Anatomy Ear

Comma Shaped Cartilage Covered by Skin (Adherent to Perichondrium → Hematoma collect () cartilage, Perichondrium)
4 Elevations (Helix – Antihelix – Tragus – Anti tragus) + 2 Depressions (Concha + Simba concha)
Auricle

Nerve Motor Facial Nerve (also sensory to concha)

Sensory Lateral: Upper 2/3 → Auriculotemporal (Mandibular) Lower 1/3 → Greater Auricular (C2, C3)
Medial: lower 2/3 → Greater Auricular (C2, C3) Upper 1/3 → Lesser occipital (C2)
24 mm canal from Concha till TM
Lateral 1/3 Cartilaginous → Skin with Hair, Sebaceous, Ceruminous (wax) → Upward, Backward
EAC
External Ear

Medial 2/3 Bony → Free Skin → Downward, Forward

Nerve: Anterior → Auriculotemporal Posterior → Arnold nerve of Vagus
Oval Membrane (8 X 10 X 0.1 mm) at Medial End of EAC → Separate External from Middle Ear
Direction: 550 with horizontal plane (Anterior, inferior > Superior, Posterior borders of EAC)
Nerve: Lateral → Same as EAC Medial → Jacobson of Glossopharyngeal
By Otoscope: Oval pearly grey semi translucent → Divided by Malleolar folds (anterior, posterior) to 2 parts
TM

1. Pars flaccida → Upper 1/5 → Only 2 layers (outer Cutaneous + inner mucosal)
2. Pars Tensa → Lower 4/5 → 3 Layers (Add Fibrous layer) → Surrounded by Anulus
Structures seen: Malleolus (lateral process, manubrium and umbo) + 2 Folds + cone of light
6 Walled Bony Cavity (Except TM) in Temporal bone → Height 15 mm, AP 15 mm, Side to side 2-6 mm
Divided by TM (in lateral wall) into → Epi-tympanum (attic) above - Meso-tympanum opposite - Hypo-tympanum below
Middle Ear

Contents:
Cavity

1. Air (Most important)

2. 2 Muscles (Tensor tympani to Handle of malleolus, Stapedius to stapes neck)
3. 2 Nerves (chorda tympani and tympanic plexus)
4. 3 Bony Ossicles (malleus, incus and stapes)
Lateral TM with Bone above, below Anterior ET - tensor tympani – Separate from ICA
 Medial Horizontal part of Facial Canal Posterior Aditus ad antrum → Mastoid Antrum
Promontory of Cochlea Stapedius and its pyramidal projection
Oval window Above →foot of stapes Vertical part of Facial canal
Round window below → secondary TM
Roof Tegmen tympani → Middle cranial fossa (temporal lobe) Floor Bone plate → Separate from Jugular bulb of IJV
36 mm from Anterior wall of Tympanic cavity to Nasopharynx → Lateral 1/3 (Bony) and Medial 2/3 (cartilage)
Directed medially Downward, forward In Children Horizontal, Wide, Short
ET

Normally closed → open at swallow or yawing by tensor veli palatini → Ventilation, drainage, equalize pressure
Air filled cavities in mastoid process in temporal → Largest one Antrum → connected to cavity by aditus ad antrum
Mastoid Air cells

Number: Cellular – diploic – Acellular (sclerotic) Not Present At birth

Function → Unknown (maybe pressure or ↓ Weight) Surface Anatomy: McEwen’s Triangle
Located in Petrous Part of Temporal between Middle Ear and Internal auditory canal → Bony part enclosing Membranous
Bony Cochlea 3 Semicircular canals Vestibule Perilymph
Bony

2.5 turns around modiolus lateral, superior, posterior () Bony cochlea, SCC Fluid around
(snail shell) perpendicular to each other membranous
Membranous cochlea 3 Semicircular Duct Utricle, saccule Endolymph
Membranous
Inner Ear

