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Otology & Neurotology > External Ear > Flashcards

External Ear Flashcards

1
Q

What are the Jahrsdoerfer CT criteria to consider EAC atresia repair? List 9

A

Score ≥7 needed for a good candidate for EAC atresia repair
1. Present stapes superstructure (capitulum+neck+crus) +2 — think “stapes is the most important so it gets 2”

Rest is +1
2. Pneumatized middle ear
3. Well aerated mastoid cells
4. Present incudostapedial joint
5. Present malleoincudal joint
6. Oval window open
7. Round window open
8. Appearance of external ear
9. Normal course of facial nerve

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2
Q

Name 20 syndromes associated with microtia/aural atresia and their genetic abnormalities (at least 6)

A
  1. Bixler (Hypertelorism-microtia-clefting)
  2. Bosley-Salih-Alorainy (HOXA1)
  3. Branchio-oculo-facial BOF (TFAP2A)
  4. Branchio-otic BO (EYA1, SIX1)
  5. **Branchio-oto-renal **BOR (EYA1, SIX5)
  6. CHARGE Syndrome (CHD7, SEMA3E)
  7. Congenital deafness, inner ear agenesis, microtia, microdentis (FGF3)
  8. Craniofacial microsomia CFM
  9. Crouzon Syndrome
  10. Fraser (FRAS1, FREM2)
  11. Kabuki (MLL2)
  12. Klippel-Feil (GDF6)
  13. Goldenhar Syndrome
  14. Lacrimoauriculodentodigital (FGFR2, FGFR3, FGF10)
  15. Mandibulofacial dysotosis (HOXD)
  16. Meier-Gorlin (Ear-patella-short stature) (ORC1 / 4/ 6, CDT1, CDC6)
  17. Microtia, hearing impairement, and cleft palate (HOXA2)
  18. Miller (DHODH)
  19. Nager
  20. Oculo-auricular (HMX1)
  21. Pallister Hall (GLI3)
  22. Townes Brocks (SALL1)
  23. Pierre Robin Sequence
  24. Treacher Collins Syndrome (TCOF1)
  25. Wildervanck (cervico-oculo-acoustic)
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3
Q

Describe the 6 nerves innervating to the EAC and Auricle (and sources of referred otalgia)

A
  1. Auriculotemporal nerve (V3)
    - Innervates: Anterior auricle, tragus, anterior EAC, tensor tympani (medial ptergoid nerve)
    - Etiologies in referred otalgia: TMJ disease, dental pathology, parotid tumor/inflammation
  2. Posterior Auricular Nerve (VII)
    - Innervates: Posterior surface of auricle/posterior auricular skin, posterior EAC, stapedius (nerve to stapedius)
    - Etiologies in referred otalgia: CPA tumors, Herpes zoster, Geniculate neuralgia
  3. Jacobsen’s nerve (IX)
    - Innervates: Medial surface of TM, promontory, eustachian tube
    - Etiologies in referred otalgia: Tonsillitis/pharyngitis, Eagle’s syndrome, sinusitis, pharyngeal tumor, sinusitis
  4. Arnold’s nerve (X)
    - Innervates: Lateral surface of TM, floor of EAC, Concha
    - Etiologies in referred otalgia: Laryngeal tumor, GERD, Thyroid inflammation/tumor pathology
  5. Great auricular nerve (C2-3)
    - Innervates: Inferior preauricular overlying parotid, medial postauricular overlying mastoid, and posterior auricle
    - Etiologies in Referred otalgia: Cervical spine degenerative diseases, Whiplash/trauma, Cervical meningiomas
  6. Lesser occipital (C2-3)
    - Innervates: Mastoid region
    - Etiologies in referred otalgia: Cervical spine degenerative diseases, Whiplash/trauma, Cervical meningiomas

Vancouver Page 274

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4
Q

What is the difference between osteoma and exostoses? What is their management?

A

Exostoses:
- Epidemiology: Common
- Type of tumor: Periostitis secondary to cold temperature (cold water)
- Location: Usually bilateral, medial in EAC (medial to the sutures on the tympanic bone)
- Clinical presentation: Multiple, broad based (sessile)
- Histology: Parallel layers of subperiosteal bone, no or poorly developed trabeculated fibrovascular channels
- Radiographic: Intact cortex

Osteoma:
- Epidemiology: Rare
- Type of tumor: True benign neoplasm
- Location: Unilateral, lateral in EAC (rise from tympanosquamous or tympanomastoid suture)
- Clinical presentation: Single, pedunculated
- Histology: Lamellar bone around trabecular cancellous bone with marrow and fibrovascular tissue

