Ryan Martin Ko, M.D

Ryan Martin Ko, M.D.
CERUMEN
 Product of the sebaceous and ceruminous glands of the
external ear
 Types: wet or dry
 Functions: 1. vehicle
2. lubrication
3. prevents dryness
4. antibacterial
5. protection
CERUMEN
 Symptoms
1. ear fullness
2. ear pain or otalgia
3. hearing loss
 Treatment
1. Cerumenolysis w/ Sodium Docusate or soften w/ Mineral
or baby oil
2. removal by direct visualization (ear curette or suctioning)
3. irrigation
ACUTE OTITIS EXTERNA
OTITIS EXTERNA
Types:
1. acute circumscribed otitis externa/ furunculosis
2. diffuse otitis externa
3. malignant otitis externa
Predisposing factors:
1. change in pH of canal skin
2. environmental changes
3. mild trauma
OTITIS EXTERNA
Principles in management:
1. careful cleaning of the canal by suction or

cotton wipes
2. evaluation of discharge, canal wall edema
and TM, if possible
3. selection of appropriate medications
ACUTE CIRCUMSCRIBED
OTITIS EXTERNA
 Furunculosis
 Cause: infection of sebaceous follicle of EAC usually
by Staph. aureus
 Signs/ symptoms:
- pain
- tenderness on manipulation
- decreased hearing
- purulent ear discharge
- circumscribed swelling
ACUTE CIRCUMSCRIBED
OTITIS EXTERNA
treatment:
(+) abscess formation  drainage;
topical antibiotics
(-) abscess formation  local heat;
analgesics;
topical antibiotics (otic drops)
Polymyxin, Neomycin, Dexamethasone (PND)
Quinolones: Ofloxacin or Ciprofloxacin
DIFFUSE OTITIS EXTERNA
“swimmer’s ear”
Secondary to acute or chronic

otitis media
Etiologic agents:
- Pseudomonas other gram-
negative organisms
DIFFUSE OTITIS EXTERNA
1. pain
2. tenderness on manipulation
3. scanty ear discharge
4. diffuse swelling of whole ear canal
5. decreased hearing – occasionally
 Treatment
1. mechanical cleaning
2. cotton wick application
3. Otic drops (Quinolones)
MALIGNANT OTITIS EXTERNA
 causes: uncommon; P. aeruginosa
1. diabetic patients
2. immunocompromised and debilitated patients
3. elderly patients
 course:
- very destructive
- spread via fissures of Santorini to Parotid gland
- Osteomyelitis of temporal bone
1. pain on manipulation
2. TMJ pain
3. deep tenderness on palpation beneath the ear
4. otoscopy: intact TM; bone & cartilage
destruction; granulation tissues
5. cranial nerve problem especially VII
6. intracranial complications
Treatment
1. local debridement
2. IV 3rd Generation Cephalosporin or Quinolones
3. pesistence or extension of infection 
local excision
OTOMYCOSIS
 Causes:
1. ear cleaning with contaminated implements
2. diabetics
3. immunocompromised patients
4. chronic use of antibiotic otic drops
 Etiologic agents:
- Aspergillus
- Candida
OTOMYCOSIS
Signs/ symptoms
1. itchiness
2. diffuse swelling of EAC
3. mycelia or sporangia
4. discharge
5. decreased hearing – occasionally
OTOMYCOSIS
Treatment
1. clean ear thoroughly

2. clean again with antiseptic solution
3. dessicating agent
4. topical fungicidal preparations with
Clotrimazole
5. keep ear dry and avoid ear manipulation
FOREIGN BODIES
 A. Animate
- cockroaches, ants, ticks
- severe discomfort and pain
- management
 kill first prior to removal (oily substance such as
baby oil)
B. Inanimate
- may or may not produce symptoms
- stones, seeds, wads of paper
- remove with proper instruments such as curette,
suction tips, aural spatula
TRAUMA
 A. Injury to auricle
- bruises
- hematoma “ Cauliflower ear ”
Treatment:
- evacuation of hematoma
- pressure dressing
- wound repair/suturing
TRAUMA
 B. Perichondritis
 Pus forms between cartilage and
perichondrium  absorption
 Etiologies:
1. injury
2. surgery
3. superficial infections
 treatment:
1. antibiotics
2. I & D
TRAUMA
 C. Traumatic rupture of TM
 Etiologies:
1. secondary to probing
2. too forceful syringing of ear
3. forceful change of pressure in the EAC
 Signs/ symptoms
- sudden pain and bleeding with decreased hearing
TRAUMA
Treatment:
1. most  heals spontaneously
2. myringoplasty
Otitis Media
 Infection of inflammation of the middle ear usually
originated from a URTI or Eustachian tube
dysfunction
 Characterized by mucoid discharge, tympanic
membrane perforation, pain, headache, hearing loss,
tinnitus and sometimes dizziness.
 Acute OM: <12 weeks
 Chronic OM > 12 weeks
Stages of Otitis Media
 Hyperemic stage (retracted TM, fever, pain)
 Exudative stage (bulging TM, fever, pain)
 Perforation stage (TM perforation, afebrile, painless,