Inside cochlea Inside 3 SCC Inside Vestibule Fluid inside membranous

Organ of corti → hearing Crista → angular acceleration Macular → Linear acceleration Endolymphatic duct, sac
Connected to cochlear division Connected to Vestibular Connected to Vestibular
Cross Section of Cochlea →
1. Scale vestibuli above → filled with perilymph end with oval window
2. Scale tympani below → filled with perilymph end with round window
3. Scale media middle → filled with endolymph → contain organ of corti + tectorial membrane above, basilar membrane below
 Ear Physiology
External Auricle collect Sound waves to EAC → Vibration of Tympanic Membrane → convert it to mechanical vibrations
Middle Ossicles transmit mechanical vibrations from TM to Oval window→ Amplification intensity 22 times
Ratio () TM area, oval window area is 17: 1 Ratio between malleolus arm, incus arm is 1.3: 1
Conductive

ET Tube equalize pressure → allow free vibration of TM, ossicles

2 Muscles protect inner ear against Excess high amplitude sounds by
Hearing

1. Tensor Tympani → Tense TM → Prevent vibration

2. Stapedius → Fixed stapes → Prevent movements, pulled away from window
Inner Vibration footplate of stapes into oval window → vibration of cochlear fluid→ Vibration of basement
membrane → stimulation of hair cells against tectorial → impulses in Cochlear Nerve
SN

Secondary TM of round window moves out with transmission of waves → Relieve pressure inside inner ear
Afferent Labyrinth (U, S, 3 SCD) + Visual + Proprioceptors
Equilibrium

Center Brain
Efferent Spinal muscles → Postural equilibrium Extraocular muscles → ocular equilibrium
Ear Symptoms
1. Deafness → Hearing Diminution or loss → Conductive or Sensory Neural
2. Tinnitus → Sensation of noise in the ear or head
3. Pain → Otalgia
4. Discharge → Otorrhea
5. Vertigo → Subjective sensation of disturbed relationship () individual, surrounding environment → usually of vestibular origin.
e.g. moving around rotating, or swaying or rocking.
 External Ear Diseases
Auricle
Congenital ANOTIA MICROTIA ACCESSORY AURICLE PROTRUDING (BAT) PRE-AURICULAR SINUS
Absent Auricle Small Deformed Small elevation Absent Antihelix Blind tract anterior
anterior Most common → +ve Family Hx Infection, Abscess
Plastic Plastic Plastic Excision Plastic Repair Plastic Excision
Inflammatory Perichondritis by Pseudomonas pyocyanea → Infected hematoma, laceration
Complications: Necrosis, fibrosis → Cauliflower ear
TTT: Antibiotics – Incision, Drainage – Removal of necrotic parts
Traumatic Closed Hematoma Open
Collection of blood between cartilage & perichondrium Laceration or Wound
Blunt Trauma Penetrating trauma
Com: Infection (Perichondritis) – Necrosis, Fibrosis (cauliflower ear) Com: Same
TTT: Antibiotics – Aspiration or Incision, Drainage TTT: Aseptic repair + antibiotics
Neoplastic Benign → Papilloma, chondroma, hemangioma Malignant → Basal cell or Squamous cell carcinoma