Management:
- Conservative
- Canaloplasty

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5
Q

Describe and differentiate Keratosis Obturans and EAC cholesteatoma

A

Keratosis Obturans:
- Pathophysiology: Keratin debris obliterates the EAC due to abnormal epithelial migration and/or hyperplastic epithelium with increased desquamation
- Age: Young adults
- Associations: Sinusitis, Bronchiectasis
- Pain: Acute, severe
- Hearing loss: Moderate, conductive
- Otorrhea: Rare
- Lateralization: Usually bilateral
- Bony Erosion: Circumferential widens canal but does not destroy bone (just pushes it)
- Organization of squamous debris: Layered
- Meatal Skin (most reliable differentiation): In tact
- Osteonecrosis (most reliable differentiation): Absent
- Treatment: Regular, lifelong, suctioning of debris

EAC cholesteotoma
- Pathophysiology: Invasion of squamous tissue into a localized area of periosteitis in the canal wall; may be acquired (due to surgery, trauma, chronic inflammation) or spontaneous
- Age: Elderly
- Associations: None
- Pain: Chronic, dull
- Hearing loss: Little to none
- Otorrhea: Frequent
- Lateralization: Usually unilateral
- Bony Erosion: Localized
- Organization of squamous debris: Random
- Meatal Skin (most reliable differentiation): Focal ulceration
- Osteonecrosis (most reliable differentiation): Usually present
- Treatment: Small limited lesion = conservative approach; Bony destruction extends into middle ear/mastoid and unresponsive to medical therapy = surgery removal of cholesteatoma and affected bone, grafting of skin

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6
Q

What are 2 diseases associated with keratitis obturans?

A
  1. Sinusitis
  2. Bronchiectasis
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7
Q

Compared to cholesteatoma, patients with keratitis obturans have 4 main differences, which are what?

A
  1. Younger patients
  2. Less or no draining ear
  3. More generalized position, compared to cholesteatoma which are just localized to lateral to annulus
  4. Widens EAC (but does not destroy bone)
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8
Q

What is the differential diagnosis of a painful nodule on the ear? Describe 6.

A
  1. Chondrodermatitis Helicis Nodularis
    - Necrotic, extruding auricular cartilage (thought to be a pressure ulcer-type phenomenon); can simulate BCC or SCC
  2. Skin malignancies
    - BCC, SCC, melanoma, adenoid cystic carcinoma, cerumoma
  3. Furuncle
    - Staph aureus infection of hair follicle/pilosebaceous unit in outer EAC.
    - Treated with antibiotics ointment, warm compresses, +/- I+D
    - IV cloxacillin if cellulitis
  4. Gout
    - Purine metabolic disorder, uric acid deposited in tissues
    - Acute pain treated with colchicine
    - Allopurinol (overproducers) or Probenecid (underexcretors) for long term maintenance
  5. Ochronosis
    - Disorder characterized by a clinical appearance of blue-black or gray-blue pigmentation
    - Alkaptonuria (black urine disease), homogentisic acid metabolic disorder; turns black when oxidized, deposited in cartilage
  6. Darwin’s Tubercle
    - Autosomal dominant, incomplete penetrance
    - Painless normal anatomic variation on the postero-superior helix (little nub)

See Vancouver page 276

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9
Q

What is the infection caused by Pseudomonas Pyocyaneus and its sequelae?

A

Perichondritis
- Characterized by diffuse inflammation of the pinna and severe pain
- If not treated aggressively with antibiotics +/- drainage, loss of cartilage and permanent deformity can result

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10
Q

List a complete differential diagnosis for acute otitis externa

A
  1. Acute otitis externa
  2. Chronic otitis externa
  3. Malignant/Necrotizing otitis externa
  4. EAC cholesteatoma (± infected)
  5. Granuloma
  6. Squamous cell carcinoma
  7. Otomycosis
  8. Otitis externa bullosa sive hemorrhagica
  9. Perichondritis
  10. Eczema
  11. Herpes zoster oticus
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11
Q

Phases of chronic otitis externa (> 3 months)

A
  1. Pre-inflammatory: Stratum Cornea edema, loss of lipid layer
  2. Inflammatory: Pain, papules
  3. Chronic - ulceration, lichenification (thickened, hardened area of skin)
  4. ± Furuncle: Staph aureus infection of pilosebaceous unit
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12
Q

List 5 bacterial etiologies of acute otitis externa

A
  1. Pseudomonas Aeruginosa (most common for malignant OE)
  2. Proteus mirabilis
  3. Staphylococci
  4. Streptococci
  5. Peptostreptococcus - klebsiella
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13
Q

What is the main bacterial etiology of chronic otitis externa?

A

Proteus vulgaris

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14
Q

What are the etiologies of fungal otitis externa?

A
  1. Aspergillus niger
  2. Candida albicans

*commonly get granulation at handle of malleus

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15
Q

What are the fissures of santorini?

A

Fissures present in the lateral cartilaginous EAC which allow passage of infection or neoplasm into the preauricular parotid tissues and glenoid fossa

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16
Q

What is the foramen of Huschke?

