Di f th Di f th Diseases of the Diseases of the External Auditory External Auditory Canal Canal PETER ROLAND, MD PETER ROLAND, MD PETER ROLAND, MD PETER ROLAND, MD UT SOUTHWESTERN UT SOUTHWESTERN DALLAS TX DALLAS TX Anatomy Anatomy Only skin lined Only skin lined i i ti i i ti invagination invagination Outer Outer 1/3 3 vs inner vs inner 2/3 S-shape shape Fissures of Santorini Fissures of Santorini Tragi hair cells Tragi hair cells Tragi hair cells Tragi hair cells
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Di f thDi f thDiseases of the Diseases of the External Auditory External Auditory
CanalCanal
PETER ROLAND, MDPETER ROLAND, MDPETER ROLAND, MDPETER ROLAND, MD
UT SOUTHWESTERNUT SOUTHWESTERN
DALLAS TXDALLAS TX
AnatomyAnatomy
Only skin lined Only skin lined i i tii i tiinvaginationinvagination
A strong recommendation that:(1) li i i h ld CI h(1) clinicians should treat CI that
causes symptoms expressed by thecauses symptoms expressed by the patient or prevents clinical examination
h t dwhen warranted.
Recommendations that clinicians h ldshould:
(1) Diagnose CI when cerumen causes symptoms; or t d d t f thprevents needed assessment of the ear
(2) Assess the pt with CI by history and/or physical examination for factors that modify managementexamination for factors that modify management
(3) Examine patients with hearing aids for the presence of CI during a healthcare encounter g
(4) Assess patients after treatment and document the resolution of CI. If the CI is not resolved, the clinician h ld ib dditi l t t t If tshould prescribe additional treatment. If symptoms
persist despite resolution of CI, alternative diagnoses should be considered
Option that clinicians may:1) Observe patients when cerumen is asymptomatic and1) Observe patients when cerumen is asymptomatic and
does not prevent an adequate assessment of the ear2) Evaluate the need for intervention in the patient who2) Evaluate the need for intervention in the patient who
may not be able to express symptoms but presents with cerumen obstructing the ear canal
3) May treat the patient with CI with cerumenolytic agents, irrigation, or manual removal other than irrigation
4) May educate/counsel patients with cerumen4) May educate/counsel patients with cerumen impaction/excessive cerumen regarding control measures.measures.
Systemic antibiotics Systemic antibiotics yywith good gram + with good gram + coveragecoveragegg
Cephalosprin, clinda.,Cephalosprin, clinda.,
I&DI&DI&DI&D
Fungal External OtitisFungal External Otitis
Uncommon as a Uncommon as a primary diseaseprimary diseaseprimary disease. primary disease. Fungal organisms Fungal organisms may grow on may grow on y gy gdesquamated desquamated epithelium or epithelium or cerumen as simple cerumen as simple saprophytessaprophytes
T f l titi iT f l titi iTrue fungal otitis is True fungal otitis is almost always either almost always either Aspergillus orAspergillus orAspergillus or Aspergillus or Candida SpeciesCandida Species
Treatment of Fungal OtitisTreatment of Fungal Otitis
Mechanical debridmentMechanical debridment
Usually responds to reUsually responds to re--acidification acidification &/or the use of topical anti&/or the use of topical anti--septicsseptics&/or the use of topical anti&/or the use of topical anti septics septics (Gentian violet, mercurochrome, )(Gentian violet, mercurochrome, )
O l l ill tif lO l l ill tif lOnly rarely will antifungal Only rarely will antifungal antibiotics be requiredantibiotics be required
L t t l Th E t l ELucente et al: The External Ear
A t DiffA t DiffAcute Diffuse Acute Diffuse Bacterial External Bacterial External OtitisOtitis
AOEAOEAOEAOE
AOE: PathogenesisTemp and Temp and humidityhumidity
S lS lSeasonalSeasonal
pHpHpHpH
DermatitisDermatitis
TraumaTrauma
Fabricant et al. Arch Otorhinolaryngol: 201-9, 1949.
