Chapter 3 Injury of the Tympanic Membrane Injury of the Tympanic Membrane •Definition Diverse circumstances may responsible for injury or rupture of the tympanic membrane, and the early treatment of such injury is of great importance Injury of the Tympanic Membrane • Causes • Direct trauma: attempts to remove wax or foreign bodies by the unskilled. • Fracture of the temporal bone. • Stapes surgery • Blast, gunfire, rapid descent in aircraft • slap or box on the ear. • Barotraumas. Injury of the Tympanic Membrane • Symptoms • Pain. acute pain ,bloody discharge from the meatus. • Tinnitus. • Deafness. • Vertigo. Injury of the Tympanic Membrane • Sings • The drum is perforated and the perforation is in the pars tensa----- because it is less accommodating to increase of pressure in the external ear. • The perforation has bleeding points on the edges Injury of the Tympanic Membrane • Sings • If it is caused by a slap or box on the ear, the perforation is irregular but after a few days the irregularity of the edges disappears ----- because the retraction of the fibrous tissue in the tympanic membrane. Injury of the Tympanic Membrane • Treatment • The only local treatment is putting a little sterile cotton-wool in the ear not to allow any extraneous substances to go into the ear. • Do not clean out the ear or remove the clot. • Do not put in drops: • Do not syringe. And do not interfere. Injury of the Tympanic Membrane • Treatment • Watch the ear daily. • In most cases the edges of the tear will unite rapidly. If there are any signs of infection supervening, e.g. discharge, give systemic antibiotics to guard against development of infection. Chapter 4 Suppurative Perichondritis of Auricle Suppurative Perichondritis of Auricle •Definition •Suppurative perichondritis of auricle is a localized suppurative inflammation of the perichondrium of auricle. Suppurative Perichondritis of Auricle • Causes • Infection secondary to laceration, contusion or surgery incisions. • Extension of infection from diffuse otitis external or a furuncle of the meatus. • Common organisms ---Pseudomonas, staphylococcus, streptococcus, coliform. Suppurative Perichondritis of Auricle • Clinical manifestation • Initial symptoms are redness, swelling, heat, painful of the auricle. The auricle becomes warm, fluctuant, erythematous and indurate. Serum or pus collects in between the cartilage and the perichondrium and this interferes with the nourishment of the cartilage causing chondritis. Suppurative Perichondritis of Auricle •Clinical manifestation • As the infection advances and extends beyond the auricle, cellulitis of the surrounding skin will appear. Suppurative Perichondritis of Auricle • Clinical manifestation • In late stage of the disease, necrosis of the cartilage takes place and necrosed pieces of cartilage get extruded. When all such pieces have been expelled, discharge stops and fibrosis takes place. Suppurative Perichondritis of Auricle • Treatment • Appropriate antibiotic should be given as early as possible. • One should be careful in treating the case of trauma or infection of the auricle. • The infected ear should be cleaned and treated with warm saline compresses four times a day. Suppurative Perichondritis of Auricle • When abscess has formed, it must be drained promptly. • Incision should be give on the posterior surface of auricle to avoid cosmetic deformity. • If chondritis and cartilage necrosis has occurred, extensive treatment with the removal of all dead cartilage and overlying perichondrium and skin is necessary. Suppurative Perichondritis of Auricle • The wound should be dressed frequently. • While making aspiration or incision for drainage, the underlying healthy cartilage should not be damaged. • Culture and sensitivity of infected matter must be carried out to prevent stenosis of external auditory meatus, gauze impregnated with antibiotic solution should be lightly packed in the meatus. Suppurative Perichondritis of Auricle • Hospitalization is desirable in a diabetic patient or immune deficiency cases. • The disease can be avoided with proper sterilization in mastoid operation or any instrumentation on ear. Chapter5 Furuncle of external acoustic meatus Furuncle of external acoustic meatus furuncle of external