A

An embryologic remnant that forms a defect within the bony EAC which allows passage of infection or neoplasm from the medial EAC into the preauricular parotid tissues and glenoid fossa

17
Q

Describe 4 basic principles of otitis externa management

A
  1. Thorough cleaning and debridement
  2. Antibiotic treatment - topical ± oral depending on severity
  3. Counselling patient - avoid instrumentation, keep dry ear
  4. Analgesia - depending on severity
18
Q

What are 4 cardinal features of necrotizing otitis externa (malignant OE)?

A

Skull base osteomyelitis, commonly caused by pseudomonas infections

Features:
1. Otalgia > 1 month
2. Otorrhea/granulation tissue
3. Advanced age, diabetes or immune suppression
4. Cranial neuropathy

Infected granulation tissue on the floor of the
cartilaginous ear canal near the osteo-cartilaginous
junction is a hallmark of malignant OAE

Vancouver notes page 277

19
Q

What are 3 cranial nerves most often involved in necrotizing otitis externa?

A

Facial (75%)
Vagus (70%)
Accessory (56%)

20
Q

What are Investigations that can be done for malignant otitis externa?

A

Bloodwork:
- HbA1c (diabetes)
- WBC
- CRP

Imaging:
- CT (Anterior TMJ bone erosion)
- MRI (to follow disease and evaluate for dural and intracranial involvement)

Nuclear Medicine Tests:
1. Technetium-99 scan: Used to identify presence of acute or chronic osteomyelitis, identifies increase in osteoblastic activity; stays positive for prolonged period & lags behind gallium for months
- Abnormal = >10% increase in activity
- High sensitivity, low specificity
- Use to follow disease resolution

  1. PMN Gallium-67 scan: Incorporated into proteins & leukocytes during acute inflammatory process, used to follow resolution of the disease, will fade as disease process settles
  2. WBC Indium 111: Best for following treatment progress, has largely replaced G-67. Earliest changes seen on MRI (within 1-2 days)
21
Q

What is the most useful imaging for tracking progress of necrotizing otitis externa?

A

Single photon emission tomographs (SPECT) with two radionuclide tracers - Indium-111-labeled leukocytes, and technetium-99m

22
Q

What is the management of malignant otitis externa? List 7 components

A
  1. Prolonged IV antibiotics with ID consult (anti-pseudomonas)
  2. Acidic, antibiotic, or antibiotic/corticosteroid combination otic drops
  3. Aggressive diabetic control (Endo consult)
  4. Meticulous cleaning and debridement
  5. Follow course with periodic indium bone scans or MRI
  6. ± HBO
  7. Surgery only if failed medical management or focal abscess present
23
Q

What are 12 classes of topical agents for otomycosis?

A
  1. Nystatin
  2. Clotrimazole cream or drops (safe for perforations)
  3. Chloraphenicol
  4. Ampho B or Tonalfate (antifungals)
  5. Locacorten Vioform (NOT safe for perforations)
  6. 1.5% Acetic acid
  7. 95% isopropyl alcohol
  8. Merthiolate (Thiomersol)
  9. Metacresyl-acetate (Cresylate)
  10. Gentian violet (carcinogenic)
  11. Aluminum Sulfate-calcium acetate (domboro)
  12. Drying agents - boric acid, hydrogen peroxide
24
Q

Four classes of agents used for otitis externa

A
  1. Acetic acid solutions
    - 2% solution (generic name acetic acid otic)
    - Acetic acid 2%, hydrocortisone 1% (generic name acetasol HC)
  2. Ciprofloxacin solutions
    - Ciprofloxacin 0.2%, Hydrocortisone 1% (Trade Cipro HC)
    - Ciprofloxacin 0.3%, Dexamethasone 0.1% (Trade Ciprodex)
  3. Neomycin, polymyxin B, hydrocortisone
    - Trade name Cortisporin Otic
  4. Ofloxacin 0.3%
    - Trade name Floxin Otic
25
Q

Discuss myringitis: Definition, Causative organisms, diagnosis, treatment.
Define bullous myringitis and special treatment circumstances.

A

Primary Myringitis: Inflammation or infection of the TM alone
Secondary Myringitis: Inflammation or infection of the TM and adjacent middle ear or EAC

Bullous myringitis: Formation of serous/hemorrhagic bullae on the epithelial surface of the TM

Causative pathogens
- Strep pneumoniae (most common)
- Mycoplasma pneumonia
- Influenza

Diagnosis: Clinical, consider culture

Treatment: Analgesia, ciprodex, oral Clarithromycin to cover possible mycoplasma
Bullous myringitis - may puncture the bullae to relieve severe pain

See image Vancouver page 278

26
Q

What is a complication of chronic otitis externa that may be difficult to manage?

A

Median canal fibrosis (results in a blind fundus)

Otology & Neurotology (17 decks)

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