EAR I-II- III & IV

Done by : Hanan Omar Khushaim & Yara Alzamil

Reviewed by : Hadeel B. Alsulami

Correction File

Color Index :
Slides - Team 433 - Important Notes - Doctors’ Notes - Lecture notes book -Toronto notes
 Anatomy of the ear
The ear consists of:

1-External ear
2-Middle ear cleft
3-Inner ear
External ear:
Is Formed of Auricles and External auditory meatus (auditory canal). Both of them
are lined by skin
Auricles:
Is Formed of fibrous cartilage and lined by skin ,except the lobule (formed of fatty
tissue)
The five most important structures of Auricles are: Helix ,Antihelix, tragus, concha
and lobule

A B

So in case of .but in case of

Perichondritis in pic(A) any skin
(inflammation of problem like
connective tissue that Erysipelas (B),
surrounds the cartilage) all of auricle is
the lobule is not affected affected.

External auditory canal:

The external auditory meatus (2.5 cm) is an S shaped canal (to protect the eardrum
and middle ear.
During examination you should pull the auricle posteriorly and superiorly to straighten the
canal).

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The auditory meatus consists of
[Link] part (lateral 1/3):
• it develops at birth and formed by elastic cartilage and coverd by skin which
means it can get any skin disorders
and contains
• hair follicles ceruminous glands (which secrete wax),: prevent particles from
entering the ear
• sebaceous glands : to keep the skin wet
[Link] part (medial 2/3):
it develops after birth (for conduction of sound)
● The narrowest portion is at the bony-cartilaginous junction. (The skin is thin and
easy to be injured during examination. (Another area of constriction is at the
tympanic membrane.

Tympanic membrane:

It forms the partition between the external auditory canal andthe middle ear.
Parts:
A. Pars Tensa, taut.(greater part) B. Pars Flaccida, thin and lax(triangular).
The Tympanic membrane consists of three layers:
A. Outer layer: stratified squamous epithelium (skin) continuous with skin of auditory
canal , ectodermal origin. (epithelial)
B. The middle layer :or lamina propria fibrous layer, mesodermal in origin. (present only
in pars tensa. which makes pars flaccida more prone to perforation) (fibrous)
C. The inner layer, endodermal in origin, comprising the middle ear mucosa. (mucosal)
• normally, it is gray or transparent in color. Red means it’s inflamed. It is normally
tense which is essential for normal hearing.
• Since the tympanic membrane is translucent, it possible on examination to see
the underlying malleus and part of the incus.

Nerve Supply of External Ear:

• Cervical II & III (greater auricular and lesser occipital).
• V cranial nerve (auriculotemporal).
• X cranial nerve (auricular or Arnold’s).
• Fibers from VII cranialnerve.
Blood supply:
Richly supplied by branches from the external carotid

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 2-Middle ear cleft
Formed of:
A. Eustachian tube(pharyngotympanic tube).
B. Tympanum (Middle ear cavity).
C. Mastoid antrum and hair cells.
-it is a narrow slit-like cavity in the petrous part of temporal bone.
Lining of middle ear:
Mucous membrane consists of stratified cuboidal epithelium, which changes to
pseudostratified ciliated epithelium around the mouth of the Eustachian tube.
(ciliated columnar epithelium anteriorly and cuboidal or flat elsewhere)
A-Eustachian tube (3.7 cm):
Connect the middle ear cavity with nasopharynx.
Lies adjacent to the ICA (internal carotid artery).
Yawning, Swallowing, eating; open up the ET
Parts of Eustachian Tube:
• Lateral ⅓ is bone.
• Medial ⅔ isfibro-cartilaginous.
* Junction between 2 parts is isthmus, narrowest
part of the tube.
ET reaches downward, forward and medially from
anterior part of tympanic cavity to lateral wall of
nasopharynx. It is lined by ciliated columnar
epithelium
Physiology of Eustachian tube:
•It opens actively by contraction of
tensor veli palatini and passively by
contraction of levator veli palatini (it
releases the tension in tubal
cartilage).

• Closed by elastic recoil of elastin

hinge + deforming force of
Ostmann fat.

Protection Ventilation Drainage

The 45 angle is
protective form
infections

Difference
between ET of
infant and
adult.
THTH

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B-Tympanic cavity (middle ear cavity):
Contents of the cavity are:
● Ossicles: malleus, incus and stapes.
● Intratympanic muscles: tensor
tympani and stapedius.
● Chorda tympani, responsible for
taste sensation (branch of facial
nerve)
● Tympanic plexus (branch of cranial
nerve IX)
● AIR (for sound conduction)

Tympanic cavity is divided to

● Epitympanum (upper part)
● Mesotympanum (middle part)
● Hypotympanum (lower part)
The Stapes receives the insertion of stapedius muscle. Handle of Malleus receives the
insertion of Tensor tympani muscle. Contraction of the stapedius muscle restricts the
movement of the stapes (this is considered as a physiologic reflex that protects the inner
ear from very loud sounds (Attenuation reflex).