Diagnosis of AOEDiagnosis of AOE
History History Pain and DischargePain and Discharge
including predisposing factors suchincluding predisposing factors suchincluding predisposing factors such including predisposing factors such as diabetes and immunosuppresionas diabetes and immunosuppresion
Physical examinationPhysical examinationPhysical examination Physical examination tenderness, erythema and edematenderness, erythema and edema
Purulent DrainagePurulent Drainage
BACTERIOLOGY OFBACTERIOLOGY OFBACTERIOLOGY OF AOEBACTERIOLOGY OF AOEAOEAOE
Systemic Systemic antibiotics are antibiotics are rarely requiredrarely requiredQuinolones)Quinolones) rarely requiredrarely required
Problem #Problem #1 1 ScienceScience
• No good data on naturalNo good data on natural historyy–No modern studies with a ‘Placebo arm”
Problem #Problem #2 2 ScienceScience
• Impact of allergicImpact of allergic sensitization on outcome
HypersensitivityHypersensitivity
• Ear molds, chrome, i k l t hnickel, matches
• often iatrogenic– Aminoglycosides,
esp. Neomycin & S lfSulfas
– Other antibiotics
– Topical anesthetics and antihistamines
SensitizationSensitization
• 1st case of contact allergy to Neomycin was reported in l952 by Baer and Ludwig in a pt withreported in l952 by Baer and Ludwig in a pt with chronic OE!
• Cross reactivity between Neomycin and otherCross reactivity between Neomycin and other Aminoglycosides is common. Cf tobra in the Netherlands
• The reaction time of the aminoglycosides in patch testing almost always exceeds 3 days and often takes 7 daysoften takes 7 days
• The routine use of Neomycin is not recommended because of the high risk of sensitizationbecause of the high risk of sensitization
HypersensitivityHypersensitivity
• WARNING: THE MANIFESTATION OFMANIFESTATION OF SENSITIZATION TO
NEOMYCIN IS USUALLY A LOW
GRADE REDDENING WITH SWELLING,
DRY SCALING AND ITCHING; IT MAYITCHING; IT MAY
SIMPLY MANIFEST AS FAILURE TO HEAL
Problem # Problem # 3 3 ScienceScience
• What is theWhat is the pathophysiology?p p y gy– Bacterial exposure?
pH?– pH?
– Host factors? I.e. blood group, cerumen?
– Virulence factors? Adhesion?
– Temp and pressure variablesp p
Problem #Problem #4 4 EducationEducation
• Continued use of systemicContinued use of systemic agentsg– Halpern: 40% prescribed both
M C 39% t i l 25% l– McCoy: 39% topical; 25% oral
Halpern et al J Am Board Fam Pract 1999 McCoy et al Pediatr Infect
Di J 2004
Problem # Problem # 5 5 EducationEducation
• Irrelevance of “MIC”Irrelevance of MIC
Problem #Problem #7 7 EducationEducation
• Frequency of fungal AOEFrequency of fungal AOE at initial presentationp
Controversy #Controversy #11
• Do you need an antibiotic?o you eed a a t b ot cOr is a steroid, antiseptic &/or an
idif i l ti d t ?acidifying solution adequate?
Controversy #Controversy #11
• To what extent should cost o at e te t s ou d costbe a consideration?
Controversy # Controversy # 22
• Does the addition of a topical steroid make a clinicallysteroid make a clinically relevant difference? Is it worthrelevant difference? Is it worth the added cost?
a low grade , diffuse infection of a low grade , diffuse infection of the external canal that persist for the external canal that persist for months or yearsmonths or yearsyy
It i h t i d li i ll bIt i h t i d li i ll bIt is characterized clinically by It is characterized clinically by pruritits, scanty otorrhea and pruritits, scanty otorrhea and progressive narrowing of the lumen progressive narrowing of the lumen of the EAC.of the EAC.of the EAC. of the EAC.
Progressive Progressive b ith li lb ith li lsubepithelial subepithelial
fibrosis leading to fibrosis leading to t it istenosisstenosis
Post inflammatory Post inflammatory di l ldi l lmedial canal medial canal
fibrosisfibrosis
PathologyPathology
Clinical PresentationClinical PresentationHearing loss is a Hearing loss is a more common more common
titipresenting presenting symptom than symptom than otorrheaotorrheaotorrheaotorrhea
Females Females 22::11Exacerbated by Exacerbated by hearing aidshearing aidsOft t t iOft t t iOften starts in Often starts in anterior sulcus anterior sulcus
Bilateral in Bilateral in 5050%%
Physical examinationPhysical examination
Absent cerumenAbsent cerumen
Raw epithelial Raw epithelial surfacesurface——erythemaerythema
BacterialBacterialGram negative, especially Gram negative, especially Pseudomonas Pseudomonas StaphyloccusStaphyloccus
MycoticMycoticyyNot common pathogens in AOE but Not common pathogens in AOE but role in COE unclearrole in COE unclear------probably probably p yp ygreatergreaterAspergillus & CandidaAspergillus & Candidap gp gSlow growing fungi may be missedSlow growing fungi may be missed“Id” reactions“Id” reactions
PsoriasisPsoriasisOccasionally is isolated to earsOccasionally is isolated to earsOccasionally is isolated to earsOccasionally is isolated to ears
May develop from seborrheaMay develop from seborrhea
NeurodermatitisNeurodermatitis
Sensitization in Sensitization in COECOE
• Rasmussen: 35% of 98 chronic OE. N i @ 8%Neomycin @ 8%. (Rasmussen Acta Otolaryngol. 1974)
• Fraki: 40% 0f 142 chronic OE. Neomycin and framycetin most common @ 16.2% (Fraki JE et al: Act Otolaryngol. 1985)
• Smith: 58% 0f 49 pts w chronic OE• Smith: 58% 0f 49 pts w chronic OE. Neomycin commonest @ 32%. Cross sensitization among aminoglycosides @ 17-sensitization among aminoglycosides @ 1750% (Smith et al: Clin. Otolaryngol. 1990.)