External Auditory Canal

Trauma FB
ETO More in Children → Animate (Fly or Larva) or Non-Animate (Vegetable or Non-Vegetable)
C/P Asymptomatic or CHL →Add irritation, Tinnitus by Animate → Dx by Otoscope
Com Traumatic injury or Infection
TTT Wash → Any FB except Impacted or Large Vegetable ± Alcohol if animate
Extraction by Forceps or Hook or Suction ± Anesthesia → Any FB (Maybe post-auricular approach if impacted)
Otitis Externa
 Bacterial
Localized Furunculosis Diffuse Malignant OE (Necrotizing skull base OM)
Def Localized inflammation of Skin of EAC Inflammation of All EAC EAC Inflammation extend beyond to Skull base
Lateral 1/3 i.e. cartilaginous part Skull base OM
ETO Staph Staph, Strept, Pseudomonas Pseudomonas, anaerobic: Necrotizing Vasculitis
RF: Laceration (Scratch, wash), Maceration (Humidity, Swim), CSOM, DM DM and Old age (Microangiopathy)
C/P G: FAHM G: FAHM
L: Deafness Tinnitus Otalgia (throbbing, ↑ Mastication) Otorrhea (Scanty purulent) L: Deafness Tinnitus Otalgia (Stabbing) Otorrhea (Scanty bloody purulent)
Ex Tenderness on pressure tragus (tragus sign) or Auricle Tenderness on pressure tragus
OT Normal TM + Otorrhea (Scanty purulent) Normal TM + Otorrhea (Scanty bloody purulent) +
Granulation tissue at Bone/cartilage junction
TF CHL CHL
INV Culture + Blood glucose level Culture - Blood glucose + CT, Hearing test (PTA) –
DD Acute Mastoiditis + Post-auricular LN Com: Osteomyelitis – mastoiditis – Cranial Nerve affection
Facial → Stylomastoid – 9,10,11 → Jugular Foramen
TTT General → Control RF General → Control RF
Local → Auricular toilet + Antibiotic drops + Packing Local → Auricular toilet + Antibiotic drops
Localized → glycerol ichthyol 10% - Diffuse → Aluminum acetate 8% Systemic → Analgesics – Antibiotics
Systemic → Analgesics - Antibiotics ± Surgical incision Quinolones or Aminoglycosides for 6 w
Surgical Debridement for Granulation, Necrotic tissues
Viral
Myringitis bullosa haemorrhagica → Parainfluenza Ramsey-Hunt syndrome → HZV Oticus
Severe Otalgia, serosanguinous discharge + TM Hemorrhagic Bullae Severe Otalgia + Vesicles + Facial Palsy ± Dry eye, 8th Cranial (Mixed HL)
Local Analgesics + Steroids + Antibiotics Local Analgesia + Steroids + Acyclovir
 Fungal Otomycosis
Def Fungal infection of Skin of inner EAC
ETO Black → Aspergillus Niger White → Candida albicans RF: DM – Prolonged Antibiotic drops
C/P General → No fever
Local → Itchy (characteristic) – Otalgia (if 2nd infection)
→ OT: characteristic white mass with black spots
INV Culture + Blood glucose level
TTT Ear wash or suction + Antifungal + 1-2% salicylic acid (keratolytic) in alcohol (fungicidal)
Wax Accumulation
Physi Secretions of ceruminous (wax), sebaceous glands Expelled by epithelial migration.
o
Cause ↑ Production - ↓ Drainage (narrow canal) – Push it deeper in attempt to clean
C/P Most common Cause of CHL in adults + tinnitus esp. after bath OTO → brownish mass
TTT Softening by glycerin NaHCO3 then Wash
Ear wash
By Sterile warm water at 37c
Indication Trauma FB – Infection Otomycosis - Wax Accumulation - Caloric test
Contraindication FB Impacted, vegetable or TM perforation, Fistula middle, inner ear or Otitis Externa
Complications 1. Reflex Vagus → Cough or syncope
2. Vertigo and Nystagmus → Caloric thermal stimulation of inner ear (excess hot or cold)
3. Trauma: TM perforation (Sudden pain → HL, tinnitus, slight bleeding, water in throat) or EAC Laceration
4. Infection: OE, Otomycosis → Non-sterile water OM → TM perforation
Whitish mass + black spots → otomycosis Red hemorrhagic bullae → Influenza Brownish mass → Wax
Whitish mass of bone → Exostosis Granulation tissue → Malignant OE Fresh friable mass → SCC
 Middle Ear Diseases
ETO Trauma → Direct (Temporal Fracture – FB – Wash – Self inflected) or Indirect (Slap – Barotrauma)
C/P Sudden pain → Deafness – Tinnitus – Bloody discharge → Air from ear during blowing nose
Traumatic Pathological (SOM)
TM Perforation