Content of Tympanum (Middle Ear Cavity)

Roof: tegmen tympani(part of
temporal bone) separates the cavity
from middle cranial fossa.

Floor: thin bone separates the cavity

from the superior bulb of internal
jugular vein.

Anterior wall: thin bone that

separates the cavity from internal
carotid artery and there are two
openings in it one for the auditory
canal and the other is canal of tensor
tympani.
Posterior wall: aditus (opening) to
mastoid antrum superiorly and
pyramid for stapedius inferiorly.
Lateral wall: formed mainly by tympanic Medial wall: lateral wall of inner ear
membrane and above it is squamous part of which has the oval and round
temporal the attic or epitympanic recess. windows, the promontory (formed by
1st turn of cochlea) and prominence of
facial canal

Clinical importance of walls of middle ear:

● Fracture of temporal bone (roof of middle ear cavity) will be presented by either CSF
otorrhea or rhinorrhea .
● Lateral sinus thrombosis secondary to otitis media (posterior wall).

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Nerve supply of middle ear:
Sensory nerve supply of mucosa of middle ear:
• Tympanic branch of the glossopharyngeal nerve.
• Auriculotemporal branch of the trigeminal nerve.
Motor nerve supply of middle ear muscles:
• Stapedius muscle supplied by the stapedial branch of the facial nerve.
• Tensor tympani muscle supplied by the mandibular division of the
trigeminal nerve.

Referred earache:
(Pain in the ear due to a disease in an area supplied by a nerve
that also supply the ear)
• CII, CIII :Neck injury, cervical spondylosis
• CN5: dental infection, sinonasal disease.
• C9: tonsillectomy or tonsillar carcinoma or tonsillitis
• CN10 :Tumors of the hypopharynx, larynx, or esophagus.

C-Mastoid antrum and air cells:

Situated in the postior portion of

petrous temporal bone
Anterior: opening of the aditus (means
entrance)
Medial :post and horizontal
semicircular canals
Roof (tegmen antri)
Lateral :squama and macewen’s
triangle
-Air-containing cells of the mastoid process are continuous with the air in the
middle ear.
• Pneumatization is complete between the sixth and twelfth years of life.
• Normal tubal function is a prerequisite for biologically active, healthy
Middle ear mucosa, and thus for the normal process of pneumatization.

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3-Inner ear Consists of:
A-Osseus labyrinth bony labyrinth
B-Perilymph
C-Membranous labyrinth

[Link] (Osseous) Labyrinth, its [Link] Labyrinth, its parts:

parts: • Cochlear duct
• Bony Cochlea • Saccule and utricle
• Vestibule • Membranous semicircular ducts
• Bony semicircular canals
Its contents: Its contents:
• Perilymph fluid (Like ECF) • Endolymph (Like ICF)
• Membranous labyrinth • Sensory epithelium:
o Cochlea: organ of Corti (has inner and outer hair cells,
responsible For hearing) – (each part of the cochlea
responds to specific kHz to conduct to the nerve)
o Utricle and saccule: maculae (The saccule tells you
when you stop moving and the utricle is responsible
for head tilting)
o Semicircular canals: cristae
D-Internal Auditory Canal, Central connection of Central connection of cochlear
Contains: vestibular nerve
• Vestibulocochlear nerve
• Facial nerve

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 Physiology of the ear

Functions of the -Auditory functions:

external ear Sound conduction
Increase sound pressure by the resonance function.
-Protection of the middle ear:
● Curvature
● Cerumen(acidic and sticky kills bacteria)

Functions of ● Protection
Eustachian tube ● Ventilation
● Drainage (of mucosal secretion)
Tube is straight in children which increases their risk of otitis media,
also Secretions or food may enter the tympanic cavity more easily
when the baby is supine particularly during feeding causing otitis
media.

Functions of middle • Conduction of sound

ear • Transformer mechanism
o Hydraulic action
o Ossicular leverage
• Protection to the inner ear
o stapedial reflex

Functions of inner Hearing Function:

ear Transduction of sound to action potentials.
Vestibular Function:
Participate in maintaining body balance
The mechanisms of maintaining body balance: Brain stem: is the
center of balance. It’s connected to : Cerebellum to coordinate muscle
tone and Cerebral cortex for the feeling of space. Input:
Proprioceptive (sensation) Visual Vestibular. Output: gives
information to: Postural muscles and Ocular muscle. (Team 431)

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 Disease of external ear and acute otitis media ear
Conditions of the pinna
• Conditions of the external auditory meatus: Conginital , wax
1-Congenital anomalies of external ear:
Protruding ear Condition is due to absence of anti-helix.
(bat ear) (A) Treatment :
Pinnaplasty
Otoplasty ( they construct anti-helix)
(Do it after school age )
Preauricular The sinus can get infected, it needs to be excised
sinus: (B) surgically.
It’s a common congenital malformation
characterized by a nodule, dent or dimple
located anywhere adjacent to the External ear.
Management:
Systemic antibiotics. If an abscess is present,it
must be incised an drained.
Microtia (C) It’s a condition in which the external portion of the ear (the auricle) is
malformed. There is also Narrowing or absence of the external auditory
canal.
Absence or severe malformation of the external ear, as in Treacher
Collins syndrome

Atresia (D) It’s the total absence of the Auricle most often
with narrowing or Absence of the external
auditory meatus.