• Ginkel: 56% 0f 34 pts w chronic OE and• Ginkel: 56% 0f 34 pts w chronic OE and CSOM. Neomycin & framycetin most common @ 35% (Van Ginkel et al: Clin Otolaryngol 1995)common @ 35% (Van Ginkel et al: Clin Otolaryngol 1995)
MixedMixed
The majority of cases of COE are The majority of cases of COE are probably in this categoryprobably in this category
TreatmentTreatment
MedicalMedicalEarly stage of disease. Ideally will Early stage of disease. Ideally will prevent stenosisprevent stenosispp
May only serve to slow progressionMay only serve to slow progression——no long term outcome datano long term outcome datano long term outcome datano long term outcome data
SurgicalSurgicalLate stage of disease. Late stage of disease.
AntibioticsAntibioticsU i lU i lUse sparinglyUse sparinglyQuinolone drops Quinolone drops PowdersPowders lastlastPowdersPowders----last last longer & can longer & can include multiple include multiple agentsagentsCultureCulture
“N T h” l“N T h” l“No Touch” aural “No Touch” aural toilettoilet
Surgical TherapySurgical Therapy
For hearing For hearing t tit tirestorationrestoration
To restore canal To restore canal patencypatency
Local flapsLocal flaps
PrePre--conchal, post auricular conchal, post auricular Tendency to contract may help pull Tendency to contract may help pull canal opencanal openpp
Decreased scarring because Decreased scarring because ↑↑vascularityvascularityvascularityvascularity
Hard to get enough length Hard to get enough length
B lkB lkBulkyBulky
FTSG vs STSGFTSG vs STSGGreater Greater resistance to resistance to traumatrauma
Most commonly Most commonly usedusedtraumatrauma
GlandularGlandularEasiest to obtainEasiest to obtain
Glandular Glandular elements provide elements provide lubricationlubrication
Less reLess re--stenosis?stenosis?
Less likely to Less likely to contractcontractcontractcontract
Resurface the bony canalResurface the bony canalResurface the bony canalResurface the bony canal
Surgical resultsSurgical results
≈ ≈ 8080% patent canal % patent canal b tb tbut recurrences but recurrences occur late occur late
earliest @ earliest @ 33yrs in yrs in Slattery’s seriesSlattery’s series
Hearing Hearing improvements range improvements range ff 1010dBdB 00dBdBfrom from 1010dB to dB to 5050dB dB
6161% with closure of % with closure of th ith i b ABG tb ABG tthe airthe air--bone ABG to bone ABG to 20 20 dB (Beckers dB (Beckers ---- 53 53 pts)pts)
COECOE
Be very cognizant of the role that Be very cognizant of the role that sensitization can playsensitization can playsensitization can playsensitization can playSteroids are a mainstay of medical Steroids are a mainstay of medical managementmanagementmanagementmanagementUse antibiotics(powder can be Use antibiotics(powder can be helpful) sparingly and culture forhelpful) sparingly and culture forhelpful) sparingly and culture for helpful) sparingly and culture for organismorganismAny manipulation of the canalAny manipulation of the canalAny manipulation of the canal Any manipulation of the canal seems to exacerbate the condition, seems to exacerbate the condition, including aggressive clearingincluding aggressive clearingincluding aggressive clearingincluding aggressive clearingSurgery is successful in Surgery is successful in 8080%%
Granular MyringitisGranular Myringitis
Proliferating granulation tissue Proliferating granulation tissue limited to TM and adjacent canal limited to TM and adjacent canal skin.skin.
STAGE ISTAGE I: infection of canal and : infection of canal and contiguous soft tissue w/wo CN VII contiguous soft tissue w/wo CN VII involvementinvolvement
STAGE IISTAGE II: Extension to include : Extension to include osteitis of skull base and multipleosteitis of skull base and multipleosteitis of skull base and multiple osteitis of skull base and multiple cranial nervescranial nerves