Pars Tensa → Central → Anterior inferior Pars flaccida or Tensa → Central or Attic or Marginal
Small Irregular Large Rounded or Oval kidney shaped
Thin Sharp Hyperemic border + Blood clots Thick Smooth Border + Pus
Normal Other TM, Mucosa Congested TM and Mucosa
TTT Conservative for spontaneous healing in 3-8 w → Antibiotics – Avoid water or blowing nose or Ear drops
Surgical if failed Healing in 3 months → Myringoplasty
ETO Marked Rapid ↓ Tympanic cavity pressure than atmospheric with Failed ET opening
C/P Mild → Retracted Drum Moderate →Effusion Severe → Perforation
Barotrauma

TTT Mild → Nasal decongestants – Auto inflation by Valsalva – Repeated swallow, shewing gum
Moderate → Myringotomy anterior inferior
Severe → Myringoplasty
Longitudinal (More common) Transverse (Less common)
Temporal Fracture

Parallel to axis of Petrous part of temporal bone → Spare 8th Perpendicular to axis of Petrous part of temporal bone → Cut 8 th
CHL → EAC Fracture – TM perforation, Ossicle Disruption SNHL → Injury of acoustic nerve – labyrinth
CSF Otorrhea + Bloody otorrhea CSF Otorrhea + Bloody otorrhea
Less Risk for Facial palsy (Most common cranial affected) More risk for facial palsy
TM → Torn or Hemotympanum TM → Intact with Hemotympanum
PT Vertigo Tinnitus - Dizziness PT Vertigo Tinnitus - Dizziness
Maybe mixed in 10%

Otitis Media
Acute Acute Suppurative OM
Chronic Non-Suppurative: Secretory – Atelectasis – Adhesive – Tympanosclerosis Suppurative → Atticoantral or Tubotympanic
Acute Suppurative OM
Def Acute Inflammation of Mucoperiosteal lining of Middle ear cleft → Tympanic Cavity – ET – Mastoid Air cells
ETO Org → Strept – Staph ET →Obstruction (Most Common) – EAC →TM Perforation – Blood → Rare
Route →→→ Nasal (Rhinosinusitis) – Nasopharynx (Adenoid, Milk Regurge) – Oropharynx (Tonsilitis, Pharyngitis)