Accessory It’s a type of ear anomaly in the tragus area.

auricle (E) Treatment :
• Plastic reconstruction
• Bone anchored hearing aid (BAHA)

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Wax
Earwax blockade can lead to 20-30% reduction in hearing.
-Cerumen Impaction:
Etiology
ear wax: a mixture of secretions from ceruminous and
pilosebaceous glands, squames of epithelium, dust, and
debris
Risk Factors
• hairy or narrow ear canals
• in-the-ear hearing aids
• cotton swab usage,
• osteomata
Clinical Features
• hearing loss (conductive)
• ± tinnitus, vertigo, otalgia, aural fullness
Treatment
• ceruminolytic drops (bicarbonate solution, olive oil,
glycerine, , Cerumenex®)
• syringing (used in the past)
• manual debridement (by MD)

2-Trauma to the auricle

- Lacerations
- Hematoma auris
Treatment: Excise fibrous tissue
‫ ـ‬Apply pressure dressing
- drain.

3-Perichondritis of pinna:
Infection of the auricular cartilage that leads to necrosis and deformity.
(cauliflower deformity from untreated infection)
it may follow:
• Haematoma,
• Surgery or otitis externa & piercing
• Commonly caused by Pseudomonas

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Signs & Symptoms :
Fever, pain, redness, and swelling (team 433)
MANAGEMENT
ABX ,Incision & drainage ,Removal of necrotic tissue
*(Any cartilaginous organ that forms a hematoma must be drained as
early as possible, to prevent necrosis as the cartilage is avascular

4-Otitis externa
1-Acute otitis externa: (infective) :
Bacterial infection involving the skin of the external canal
Pathophysiology: Causes
aggressive washing the wax or retention water
risk factors:
• Microtrauma (cotton swabs,fingernails ),
• associated with swimming (“swimmer’s ear”)
• mechanical cleaning (Q-tips®), skin dermatitis, aggressive scratching
• devices that occlude the ear canal: hearing aids, headphones, etc.
• allergic contact dermatitis, dermatologic conditions (psoriasis, atopic dermatitis)

Pathogens;
pseudomonas aeruginosa, staphylococcus (furuncle) (in 90% it is bacterial)
fungus: Candida albicans, Aspergillus niger can also cause it.

Symptoms :
• Pain (otalgia) increased by jaw movement
• Irritation & pruritus (itchiness)
• Discharge (scanty)
• tragal tenderness
• edematous erythematous EAC,
• conductive hearing loss Deafness (mild)
Signs
• Meatal tenderness, especially on movement of the pinna or compression of the
tragus In acute otitis externa, pain is aggravated by movement of auricle (traction of
pinna or pressure over tragus) *Pulling on the pinna is extremely painful in otitis
externa, but is usually well tolerated in otitis media
• Moist debris, often smelly and keratotic Patient may also have otorrhea (sticky yellow
purulent discharge
• Red desquamated skin and oedema of the meatal walls
• posterior auricular lymphadenopathy
MANAGEMENT
Suction cleaning, Ear drop,Analgesia and antibiotic.
(antipseudomonal otic drops (e.g. ciprofloxacin) or a combination of antibiotic and
steroid)

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*systemic antibiotics if either cervical lymphadenopathy or cellulitis is present.
Treatment of otitis externa/dermatitis ;
1. Clean the ear canal thoroughly (q..).
2. If there is any suspicion of a sensitivity reaction, stop topical treatment with
antibiotics.
3. The ear may be treated by a glycerine and ichthammol wick, or an emollient
ointment.
4. Apply steroid ointment sparingly.
5. Severe cases may require admission to hospital.
Herpetic lesions:
Ramsay hunt syndrome= herpes simplex type 1 virus
causing otitis externa
Signs & Symptoms :
Severe pain, Vesication, Cranial nerve lesion
deafness SNHL, Vertigo, Facial nerve palsies,
RX:
oral and topical acyclovir early, if infection is involving facial nerve give steroid
Herpes simplex (acyclovir in severe cases),herpes zoster oticus
Otomycosis :
Aspergillus ,candida
Risk factors : moist ear (swimmers ) , Diabetes mellitus
signs & symptoms :
moist tissue –paper dotted gray membrane, pruritic, (NEWSPAPER
APPEARANCE)
RX:: suction cleaning Fungicides :nystatin ,econazole
2-Reactive otitis externa:
A-Eczematous otitis externa: Allergic dermatitis
Signs & Symptoms ;
pruritis - redness oedema - mild pain- dry scaly skin
Management :
• recognize the allergen
• Hydrocortisone cream
• Antihistamin
• Coal tar ointment ,silver nitrate ,canalplasty (chronic stage)
B-Seborrhoeic otitis externa :
Greasy, scaling and crusting condition
Causes: abn sebum and wax
Signs & Symptoms :
Greasy yellow scales, itching
Management :
Shampoo selenium sulphide and ketoconazole
Ointment; salicylic acid and sulpher 2%

