otorrhea after a prolonged
temporal
Noteoral
the missing
posterior
of the
course
of bone.
systemic
antibiotics.
As awall
result
auditory
canal the
(short
arrow).
Mastoid
air cells
ofexternal
ongoing
infection,
left
temporal
bone
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 ‫مثل قطعة صغيرة مبللة من ورق‬
‫جرائد‬
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 ‫انظر الشريحة القادمة لتري‬
‫نموذج لمريض تم اجراء هذه الجراحة له‬
Chest X ray
Abdominal
ultrasound
Bone scan CT scan
Of brain
• From;
http://www.caritas.ab.ca/ther_new/respcare/hbo/case5
.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?
‫ماهو الصمالخ؟‬
• 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 كثيرا بعد االستحمام أو نزول البحر حيث ينتفخ‬
‫الصمالخ بالماء‬
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
‫بوضع قطعة شاش عليها فازلين في‬
‫األذن عند غسل الرأس أو االستحمام‬
- Ear drops
Surgical:
- Myringoplasty ‫لو لم يحدث‬
‫التئام 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