auditory meatus Definition : It is staphylococcal infection of hair follicle of external acoustic meatus . Cause: boil occurs only in the outer 1/3rd part of the meatus. (1) There is injury of the skin (scratch the ear with a fingernail ,hairpin ,knitting needle) (2) unskillful removal of foreign bodies, syringing, swimming in the infected water, (3)suppurative otitis media with a discharging. furuncle of external auditory meatus • Symptom : ----pain, deafness, rise temperature • Sign : ----Marked tenderness on compression of tragus. ----Severe pain as soon as the pinna is touched or the speculum is inserted in the ear or moving the auricle. .. furuncle of external auditory meatus ---Total leucocyte count shows a definite leucocytosis with relative preponderance of the polymorphs ----Regional lymph nodes may be enlarged. ---If the boil bursts, there may be purulent or sanguineous discharge from the ear. ---After the boil has burst, pain, fever and leucocytosis go down. furuncle of external auditory meatus • Differential diagnosis (1)Acute otitis media: no pain on pulling the pinna or mastication. On examination, the external meatus is clear and the drum is congested, angrylooking and bulging out, if not perforated. furuncle of external auditory meatus (2)Postauricular subperioteal abscess: the apparent swelling is situated deep down in the bony meatus and not in the cartilaginous part. Also, there is no pain on pulling the pinna. (3)Polypus in the ear. no pain on pulling pinna and the fundus of the polypus is reddish in color and a probe can be passed round the fundus, whereas this cannot be down with a boil as it is attached on one side to the wall of the meatus. Furuncle of external auditory meatus • Treatment • 10 per sent ichthyol glycerin or concentrated magnesium sulphate paste wicks should be inserted into the meatus and replaced once or twice daily. • Hot fomentation with hot water bottle. Electricpad or short wave diathermy is helpful. furuncle of external auditory meatus • Treatment: • Analgesics • Be incised under a general anesthetic or local anesthetic. • broad spectrum systemic antibiotics • In cases of recurrence, the cause should be investigated e.g., diabetes, seborrhea, a septic focus, malnutrition etc. Chapter 6 Otitis Externa Otitis Externa • Definition • Otitis externa means generalized inflammation of the skin of the external auditory meatus. • It may be bacterial or mycotic (otomycosis), and is characterized by irritation, desquamation, scanty discharge, and tendency to relapse. • It may be acute or chronic. Otitis Externa • Causes • Otitis externa has a predilection for certain persons---some person (eczema) who allow water to remain in the ear after washing or bathing; those who frequent crowed swimming baths and not drying the ear ,traumatize them with the screwed-up corner of a dirty towel. • Otitis externa is frequently seen in torrid zoned area. • Ear-syringing • Scratch with fingernail Otitis Externa • Pathology • Common organisms responsible for otitis externa are hemolytic streptococcus, staphylococcus, Pseudomonas, bacillus proteus, colibacillus but more often the infection is mixed. Otitis Externa • Symptoms: • In acute stage: ---The external meatus looks markedly congested and inflamed, and purulent discharge. ---The condition is painful and pinna is tender to touch. ---There may be a rise of temperature. ---allergy, anxiety ,worries. Otitis Externa • Symptoms: • In chronic stage: ---The skin may be thickened. Other signs and symptoms are as for the acute stage but less marked. Otitis Externa • Sign: • Tenderness • Moist debris. • Red desquamatory meatal walls • Edema of the meatal skin. Otitis Externa • Treatment: (1)General treatment: a, The ears should be kept dry. b, Trauma to the ear should be avoided. c, A high standard of personal hygiene should be maintained. Otitis Externa d, The patient should be instructed to stick to a routine of life ensuring adequate rest, exercise and freedom from anxiety and tension. For relief of pain, analgesics should be prescribed. Otitis Externa Treatment: (2)Local treatment • a. In the acute stage: the external meatus should be gently cleaned out with cotton wool on a carrier dipped in liquid paraffin or by gently syringing with warm