Malignant otitis externa (osteomyelitis of skull base):

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Pseudomonas infection occurring in elderly diabetic patients .
Definition
• osteomyelitis of the temporal bone
Epidemiology
• occurs in elderly diabetics and immunocompromised patients
SIGNS & SYMPTOMS :
• Granulation tissue in EAC at the bony cartilaginous junction
• Persist otalgia, otorrhea
• Cranial nerve involvement VII, IX ,X XI ,XII,V,VI
e.g.
Diagnosis:
CT scan, bone scan ,culture
Management: (admit patient)
diabetic control,
Prolonged parenteral anti- pseudomonas antibiotics , ear drop,
debridement and hyperbaric oxygen.

inflammation of the middle ear

5-Acute otitis media
Inflammation of the middle ear cavity (<3 weeks)
*most frequent diagnosis in sick children visiting clinicians’ offices and most common
reason for antibiotic administration peaks in winter
Pathophysiology :
ET dysfunction ,spread of the infection via submucosal lymphatic or direct spread,
primary defect causing AOM: Eustachian tube dysfunction/obstruction
stasis/colonization by Pathogens
Predisposing Factors (
1. Eustachian tube dysfunction/obstruction/abnormality
• swelling of tubal mucosa
o upper respiratory tract infection (URTI)
o allergic rhinitis
o chronic rhinosinusitis
• obstruction/infiltration of Eustachian tube ostium
o tumour: nasopharyngeal carcinoma (adults)
o adenoid hypertrophy (not due to obstruction but by maintaining a source
of infection)
o barotrauma (sudden changes in air pressure)
• inadequate tensor palati function: cleft palate (even after repair)
• Abnormal Eustachian tube
o Down syndrome (horizontal position of Eustachian tube)
o Crouzon syndrome
o Cleft palate
o Apert syndrome
2. Disruption of action of
• cilia of Eustachian tube: Kartagener's syndrome

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 • mucus secreting cells
• capillary network that provides humoral factors, PMNs, phagocytic cell
3. immunosuppression/deficiency due to chemotherapy, steroids, DM,
hypogammaglobulinemia, cystic fibrosis
Pathogens;
S,pneumonia, H, [Link]
• commonly due to bacterial/viral co-infection, in 90% cause is viral
Risks:
Craniofacial abnormality ,Recurrent URTI(recurrent upper respiratory tract infection) ,
Day care, Bottle feeding, smoking, immunological disorders IgA ,IgG deficiencies, Ciliary
dysfunction, Adenoid hypertrophy GERD, NGT(nasogastric tube)
Signs & Symptoms :
Triad of otalgia, fever (especially in younger children), and conductive hearing loss
other:
acute otorrhea ,aural fullness, tinnitus ,fever, unexplained irritability, upper respiratory
symptoms, poor sleeping, anorexia
Hyperemic TM ,non mobile bulging TM ,air fluid level opacification of TM
Otoscopy of TM
• hyperemia
• marked discolouration (hemorrhagic, red, grey, or yellow)
• bulging, pus may be seen behind TM
• loss of bony landmarks: handle and long process of malleus not visible

Hyperemia Bulging (fluid behind TM

Management :
oral Antibiotics for 10 days, 1st line treatment (no penicillin allergy):amoxicillin: 2nd line
treatment: cefprozil
Antipyretics , analgesia oral and nasal decongestants
Myringotomy (draining the pus through poking a hole into tympanic membrane)
►severe otalgia
COMPLICATIONS:
• Extracranial
o hearing loss and speech delay (secondary to persistent MEE)
o TM perforation
o extension of suppurative process to adjacent structures (mastoiditis,
petrositis, labyrinthitis)
cholesteatoma
o facial nerve palsy
o middle ear atelectasis,
o ossicular necrosis
o vestibular dysfunction

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 • intracranial
o meningitis
o epidural and brain abscess
o subdural empyema
o lateral and cavernous sinus thrombosis
o carotid artery thrombosis
o facial nerve paralysis
• other
o mastoiditis
o labyrinthitis
o sigmoid sinus thrombophlebitis