otorrhea)
 Coalescent Mastoiditis stage (Postauricular pain, +/- fever

and otorrhea)
 Resolution or Complication stage

Complications of Otitis Media
 Extracranial
 Facial Nerve Paresis/Paralysis
 Subperiosteal Abscess
 Conductive/Sensorineural Hearing Loss
 Labyrinthitis
 Apical Petrositis
 Intracranial
 Meningitis
 Brain abscess
 Lateral Sinus Thrombophlebitis
 Otitic Hydrocephalus
Facial Nerve Paresis/Paralysis
 40% to 50%  dehiscent
 Acute OM
• direct extension
• tx: Myringotomy + antibiotic
 Chronic OM
• 20 bone erosion by cholesteatoma or granulation
• tx: mastoidectomy with FN decompression
Subperiosteal Abscess
 Types:
1. Post-auricular
2. Zygomatic/preauricular
3. Bezold’s
4. Parapharyngeal
Subperiosteal Abscess
 Management:
 IV antibiotics +/- steroids
 Drain the abscess
 Request for laboratory test including imaging studies
such as Towne’s view or CT Scan of the Temporal Bone
Axial and Coronal Cuts Bone Window, 1-1.5mm distance
 Mastoidectomy
Hearing Loss
Hearing Loss
 Management:
 Control the infection
 Request for hearing test (Pure tone Audiometry with
Tympanometry)
 Laboratory tests and imaging studies
 Mastoidectomy with Myringoplasty or Tympanoplasty
(for Conductive HL)
 Mastoidectomy with post-operative hearing aid
application for Sensorineural HL
Labyrinthitis
Labyrinthitis
 Direct extension into labyrinth in AOM
 Bone erosion in COM
 Hematogenous
 S/Sxs:
• sudden/progressive/fluctuating hearing loss
• Vertigo
• N/V
• tinnitus
Labyrinthitis
Labyrinthitis
 Treatment:
Acute cases  high dose antibiotic +
myringotomy
Chronic cases high dose antibiotic +
mastoidectomy
Apical Petrositis/Gradenigo
Syndrome
Apical Petrositis/Gradenigo
Syndrome
 Triad:
 Diplopia (CN VI)
 Otorrhea
 Retroorbital pain (CN V)

Meningitis
 Most common cause of meningitis is Chronic Otitis
Media (~90%)
 Cause/s:
• hematogenous
• direct extension
• preformed pathways (Foramen, Fissures,
Canals and Ducts)
Meningitis
 Clinical presentations:
 Fever
 Headache
 Seizures
 Hemiplegia
 Coma
Meningitis
 Treatment:
 IV antibiotics that are able to pass the BBB
 CT Scan of the Brain and Temporal Bone, Axial and
Coronal cuts, 1-1.5mm distance with contrast
 Antiseizure medications
 Mastoidectomy
Brain abscess
Brain abscess
 Direct extension of extradural abscess or
extension of thrombophlebitis
 Destruction of bone adjacent to the dura
 Chronic OM with cholesteatoma

Brain abscess
 Treatment:
 Antiseizure medications
 Craniectomy with evacuation of abscess and
Mastoidectomy
Lateral Sinus Thrombophlebitis
 Inflammation of the sinus adventitia and
penetration of the venous wall
 Sxs:
septic fever (picket fence)
chills
pain
 Treatment:
 Mastoidectomy
Otitic Hydrocephalus
 Focal areas within the brain becomes edematous and
inflamed due decreased absorption of CSF in Lateral
Sinus Thrombophlebitis
 Manifestations:
• signs/symptoms of increased ICP
papilledema
headache
• no CSF abnormalities
 Treatment:
 Treat Lateral Sinus Thrombophlebitis
 Self-limiting  decompression
Otitis externa Otiits media
pain Very severe Not as severe
Tenderness on present absent
manipulation
fever Usually absent Usually present
Hx of URTI (-) (+)
Hx of ear (+) (-)
manipulation
hearing Not impaired impaired
Mastoid x-ray normal mastoiditis
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Ryan Martin Ko, M.D

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Ryan Martin Ko, M.D

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Ryan Martin Ko, M.D.

1. careful cleaning of the canal by suction or

Secondary to acute or chronic

1. clean ear thoroughly

 Exudative stage (bulging TM, fever, pain)

 Perforation stage (TM perforation, afebrile, painless,

 Coalescent Mastoiditis stage (Postauricular pain, +/- fever

 Resolution or Complication stage

 Retroorbital pain (CN V)

 Destruction of bone adjacent to the dura

 Chronic OM with cholesteatoma

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