DISEASES OF EAR

DIFFERENTIAL DIAGNOSIS
Conduc t ive
! external ear canal
cerumen
otitis externa
foreign body
congenital atresia
keratosis obturans
tumour of canal: squamous cell carcinoma (rare)
! middle ear
acute otitis media
serous otitis media
tympanic membrane perforation
otosclerosis
congenital: ossicular fixation
trauma, i.e. hemotympanum
tumour, i.e. cholesteatoma
Sensorineural
! congenital
! acquired
presbycusis (very common in elderly)
Menire's disease
noise-induced (dip at 4000 Hz on audiogram)
ototoxic drug (high frequency loss)
head injury
sudden sensorineural hearing loss
labyrinthitis (viral or bacterial)
meningitis
demyelinating disease (e.g. MS)
trauma (e.g. temporal bone fracture)
tumour (e.g. acoustic neuroma)

Tympanic Membrane :
Normal
1)
2)
3)
4)
5)
6)
7)
8)
9)

Color : Pearly white/grey white

Cone of light is in the ant.inferior region
Head of malleolus is umbo
Ant.malleolar fold
Post. Malleolar fold
Attic area lies above lateral process of malleolus
Pars falcida
Pars densa
Chalk deposits in some people due to deposition of chalk.

Signs Of Retraction :
1)
2)
3)
4)
5)

Dull and Lusterless

Cone of light is absent
Ant and post malleolar fold becomes sickle shaped
Lateral process of malleolus is more prominent
Handle of malleolus is more foreshortened

DISEASES OF EAR

Causes :
1.
2.
3.
4.
5.
6.

Due to hairpin or knitting pin or match stick

Sudden Change in air pressure like slap on face
Pressure by fluid column in diving , swimming
Barotrauma ocassionally
Fracture of temporal bone
Pressure due to blast

Treatment :
1)
2)
3)
4)
5)
6)

Analgesic
Local drops are contraindicated
Prevent from entry of water
Give Systemic antibiotic
Apply sterile cotton woo in meatus to prevent entry of foreign body into ear
90 % cases heal spontaneously within 4-5 weeks . If not do myringoplasty

Mastoid Air Cells

Types of mastoid
According to cellularity,there are three types of mastoid
1. Cellular-Most common type.(80% )air spaces are present.
2. Sclerotic or acellular-10%
3. Diploeic or mixed-Air spaces and marrow spaces are present.
Importance-In mastoid surgeries.
Mastoid air cells

Perilabrynthine,which include supralabrynthine and infralabrynthine cells.

Peritubal cells.

Retrofacial cells.

Perisinus cells.

Tegmen cells

Tip cells

DISEASES OF EAR

Marginal cells

Squamous cells

Zygomatic cells

Barotrauma /Aero Otitis Media

Its an non supprative condition in which ET fails to maintain
middle ear pressure at ambient atmospheric level.

Etiopathology
Pressure changes: When the pressure is relatively high
in the middle ear (during ascent), air escapes via the ET
passively. But when the pressure is low the equalization of
pressure may not occur due to the locking of the tube. ET
is actively opened by swallowing and yawing. A descent
(during a flight and deep water diving) produces a relative
negative middle ear pressure.
. Eustachian tube dysfunction: Edema or obstruction of the
ET due to adenoids, rhinitis or deviated nasal septum
aggravates the problem of locking of the tube.
.

Clinical Features
.
.

Deafness may get relieved by swallowing and yawning.

Earache may be severe.

.
.
.

Tinnitus may be present.

Vertigo is not common.
Middle ear may have air bubbles or effusion.

Treatment

Repeated swallowing, yawning and Valsalva maneuver.

Antibiotics, analgesics, decongestants (topical nasal drops
and oral tablets).
. Myringo puncture with injection of air into the middle ear.
. Myringotomy with grommet insertion in refractory cases.
.
.

Prophylaxis
Avoid flying and diving during rhinitis.
Decongestion of the nose before the flight
especially
before the descent. Take decongestant nasal
drops/spray
and tablets.
. Repeated swallowing during descent, e.g. sipping
of water/
drinks; sucking of sweets/chocolates/chewing gum.
. Never sleep during the descent.
. Perform intermittently Valsalva maneuvers.
. Treatment of the cause of ET dysfunction such as
nasal polyps, septal deviation, adenoids, allergy,
chronic rhinosinusitis
.
.