Acute mastoiditis:
Definition
• infection (usually subperiosteal) of mastoid air cells, most commonly seen
approximately two
weeks after onset of untreated or inadequately treated acute suppurative otitis
media
• more common in children than adults
Etiology
• acute mastoiditis caused by the same organisms as AOM: S. pneumoniae, H.
influenzae
Features: recent URTI, ear discharge, fluctuant tender swelling and fever.
It has a Classic Triad of
• Otorrhea
• Tenderness to pressure over the Mastoid and
• Retroauricular swelling with protruding ear
Management
• Systemic Antibiotics
• analgesia
• URGENT REFERRAL.
(early infection to mastoid=>admit+
Antibiotics but if infect reaches
subcutaneous tissue urgent evacuation
is needed.)
• the white (hyperdense areas in CT is pus in mastoid)
Recurrent acute otitis media:
Three or more attacks over a 6-months period or (five or six attacks in a year).
Management of recurrent acute otitis media :
Myringotomy with pressure equalization tube and Long-term low dose
antimicrobials.
Secretory otitis media, otitis media with effusion:
Definition :
Persistence of fluid in the middle ear space without evidence of infection.
• most common cause of pediatric hearing loss
SIGNS & SYMPTOMS

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 • nonmobile TM, air fluid levels, aural fullness, hearing loss,
o conductive hearing loss ± tinnitus (confirm with audiogram and
tympanogram (flat))
• fullness – blocked ear
• ± pain, low grade fever
• otoscopy of tympanic membrane
o discolouration – amber or dull grey with “glue” ear
o meniscus fluid level behind TM
o air bubbles
o retraction pockets/TM atelectasis
o most reliable finding with pneumotoscopy is immobility
Diagnosis tympanometry
Treatment :Antibiotics , Myringotomy (drains pus, rarely done) with pressure
equalization tube.(as the TM is covered by skin the tube will fall by itself with time
with the skin superficial layer)
Complications of Otitis Media with Effusion
• hearing loss, speech delay, learning problems in young children
• chronic mastoiditis
• ossicular erosion
• cholesteatoma especially when retraction pockets involve pars flaccida
• retraction of tympanic membrane, atelectasis, ossicular fixation

Chronic otitis media

• Chronic Otitis Media is an infection involving a part of the middle ear cleft or all
its components that is more than 3 months.
• The tympanic membrane is intact (not perforated) in Chronic non-suppurative
otitis media, while in chronic suppurative otitis media it is not intact (perforate)
• To have a discharge coming through the external canal the membrane has to be
perforated.
Classification of chronic otitis media
A-CHRONIC NONSUPPURATIVE OTITIS MEDIA ( B-CHRONIC SUPPURATIVE OTITIS
no pus coming through external canal ) MEDIA(CSOM)
( pus + perforation of drum)

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Otitis media with effusion (OME) • Tubo-tympanic (TT) (safe)

Example : child has URTI → viral→ spread to o No risk of serious complications

middle ear through eustachian tube lead to o The perforation at the middle (central
inflammation which release fluid , 90 % will ) of tympanic membrane .
recover within 3 months and some will not as a
result of damage to the mucosa (irreversible )
or obstruction of eustachian tube→ collection
of fluid in the middle ear → hearing loss . ● Attico-antral (AA) (unsafe)
○ high risk of developing
-If not treated properly or not cured by itself it complications.
could lead to adhesion in the tympanic
membrane in middle ear (adhesive otitis
media).

● Adhesive otitis media

Middle ear is like a box if the tympanic
membrane adherence to the promontory
of middle ear leading to inability to elevate
it from the promontory .It could be
complete or partial.

A-CHRONIC NONSUPPURATIVE OTITIS MEDIA:

1 - Otitis media with effusion =secretory OM = Glue ear =Catarrhal otitis
media.
Middle ear filled with serous or mucoid fluid , No purulence , Often present after
otitis media is treated with antibiotics, Most will clear within 3 months .
Previously thought sterile , 30-50% grow in culture , Over 75 % PCR+ , Usual
organisms .
Etiology :
BACTERIA VIRUS
• Strep pneumonia. • RSV
• Moraxella cat. • Rhinovirus
• Haemophilus influ. • Parainfluenza virus
• Influenza virus
Management of otitis media with effusion:
Observation – many European countries wait 6-9 months prior to placement of
ear tubes.
Antibiotics: Meta-analysis shows beneficial short-term resolution of OME.
• Audiogram at 3 months with persistent effusion to determine impact on
hearing
Surgical treatment: Tympanostomy Tubes.
• chronic OME >3mos with hearing loss and/or speech delay is an indication for
tympanostomy tube placement
• Bypass Eustachian tube to ventilate middle ear

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 2- Adhesive otitis media
Formation of adhesion in the middle ear after reactivation and subsequent healing of either
CSOM or OME.
clinical Features :
• history of CSOM or OME
• Deafness is usually the only symptoms
• TM shows various structural changes
• Lack of middle ear ventilation results in negative pressure within the tympanic cavity.
• The ear drum retracts medially onto structures within the middle ear.(manly ossicles).
• The result of long standing Eustachian tube dysfunction.
• The drum loses structural integrity and becomes flaccid.
• Contact between the drum and the incus or stapes can cause bone erosion at the
Incudostapedial joint ( IS) joint
Can sometimes be treated with tympanostomy tubes .