normal saline. Otitis Externa • The ear should then be packed with strip gauze soaked in 10% aluminium acetate. This procedure is repeated daily till the ear is dry. In more than half the cases this is achieved within a week or so, after which the ears are packed daily with 30% ammoniated mercury ointment. Otitis Externa • If the condition does not respond to the above treatment, neomycin 1/2 per cent and hydrocortisone 1 per cent in equal amounts, or soframycin hydrocotisone solution are used. • If still there is no response, ear swab should be taken for culture and sensitivity and treatment carried out as guided by its result. Otitis Externa • b, In chronic stage: swelling of the walls of the meatus, if present, should be reduced by daily packing with strip gauze soaked in 10% ichthyol glycerin. Once swelling has subsided, the treatment is the same as for the acute stage. Otitis Externa • Instillation of drops etc. without previous cleaning of the external meatus is much less efficacious. In doubtful cases, look for fungus and examine the urine. Antibiotics and antiallergics may be given if indicated. otomycosis Chapter 7 Cerumen impacted cerumen • Definition :Earwax (cerumen) is formed by special ceruminal glands in the cartilaginous ear canal, some have overactive glands that produce excessive accumulation of wax ,other have impacted cerumen. • Symptom ：deafness, tinnitus, acute pain impacted cerumen • Examination • Treatment---- removal: Wax hook Ear-syringing: instilling warm soda glycerin drops in the ear four times a day for 3-4 days----soft the dry and hard wax. Sucking Chapter 8 foreign bodies Foreign bodies • Causes： animal ,vegetable or lifeless : • There are two constriction in the external auditory meatus, foreign bodies usually in there ： • 1、the junction of the bony portion and the cartilaginous portion • 2、the isthmus： at the bony portion and is apart from tympanic membrane 0.5cm • Treatment :remove • Vegetable: syringing with alchol, or hook • Animal e.g. insects: plug a cotton wool soaked in chloroform—let it unconscious---remove Exercise 1. Choice true or false : When it is injury of the tympanic membrane, (1)the drum is perforated and the perforation is in the pars tensa. (2) If it is caused by a slap, the perforration is round at first, but after a few days turn into irregularity . (3) We should give ear drops and syringe immediately . 2. Choice true or false : When it is furuncle of external acoustic meatus: (1) It is staphlococcal infection of hair follicle of external acoustic meatus . (2) It is generalized inflammation of the skin of the external auditory meatus. (3) It has no pain on pulling the pinna . 3. Choice true or false : When it is otitis externa: (1) In acute stage, the external meatus looks markedly congested and inflamed, and purulent discharge. (2) In chronic stage, the skin may be thickened. (3) It is redness, swelling, heat, painful of the auricle. the auricle becomes warm, fluctuant, erythematous and indurated 3. Choice true or false : When it is otitis externa: (1) In acute stage, the external meatus looks markedly congested and inflamed, and purulent discharge. (2) In chronic stage, the skin may be thickened. (3) It is redness, swelling, heat, painful of the auricle. the auricle becomes warm, fluctuant, erythematous and indurated • Question : 4.(1)What is Suppurative Perichondritis of Auricle? (2)What is the main Clinical manifestation of it? 5.Which positions of ear are the foreign bodies usually in? answer • 1. (1)T (2)F (3) F • 2. (1)T (2)F (3) F • 3. (1)T (2)T (3) F • 4.(1) Suppurative perichondritis of auricle is a localized suppurative inflammation of the perichondrium of auricle. (2) Main clinical manifestation : At first: redness, swelling, heat, painful of the auricle. The auricle becomes warm, fluctuant, erythematous and indurated. Serum or pus collects in between the cartilage and the perichondrium -----chondritis. Then necrosis of the cartilage takes place and bad cartilage get extruded. At last fibrosis takes place. 5.There are two constriction in the external auditory meatus, foreign bodies usually in there ： • 1、the junction of the bony portion and the cartilaginous portion • 2、the isthmus： at the bony portion and is apart from tympanic membrane 0.5cm