C/P ET Catarrhal OM Catarrhal OM Suppurative OM Perforation

Pa ET Congestion, Edema→ Middle Ear congestion Exudate Become Purulent Pressure Necrosis of TM
Obstruction, Retraction → Serous Exudates under tension → Bulging TM Perforation
G No No Severe Fever ↓↓ Fever
L Deafness, Tinnitus, Autophony Deafness – Tinnitus – Otalgia Add Severe Throbbing pain ↓↓ Pain + Discharge
OT Retracted TM → Congested TM Bulging TM Pathological Perforation
1. Lusterless
2. Absent or Disturbed Cone light
Start Periphery Loss Landmarks Central
3. Malleolus short horizontal Then whole Drum Otorrhea →
handle, Prominent lateral
4. Mobility → limited Mucopurulent or Bloody
TF CHL CHL CHL CHL
INV PTA - Culture, sensitivity - Mastoid X-ray
TTT Before Perforation After Perforation
Antibiotics for 10 Days + Analgesics, Antipyretics Antibiotics for 10 d + No Need Analgesics or Antipyretics
Local → Decongestant nasal drops + Phenol glycerin drop 5% Local → Aural toilet – Antibiotic drops – Avoid water
Myringotomy, Pus Drainage Myringotomy, Pus Drainage
 Severe (Impending perforation or Complications) - ↓ Pain – Culture Need high or small → inadequate for full drainage
Infant More common →
1. ET short, wide, Horizontal
2. ↑ Adenoid, tonsillitis
3. ↑ Aspiration → Bottle feeding
4. ↓ Immunity (Artificial feeding, teething, gastroenteritis)
More Severe → Fever – Vomiting – Diarrhea - Pulling & rubbing the ear
Late Bulging (thick TM) → Require Early myringotomy
Chronic Secretory OM (OME)
Def Chronic Inflammation of Mucoperiosteal lining of Middle ear cleft characterized by Non-Purulent Discharge with intact TM
EPI Children → More Common (Most common cause of CHL in children) → More Bilateral → More Mucinous → Mostly by Adenoid
Adults → Less Common → Unilateral → Serous → Suspect nasopharyngeal carcinoma
ETO 1. ET Prolonged Obstruction (Most common) → Adenoid
2. Unresolved ASOM → Inadequate TTT or Drainage or High virulent or low resistant
3. Others: Viral infection – Allergic - ↓ Ig
C/P Asymptomatic or Deafness – tinnitus – Otalgia → Bubbling sound (characteristic)
OT → Retracted TM + Amber yellow or Greyish white (Discharge) + Fluid level (biconcave hair line) or air bubbles (Characteristic)
TF → CHL
INV PTA (CHL) – Tympanometry (Type B) – Cause → X ray for adenoid or Nasopharyngoscopy for malignancy
TTT Medical → For 3 months Surgical → if failed medical after 3 m
1. Antibiotics, corticosteroids, mucolytics Myringotomy with Ventilation Tube insertion → Anterior inferior
2. Auto inflation by Valsalva Maneuver and decongestants Short term (3-6 m as Grommet’s) or Permanent (T Tube)
3. Avoid Anti histamine → ↑ Viscosity of secretions S/E: Infection - Atrophic scar of TM – Permanent Perforation
 Chronic Suppurative OM
Chronic inflammation of Middle ear cleft characterized by Purulent Discharge from Perforated TM
Tubotympanic Atticoantral
Def Affecting ET, Tympanic cavity Attic part (epitympanum) and Mastoid Antrum
ETO ASOM → Unresolved or Recurrent (Persistent RF or TM perforated) Cholesteatoma → Abnormal Skin in abnormal Area
Cystic mass of keratin and cholesterol crystals, Proteolytic enzymes
Congenital TM Remnants → Intact TM
Acquired Primary (No OM) Invagination by ET Obstruction or Invasion from TM Epithelium
Secondary (OM) Migration by EAC, TM perforate or Metaplasia by Chronic
Pat Mucosa → Congested with Purulent Exudates Mucosa: Granulation tissue, Scanty Exudates
h Bone → Rare affected → Safe Type Bone: Erosion → Osteomyelitis, Ossicular, Inner ear affect →Unsafe
Can be Active (Pus) or Inactive (Dry) Maybe Polyps
C/P Deafness – tinnitus – Discharge (continuous or intermittent) Deafness – tinnitus – Discharge (continuous or intermittent)
OT TM → Central pathological perforation OT TM → Attic or marginal pathological perforation
Mucosa →Congested (active) or pale pink (Dry) Mucosa → Cholesteatoma + Granulation, Polyps
Otorrhea → Profuse – odorless – Mucopurulent Otorrhea: Scanty – Fetid – Purulent
TF CHL → Mild to moderate TF Severe CHL → affect ossicles Maybe mixed → Inner ear
INV PTA -Culture – CT, Mastoid X-ray PTA -Culture – CT, Mastoid X-ray
TTT Medical → To get it Dry Only Surgical Mastoidectomy
Antibiotics – Aural toilet – Avoid water – Control RF Open Remove posterior wall of EAC → cavity for dry safe ear
Canal wall down
Surgical 1. Atticectomy: localized attic cholesteatoma
Dry for 3 m → Tympanoplasty 2. Modified radical: posterior Mesotympanum
(myringoplasty ± ossiculoplasty) → Restore Hearing 3. Radical: Extensive to inner ear (SNHL)
 Persistent Active → Tympanoplasty Closed Preserve posterior wall of EAC →Save anatomy
(myringoplasty + Mastoidectomy → Control infection, Restore Hearing) Canal wall up localized cholesteatoma with serviceable hearing