Middle ear Atelectasis (TM retraction):

• The result of long standing eustachian tube dysfunction.
• The drum loses structural integrity and becomes flaccid .
• Contact between the drum and the incus or stapes can cause bone erosion
at the IS joint .
• Can sometimes be treated with tympanostomy tubes
Treatment:
Observation every 6 months
Surgical treatment : Ventilation Tube is the treatment of choice in children
Hearing aid will help a lot

B-CHRONIC SUPPURATIVE OTITIS MEDIA(CSOM) with and without cholesteatoma

ETIOLOGY: 3D of CSOM :
• Environmental Duration > 3 months despite treatment
• Genetic Discharge mucopurulent otorrhea
• Previous OM Deafness Perforation/Ossicular chain
• Upper respiratory tract infection dysnfunction
PATHOLOGY :
• Signs of supportive infection
o Discharge (Otorrhea)& perforation (permanent)
o Chronic inflammatory reaction in the mucosa and the bone (osteitis )
• Signs of healing attempts:
a. granulation tissue & polyps
b. Fibrosis & Tympanosclerosis
Symptoms of CSOM:
• Otorrhea
o Intermittent, profuse & odorless in TT type
o Persistent, scanty &malodorous in AA type
• Deafness
• Tinnitus .

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 N.B. any other symptoms means complication
Clinical features of CSOM (Clinico-pathological types)
TUBO-TYMPANIC (SAFE) ATTICO-ANTRAL (UNSAFE)

● Simple perforation ● Chronic (persistent), scanty ,offensive

● Intermittent non offensive (odorless , and bloody ear discharge
)non bloody ear profuse discharge ● On examination marginal perforation
● On examination (central perforation) ● You may see cholesteatoma

Tubo-tympanic Safe:The squamous Attico-antral (Cholesteatoma) The

Epithelium will find its way out Perforation is marginal, so it goes to
the bone.

OTOSCOPIC EXAMINATION:
• DISCHARGE
○ Present in TT type if active but may be absent
○ Usually is present in AA type
• PERFORATION
o Central in TT type
o Marginal or attic in AA type with cholesteatoma
• Polyps (if you see a polype in the ear you should suspect cholesteatoma to confirm it
do CT) , granulation tissue, tympanosclerosis
✓ polyps means there's a chronic non-healing process is going and most likely there's
cholestatoma
Treatment of Tubotympanic CSOM:
Conservative treatment:
(Until we move the patient from active to inactive)
● Treatment of any predisposing factors
● Keep the ear dry
● Ear toilet
● Antibiotics
● Removal of polyps and granulations
Tympanoplasty :

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An operation performed to eradicate disease in the middle ear cavity and to reconstruct the
hearing mechanism. If there’s ossicles problem we do ossiculoplasty (We replace the missing
ossicle with prosthesis)

Aims of tympanoplasty:
• To close the perforation
• To prevent reinfection
• To improve hearing
• Myringoplasty: An operation performed to repair the tympanic membrane.
Treatment of attico antral CSOM
Removal of cholesteatoma by mastoid operation
There is no conservative therapy for cholesteatoma
Surgical: mastoidectomy ± Tympanoplasty± ossicular reconstruction

Conc treatment AA CSOM:

• Radical mastoidectomy:
An operation in which the mastoid antrum and air cells, attic and middle ear are converted
into common cavity, exteriorized to the external [Link] tympanic membrane, malleus
and incus are removed leaving only the stapes in situ.
• Modified Radical Mastoidectomy:
An operation in which the mastoid antrum and air cells,attic and middle ear are converted
into common cavity, exteriorized to the external [Link] tympanic membrane and the
ossicles remnants are retained.
Aims of radical & modified radical mastoidectomy:
- Safety
- Dry ear
- Preserve hearing

What is Cholesteatoma :
A cyst composed of keratinized desquamated epithelial cells occurring in the
middle ear ,mastoid ,and temporal bone .
• Skin in the wrong place. The superficial layer of TM is squamous epithelium–
usually there’s shedding of the lining epithelium.
PATHOGENESIS :
• Implantation
o congenital : presents as a“small white pearl” behind an intact tympanic
membrane(anterior and medial to the malleus) or as a conductive hearing
loss

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 • acquired (Primary & Secondary)
• Metaplasia
• Epithelial migration
Congenital (with intact TM) Acquired ( as a result of infection)

Effect of cholesteatoma : INVESTIGATION :

• Keratin encourages • Audiometry
• persistence of the infection • Bacteriology (swab)
• Matrix causes bone erosion • Imaging : We do CT scan to see
its extension

The complication of acute and chronic otitis media

Predisposing factors:
Most of the times otitis media is cured without any complications
• Virulent organisms
• Chronicity of disease
• Presence of Cholesteatoma and bone erosion. (cholesteatoma: the
presence of skin “white keratin material”in abnormal location that will
secretes enzymes and eat up the bone,causing a pathway for disease to
spread. Anatomically there is no skin in the middle ear)
• Obstruction of natural drainage e.g. by a polyp. (Natural drainage :
eustachian tube)
• Low resistance of the patient (patient’s immune status)

