The External Ear

Question 1

What is ear trauma commonly related to?

Answer 1

Sports injuries

Violence

Question 2

How severe is ear trauma normally?

Answer 2

Normally uncomplicated and treatable under local anaesthetic

Question 3

Why is the sensory supply to the pinna important?

Answer 3

Allow you to perform regional nerve blocks

Question 4

How are most lacerations of the external ear managed?

Answer 4

Clean wound

Simple primary closure of skin with suture

Question 5

How should a laceration with exposed cartilage be managed?

Answer 5

Cover any exposed cartilage with skin

Question 6

What may be done if there is skin loss or a skin laceration can’t be closed by primary closure?

Answer 6

Plastic reconstructive surgery

Question 7

What is the main risks with bites to the ear?

Answer 7

Infection from skin commensal or oral commensal of offending creature/person

Question 8

How would you manage a patient with an ear bite?

Answer 8

Take a good history - work out likely organism

Leave wound open

Irrigate wound thoroughly

Antibiotics

Question 9

Why are pinna haematoma’s dangerous?

Answer 9

Disrupt blood supply to cartilage as it normally obtains nutrients via diffusion from vessels in the perichondrium.

Can lead to avascular necrosis

Question 10

What is cauliflower ear?

Answer 10

Cartilage undergoes avascular necrosis which stimulates the formation of new cartilage but it grows asymmetrically

Question 11

What can cause a tympanic membrane perforation?

Answer 11

Blunt force - trauma to side of head
Penetrating trauma - e.g. cotton bud
Otitis media
Barotrauma - explosion/scuba diving

Question 12

How does a tympanic membrane perforation present?

Answer 12

Pain
Conductive hearing loss (possibly)

Can get tinnitus and serosanguineous discharge

Question 13

How can tympanic membrane perforation be managed?

Answer 13

Most heal within 8 weeks- monitoring
Antibiotics if contamination
Keep clean and cry

Not healing after 6 months or hearing loss/recurrent infection - myringoplasty

Question 14

What is haemotympanum?

Answer 14

Blood in the middle ear

Question 15

What can cause haemotympanum?

Answer 15

Basal skull fracture - most common
Nasal packing
Bleeding disorders/anticoagulants
Recurrent ear infections

Question 16

How does haemotympanum present?

Answer 16

Seen through tympanic membrane

Associated with conductive hearing loss

Sense of fullness in ear

Pain

Question 17

How is haemotympanum managed?

Answer 17

Treat conservatively but follow up to ensure no residual hearing loss

However commonly associated with other issues - head trauma

Question 18

What is swimmer’s ear?

Answer 18

Otitis Externa - inflammation of the external ear canal lining

Question 19

What can cause Otitis Externa?

Answer 19

Bacteria - pseudomonas aeruginosa, staph aureus
Fungi - aspergillus and candida
Furuncle - deep folliculitis
Allergic

Question 20

How does otitis externa present?

Answer 20

Painful discharge from ear
History of itchy ear
?History of swimming on holiday
Muffled hearing side of discharge
Fever
Peri-auricular lymphadenopathy

Question 21

Who commonly gets Malignant Otitis Externa?

Answer 21

Elderly, Diabetics or Immunocompromised

Question 22

How can Otitis Externa spread?

Answer 22

Through into bone causing several complications

Question 23

What are the possible complications of Otitis externa?

Answer 23

Perforated Tympanic Membrane
Abscess
Sepsis
Become Chronic
Cellulitis
Malignant otitis externa - high mortality rate (10%) even with aggressive management

Question 24

How does malignant otitis externa present?

Answer 24

Chronic ear discharge despite topical treatment
Deep seated ear pain - out of proportion pain
Oedema
Exudate
Cranial Nerve palsies - usually CNVII

Question 25

How is otitis externa managed?

Answer 25

Topical drops for at least a week - Mild - acetic acid - Everything else - neomycin Oral fluclox if systemically unwell/lymphadenopathy Insert ear wick coated in steroid/antibiotics Ear health advice - keep dry, dont use cotton buds, olive oil to stop wax build up

Question 26

How is malignant otitis externa treated?

Answer 26

Urgent ENT referral Aggressive IV antibioic therapy alongside topical treatment - gentamicin

Question 27

What advice is given for swimming and flying for patients with otitis externa?

Answer 27

Ear plugs for swimming Avoid getting water/shampoo in ears Don't fly with ear infections ideally - increase pain, risk of perforation and time to settle

Question 28

How can discharge be indicative of aetiology of otitis externa?

Answer 28

White-yellow - bacterial Thick, grey with visible spores - fungal Clear grey - likely otitis media

Question 29

What risk factors predispose otitis externa?

Answer 29

``` Humid environment Swim Old age Immunocompromised Presence of foreign bodies or polyps Eczema Psoriasis Seborrheic Dermatitis ```

Question 30

How long is the external auditory meatus and how is it made up?

Answer 30

2.5cm Outer 2/3 - cartilaginous + hairs Inner 1/3 - petrous part of temporal bone

Question 31

What are the key parts of the tympanic membrane that can be seen?

Answer 31

``` Pars flaccida (top) Pars Tensa (vibrates) Cone of light ```

Question 32

How does a pinna haematoma occur?

Answer 32

Shearing forces separate the perichondrium from the tightly adhered cartilage Perichondrial blood vessels tear leading to haematoma formation

Question 33

What are the complications associated with pinna haematoma?

Answer 33

Superimposed infection | Cauliflower ear

Question 34

How is a pinna haematoma managed?

Answer 34

Drainage within 24 hours of injury Tight head bandage

Question 35

What problems may be associated with tympanic membrane perforation?

Answer 35

Basal skull fracture Facial nerve palsy Temporal bone fracture

Question 36

How does otitis external appear on examination?

Answer 36

Ear canal with erythema, oedema and exudate

Question 37

What happens in furuncle otitis external?

Answer 37

Small localised infection causing lots of pain and swelling If lesion burst, there is a sudden relief of pain

Question 38

What happens in allergic otitis external?

Answer 38

Contact dermatitis Fast onset with itching as main symptom

Question 39

How is otitis external investigated?

Answer 39

Only need to swab of MC&S if treatment failure or atypical

Question 40

What is malignant (necrotising) otitis externa?

Answer 40

Life threatening spread of otitis external into the mastoid or temporal bone

Question 41

When is otitis external classified as chronic?

Answer 41

>3 Months

Question 42

What must you consider with patients that have chronic otitis externa?

Answer 42

Poor compliance Abx drop can lead to fungal infection Contact sensitivity to Abx drop

Question 43

How is chronic otitis external investigated and managed?

Answer 43

Swab 7 days acetic acid + corticosteroid drop