Complications of OM
Spread of Infection Beyond Middle ear → Bone erosion or Retrograde thrombophlebitis
Cranial Mastoiditis – Pertositis – Labyrinthitis – Ottitic Facial palsy
Intracranial Meningitis – Epidural and Subdural abscess – Temporal lobe abscess - lateral sinus thrombophlebitis
Extracranial Otitis externa – Mastoid abscess – jugular thrombophlebitis
Def Inflammation of Bony septa between mastoid air cells → Most common Cranial complication
Path 1. Acute Coalescent mastoiditis: Pus accumulation → Septa Erosion → Coalescence to abscess cavity
2. Subperiosteal abscess: Spread abscess to cortex
3. Mastoid fistula: Pus pressure necrosis of skin
C/P Fever and throbbing pain, Pus discharge from skin if fistula
Ex Tenderness Tip (most superficial) – Antrum (largest) – Posterior (Emissary vein)
Acute Mastoiditis

Swelling Post-auricular Push Down, forward Bezold Deep to sternomastoid

Zygomatic Spread anterior Citelli Deep to Posterior belly of digastric
OT TM → Perforation or Congestion
EAC →Sagging of posterior bony wall by edema from osteitis (preantral cells)
Otorrhea: Profuse, Mucopurulent, Fetid + rapid reaccumulate (+ve Reservoir sign)
TF CHL
INV X-ray – CT – Aspiration, Culture
TTT Antibiotics + Analgesics + Myringotomy for 48 h
Surgical: cortical mastoidectomy if failed medical or subperiosteal abscess (Schwartz)
Def Inflammation of apex of Petrous part of temporal bone → Mostly associated with mastoiditis esp. old age + DM
P
etrosi C/P Gardienger syndrome → Otorrhea (CSOM) – Convergent squint (Abducent palsy) - Retroorbital pain (trigeminal ganglion)

tis TTT Same as mastoiditis + drainage of petrous apex

Otitic Labyrinthitis
Localized Diffuse
Def Localized inflammation of Inner ear by OM by Fistula Diffuse inflammation of inner ear secondary to OM
ETO Cholesteatoma Bony erosion → Spread infection 1. Diffuse Serous → No pus + Reversible SNHL
Lateral semicircular canal 2. Diffuse Suppurative → Pus + Irreversible SNHL
C/P Induced vertigo: Transient, recurrent by C/P of active CSOM
Ear manipulation, loud noise (Tulio Phenomena) Vertigo, nystagmus, SNHL, Tinnitus
Fistula test: vertigo, nystagmus by pressure change in EAC Spontaneous nystagmus (toward diseases in serous – toward normal in suppurative)
Tragus pressure or OTO Ex Absence caloric response in suppurative
TTT Radical mastoidectomy + Close by Graft temporalis fascia Medical: Antibiotics + Labyrinthine sedative by anti-vertigo drugs
Surgical: Radical mastoidectomy (serous) ± labyrinthectomy (suppurative)
ASOM By Congenital dehiscence of canal Myringotomy
Facial
Palsy

CSOM By Cholesteatoma erosion of canal Radical mastoidectomy + Facial Decompression

Mastoiditis Spread of infection Cortical mastoidectomy + Facial Decompression
Def Thrombosis of transverse (Sigmoid) sinus by extension of infection from OM
C/P Peri sinus abscess Headache – low grade fever
Peri phlebitis Bacteremia → Fever (continuous like typhoid – periodic like malaria) + Rigors
Lateral Sinus

Thrombus Occlusion →↑ ICT

+ve Crow sign → No retinal BVs Dilation if compressed IJV
+ve Tobey Ayer (Queckensted) → No ↑ CSF pressure if compressed ipsilateral IJV
Emboli Cavernous sinus – IJV - mastoid emissary vein → Geisinger sign (tender posterior mastoid)
INV CBC – Culture – CTA, MRA
TTT Medical: Antibiotics and Anticoagulant Surgical: Exposure of sinus & removal thrombus