Pathways of infection:
• Extension of infection is by bon erosion due to a cholesteatoma.
• Vascular extension (retrograde thrombophlebitis)
• Congenital dehiscence
• Fracture lines
• Round or oval window membrane to the labyrinth Dehiscence due to
previous surgery

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 Classification n

extracrinal intratemporal intracrinal

1- Extension to the 1-Labyrinthine 1-Subdural abscess

neck Fistula

2. Facial Nerve 2--Extradural

2- Bezold Abscess
paralysis abscess

3. Acute Mastoiditis
4-Petrositis (apical 3-- Meningitis
apicitis)

4-Venous sinu
thrombosis

5- Brain Abscess

Intracranial complication
1-Extradural abscess
(Collection of pus against the dura in the middle or posterior cranial fossa)
Outside the dura of the lateral venous sinus is called perisinus abscess.
★ What are the natural barriers between brain and temporal bone?
Bone and meninges
Clinical picture :
[Link] headache on the site of OM.
[Link] discharge.
[Link]
4-Asymptomatic (discovered during surgery)
Diagnosis:
CT scans reveal the abscess as well as the middle ear pathology.
Treatment:
1- Mastoidectomy.
2- Drainage of the abscess
+IV ABx to prevent

Axial and coronal MRI showing extradural

abscess

2-Subdural abscess
(Collection of pus between the dura and the arachnoid. It’s a rare pathology)

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Clinical picture:
1– Headache without signs of meningeal irritation
2- Convulsions
3– Focal neurological deficit (paralysis, loss of sensation, visual field defects)
Investigation: CT scan & MRI
Treatment:
1– Drainage (neurosurgeons)
2– Systemic antibiotics
3 – Mastoidectomy.
The subdural abscess is within the dura (a white thin line). It’s a landmark to
distinguish between extra and subdural abscess
lumbar puncture should not be done as it can cause
hernation of the cerebellar tonsils. it is a neurological
emergency. A series of burr holes or a craniotomy is done to
drain subdural empyema intravenous antibiotics are
adminisetred to control infection. Once infection in under
control, attention is paid to caustive ear disease which may
require mastoidectomy

Meningitis:
(Inflammation of meninges (pia & arachinoid)
Pathology → Occurs during acute exacerbation of chronic unsafe middle ear
infection.
Meningitis is the most common intracranial complication of Otitis Media
Clinical picture:
General symptoms and signs: High fever, restlessness, irritability, photophobia
and delirium.
Signs of meningeal irritation: Kernig's and Brudzinski's sign
Diagnosis: Lumbar puncture.
Treatment:
Aims: Treatment of the complication itself and control of ear infection:
• Specific antibiotics.
• Antipyretics and supportive measures
• Mastoidectomy to control the ear infection

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4: Venous Sinus Thrombosis:
(Thrombophlebitis of the venous sinus)
Etiology→ It usually develops secondary to direct extension.
★ First irritation of the wall then progress to thrombus then either it will
regress or causes symptoms of obstruction (increase ICP, central nerve
palsy).

Clinical picture:
-Signs of blood invasion: (spiking) fever with rigors, chills and persistent fever
(septicemia).
- Positive Greissinger’s sign which is edema and tenderness over the area of the
mastoid emissary Vein. (Pressing on the mastoid process will cause tenderness and
edema because of small vessel blockage)
- Headache, vomiting, and papilledema (increase intracranial pressure) The 6th
cranial nerve might be affected because it is the longest cranial nerve passing
through the cavernous sinus.
Diagnosis:
• Clinical
• CT scan with contrast
• MRI, MRA, MRV
• Angiography, venography
• Blood cultures is positive during the febrile phase. Start clinical, blood culture
then imaging.
Treatment
– Medical:
• Antibiotics and supportive treatment.
• Anticoagulants
– Surgical:
• Mastoidectomy with exposure of the affected sinus and the intra- sinus abscess
is drained.

5-Brain abscess:
( Localized suppuration in the brain substance.)
● It is most lethal complication of suppurative otitis media
● Incidence→ 50% is Otogenic brain abscess
● Pathology→ Site: Temporal lobe or less frequently, in the cerebellum (more
dangerous).
Clinical manifestations:
general manifestations:
fever, lethargy, headache sever generaliztion worse in the morning
manifestations of rasied ICP (headache , nausea & vomiting)
the latter ususally projectile seen more often in cerebellar lesions.

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focal manifestations
temporal: Aphsia , hemianopia , paralysis
Cerebellar: ataxia, vertigo , mystagmus , muscle incoordination
Diagnosis:
CT scans / MRI.