DISEASES OF EAR

Otalgia

Difference Between Pure tune audiometry/Impedence Audiometry

Pure Tone
1) Subjective Test so cant be used for
infants or malingers
2) This non-invasive subjective test is a
graphic recording of hearing level
both quantitatively and qualitatively
3) Pure tunes 125-8000 Hz for AC &

Impedence
1) Objective Test can be used for
infants
Principle: when a sound hits tympanic
membrane, some of the sound energy is
absorbed while the rest is reflected. A stiffer

DISEASES OF EAR

250 to 10000 Hz for BC

4) Graphic record is called Audiogram
5) Acoustic reflexes ,stapedial muscle
activity and EU tube function cannot
be assessed
6) Physiological volume of ear cannot
be measured
7) Air Conduction and Bone conduction
can be assessed.

tympanic membrane reflects more of sound

energy than a compliant one. The pressure
in a sealed Ext.auditory meatus is changed.
The reflected sound energy is measured to
find the compliance or stiffness of the
tympano-ossicular
system. The compliance of tympanoossicular system
against various pressure changes is
charted.

2) Tone is fixed i.e220 Hz

3) Graphic record is called
Typanogram
4) All Functions can be measured
5) Amount of energy absorbed and
reflected at TM can be measured.

Syringing Of Ear

Aural Syringe: This metal syringe consists of a cylinder with

a well fitting piston and a nozzle

Method

Patient is seated comfortably and the diseased ear

faces
towards the doctor. A towel is placed on the shoulder.
Patients
head is slightly tilted toward the shoulder. A kidney
tray is held
snugly well below the ear to collect the return fluid.
Boiled tap
water cooled to body temperature (or normal saline)
is used.
The auricle is pulled upwards and backwards while
the
direction of the stream of ear syringe is towards the
posterosuperior wall of the meatus. Pressure of water
that builds up deeper to the wax expels the wax out . In cases of
impacted wax, some space is created between the wax and
the meatal wall so that stream of water passes through that.
Otherwise wax would be pushed deeper. After the procedure,
ear canal and tympanic membrane are dried with cotton.
Indications
1) Wax Removal
2) Foreign Body Removal
3) Coupious Ear discharge
Contraindications :

DISEASES OF EAR

1) Boil 2) Otitis Externa 3) Rupture of TM 4) Acute otitis media Patients with heart
disease and fear of vagal stiumulation 5) Patients with fracture of the base of the
skull with a fear of cranial cavity infection.
*Not an ideal method due to vasovagal reflex danger.

EAR WAX

Components of ear wax

The ear wax is made up of the following components:
Sebaceous glands secretion, which is rich in fatty acids
Ceruminous glands secretion, which is rich in lipids and pigment granules
Hairs
Desquamated epithelial debris and keratin, which are shed from the TM and bony meatus
Dirt

Clinical features

Hearing loss or sense of blocked ear: Sudden hearing loss may occur when water enters
into the EAC (wax swells up) while bathing or swimming.
Tinnitus and giddiness due to impaction of wax against the TM.
Reflex cough can result from the stimulation of auricular branch of vagus nerve.
Wax granuloma: The impacted wax ulcerates the meatal skin and results in granuloma
formation.

Removal Of Wax :
A) Dry Method
B) Wet Method
C)
Dry Method :
Use Wax hook or suction machine. Sometimes General anesthesia is used esp in nervous
children
Wet Method :
1) If wax is soft and shiny it can be removed by syringing
2) If wax is hard then soften it by apply SODA GLYCERINE 4X4X4 ( 4 drops X 4 times a
day for 4 days)
And then plug meatus by cotton wool and then syringing is done
3) H202 can be used too if there is any emergency case
REMOVAL OF FB IN EAR :
Antibiotics: Antibiotics facilitate in controlling infection and edema.
Ear drops: Hygroscopic FB can be shrunk with glycerin and absolute alcohol drops.
Removal of foreign body: The best way is to remove them under ear microscope. Unskilled
attempts may lacerate not only the meatal lining but can also damage the TM and the
ear ossicles.
Methods of removing a foreign body include:
>> Forceps removal: Soft and irregular FBs, such as piece of
paper, swab or a piece of sponge, can be removed with

DISEASES OF EAR

forceps. Smooth and hard objects, such as steel ball

bearing, tend to slip from the forceps and move inwards
and may injure the TM while grasping with forceps.
>> Syringing: Seed grains and smooth objects can be
removed with syringing.
Hooking out: Wax hook or vectis is passed beyond the
FB and pressed against either floor or posterior wall and
FB is hooked out.
Insects: First, they are killed by instilling oil, spirit, chloroform
or water and then removed.
Postaural approach: FBs impacted in deep meatus, medial
to the isthmus and pushed into the middle ear may need
postaural incision for their removal.
Removal under general anesthesia: In cases of impacted
FB, uncooperative children, and FB that failed to come
out with earlier attempts are removed under general
anesthesia.