Treatment:
Medical:
• Systemic antibiotics.
• Measure to decrease intracranial pressure.
Surgical:
• Neurosurgical drainage of the abscess .
• mastoidectomy operation after
• subsidence of the acute stage

Intratemporal complication
1- Labybrinthitis : if the infection spread from the middle ear to the inner ear and
would present with vertigo and sensory neuron loss.
2- Ossicular fixation or erosions
3- Labyrithine fistula
4- Facial nerve paralysis
6 -Mastoiditis /mastoid abscess

6 -Petrositis (apical apicitis)

What are the vascular structures that pass through temporal bone? Carotid and
internal jugular (vein more common than artery) may get affected from
thrombophlebitis (inflammation of the lining wall of the vessels)

1- Labyrinthine fistula (most common)

Definition: Communication between middle and inner ear.
Etiology: It is caused by erosion of bony labyrinth due
cholesteatoma (iatrogenic caused by surgeries)
Most common in the: lateral semicircular canal

Clinical picture:
• Hearing loss (may show a sensorineural hearing loss)
• Attack of vertigo mostly during straining, sneezing and lifting heavy object.
(Pressure induced maneuver)
• Positive fistula test. Pressing on the tragus will cause pressure on the inner ear,
the pressure difference with cause imbalance and nystagmus (positive in 70%)
Diagnosis:
• High index of suspicion

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 • Longstanding disease
• Fistula test (clinical)
• CT scan of temporal bone
Treatment: Mastoidectomy

2. Facial nerve paralysis:

❏ Congenital or acquired (inflammation and erosion) dehiscence of nerve
canal
❏ It is possibly a result of the inflammatory response within the fallopian canal
to the acute or chronic otitis media
❏ Tympanic segment is the most common site to be involved
Diagnosis:
• Clinical
• May occur in acute or chronic otitis media
• Ct scan

How to differentiate between upper and lower Facial nerve palsy?

Lower: upper and lower parts of the face are affected
Upper: lower part of the face is affected (upper part has bilateral supply
from both hemisphere)

Treatment:
• Acute otitis media and acute mastoiditis (cortical mastoidectomy +
ventilation tube)
• chronic otitis media with cholestetoma (mastoidecomy ± facial nerve
decompresion )

3- Mastoiditis:
(Dr. Fatma said it was the most common) + this complication is seen more in
children + may give an appearance of a unilateral bat ear.
Definition: It is the inflammation of mucosal lining of antrum and mastoid air cells
system.
infection (usually subperiosteal) of mastoid air cells, most commonly seen
approximately two weeks after onset of untreated or inadequately treated acute
suppurative otitis media
Pathology:
• Production of pus under tension
• Hyperaemic decalcification
• Osteoclastic resorption of bony walls (causes bone fracture pus excrete
outside “subperiosteal abscess”).
There will be + Reservoir Sign in acute mastoiditis

Symptoms: Signs:
• Earache • Mastoid tenderness
• Fever • Sagging of posterosuperior meatal wall

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 • Ear discharge • TM perforation
• Swelling over mastoid
• Hearing loss
Diagnosis: (clinical + imaging)
Investigation:
•CT scan temporal bones
•Ear swab for culture and sensitivity
Treatment:
Medical treatment:
• Hospitalize (Admission)
• IV Antibiotics
• Analgesics
Surgical treatment:
• Myringotomy (surgical incision into the eardrum).
• Cortical mastoidectomy

4-Petrositis (apical apicitis):

An extension of infection from the middle ear into a pneumatized petrous apex
It’s an important complication, but it is rarely seen in a non-pneumatized apex.
Petrous temporal bone :
• Strongest bone in the skull.
• Bone harboring the middle ear.
• Petrous apex is the most anterior
part of the petrous
Next to it lies the ganglion of CN5 and
the abducent nerve (CN6)
DIAGNOSIS OF PETROSITIS
• Gradenigo’s syndrome
o Retro-orbital pain, due to trigeminal nerve involvement.
o Lateral rectus palsy (squint), due to Abducens nerve palsy.
o Discharge. Otitis media (persistent otorrhea).
✓ Gradinigo Syndrome is a Triad of:
o trigeminal neuralgia (CN5),
o diplopia OR retroorbital pain OR squint (CN6),
o increased ear discharge.
• Imaging
Treatment of petrositis
• Broad spectrum antibiotics which covers staphelococus areaus.
• Myringotomy if tympanic membrane was not perforated, t evacuate all the
discharge.

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 • Surgical drainage if
antibiotics failed,
mastoidectomy must be done
to remove the infection from
the ME and petrous
temporalic bone.

Other complications
Labyrinthitis is another important complication. It’s seen more with CSOM with
cholesteatoma. It involves ALL the inner ear. We treat it with IV Antibiotics and
antiemetics. Complications include: permanent imbalance, SNHL, chronic
labyrinthitis.

Extracranial complication
• Extension of infection to the neck Bezold abscess (extension of infection
from mastoid to SCM). The sternocleidomastoid and digastric muscle are
attached to the mastoid process and covered by a sheath, the mastoid
abscess can drag through and extend down to the neck (rare)

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