Download - External Ear
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Disease of External Ear
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Auricle
• Elastic cartilage• Perichondrium, Subcut, Skin• 피하 지방층이 없고 혈관도 단층만으로 되어 있어서 Fro
stbite 에 잘 걸린다 .
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Landmarks of Auricle
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• Tragus (Tragal cartilage)• Concha : Cavum conchae, Cymba conchae• Incisurae Santorini
• Anterior incisura• Endaural incision
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Preauricular fistula
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Embryology
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Auricle - 6 Hillock fusion
Fusion defect = Preauricular fistula
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Microtia , Congenital aural atresia
Grade I II III
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Auricle fusion defect
• R fusion defect• L preauricual fistula
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BAHA
• Bone Anchoring Hearing Aid
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BAHA Before vs After
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Cauliflower deformity
• Wrestler
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External OtitisOtalgia
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Common Clinical Presentation
• Otalgia / Otorrhea(<<scanty discharge) with Normal TM• Usually without or minimal HL complaint• Gross dx • Pain on speculum insertion• If normal TM on P/E
• Referred otalgia? R-H syndrome?
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Sensory Innervation of EAC – Otalgia vs Referred otalgia
• 1) Tympanic branch of Glossopharyngeal nerve (Jacobson's nerve) • 예 ) Tonsillitis 시 otalgia, Glossopharyngeal neuralgia
• 2) Auriculotemporal branch of V3 - • 예 ) dental origin 의 otalgia
• 3)Auricular branch of Vagus n. (Arnold's nerve) • 예 )EAC 만질 때 coughing reflex
• 4) Facial nerve • 예 )Herpes zoster 시 otalgia
• 5) C2,3
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Quiz
• 외이도의 신경지배를 보여주는 그림이다 . 연결이 옳은 것은 ?• 가 . A-CN V2 B-CN VII• 나 . A-CN VII B-CN V2• 다 . A-CN VII B-CN V3• 라 . A-CN V3 B-CN V2• 마 . A-CN V3 B-CN VII
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Otalgia – Referred otalgia (Neuralgia)
• F/20• C.C Otalgia• TM – WNL
• Referred Otalgia ?• Herpes Otalgia ?
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Ramsay-Hunt syndrome and Otalgia
• = Herpes Zoster Oticus• FNP worst prognosis
• CN7 - Facial nerve paralysis• CN8 – Hearing loss, Vertigo • Skin vesicle
• without FNP or Skin vesicle• Otalgia may be only symptom
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RH syndrome with vesicle
• 차달례 10807728
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Ramsay Hunt Syndrome
• 10542425 임희 O F/65• 2004.6.15 OPD L) Otalgia
• L ear vesicle• HL(-), FNP(-)
• 2004.6.22 OPD L) FNP HB Grade 2-3
• 2004.6.23 – 6.28 Admission• IAC MR - WNL
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EAC Quiz
• 성인 외이도에 대한 설명 중 틀리는 것은 ?
• 길이는 3.5cm 이고 2/3 은 골부이다 . • 이경검사시 이개를 후상방으로 당긴다 . • 공명강으로서 작용한다 .• Otofuruncle 은 골부에 생긴다 . • 외이도를 건드리면 기침이 난다 .
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Otoscopy with Aural Speculum
• 이경의 목적 - Cartilage EAC를 확대• 가능한 한 가장 큰 것 • 단 이경이 Bony EAC 닿으면 pain 있으므로 Cartilage
EAC 까지만 • Auricle traction
• S – shaped EAC• Superior + Posterior• 단 4 세 이하 : Inferior + Posterior
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Anatomy of External ear• Lateral 1/3 Cartilage, Medial 2/3 Bone• Bony EAC :
• Skin - thin, devoid of glands, directly adherent to periosteum• Periosteum – heavily innervated by CN5, 7,10, GAN• Severe otalgia even in mild inflammatory reaction
• Cartiliginous EAC: • Skin – thick, ceruminal glands(apocrine, exocrine) and hair follicles• Cerumen – secretions from glands, hydrophobic, acidic, lysozyme
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External Auditory Canal (EAC)
• Anteroinferior direction• Horizontal section: S- shaped
• 먼저 Ant , 다음 Post, 다시 Ant• Coronal section:
• 먼저 Sup, 다시 inf• Cf. Auricle traction
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EAC Fig by Earmold
• L from behind• EAC cross section• Axial section of the deep external ear canal. The skin and sparse connective tissue lie directly on the bony walls of the deep canal.
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Self protection mechanism of EAC
• Cerumen – 귀밥 , 귀지 , Earwax• Do not remove your cerumen. Why?
• Unique feature of EAC skin• continuous centrifugal growth & laterally• prob d/t migrating Keratinocytes in the parabasal cell layers
•
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EAC FB with Itching, discomfort
• Impacted cerumen• Foreign body
• Inanimated FB : isthmus 안으로 집어넣지 않도록 유의• Animated FB: 올리브유 , Saline 등 사용
• Otomycosis
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EAC infection with Otalgia
• Pain on • Auricle traction , Speculum insertion(Tragal cart)
• Otofuruncle• Hair follicle infection • Staphylococcus, Streptococcus
• Diffuse external otitis• Swimmer’s ear• Breakdown of natural skin protection – pH 6 (acid)• Pseudomonas
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Otofuruncle
• Hair follicle infection• Staphylococcus, Streptococcus
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Acute Diffuse External Otitis
• Acute external otitis (swimmer’s ear). The inflamed canal has narrowed
• to a slit as a result of edema. Note the absence of cerumen and the peau d’orange appearance of the canal.
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(Acute) Diffuse External Otitis• Symptoms:
• pruritus, otalgia varying from sense of fullness to throbbing pain, hearing loss.• Signs:
• Edema and erythema of canal skin, tenderness of tragus, foul-smelling secretions, possible periauricular cellulitis.
• Treatment: • Clean EAC• Topical otic neosporin-polymyxin B (or colistin)-hydrocortisone for gram negative bacilli (mos
t commonly Pseudomonas aeruginosa) for 10 days;• impregnated wick for severe edema; • adequate analgesic.
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Chronic (recurrent) otitis externa
• Preventive Measures for Recurrent Otitis Externa: • Ethyl alcohol drops (70%) • acetic acid - nonaqueous solutions (2%) after swimming or bat
hing. • Avoid self-instrumentation.
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Chronic external otitis• The hallmarks are atrophy of the skin of the ear canal and stenosis due to chronic irritation. This patient abused cotton-tipped applicators; debris from the canal
with cotton fibers has been pushed medially against the tympanic membrane.
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Necrotizing external otitis
• =Skull base osteomyelitis SBO• = Malignant external otitis NEO
• Chronic external otitis in DM patient
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SBO• DM complication after Minimal EAC trauma• Symptoms & Signs:
• Progressive pain and drainage from the EAC. • Granulation tissue often present. • Pseudomonas aeruginosa invasion of soft tissue, cartilage and bone. • Occasional facial nerve palsy. • Lower CN palsy Resp arrest Fatal (Malignant EO)
• Treatment: • Radical surgical debridement with combination semi-synthetic penicillin and amino
glycoside for 4-6 weeks. Significant mortality in diabetics who acquire disease.
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NEO• A nubbin of granulation tissue sits on the floor of the ear canal at the junction of the bony and cartilaginous portions.
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EAC Cancer
• Suspect in chronic external otitis
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Osteoma
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Myringitis
• TM inflammation without MEE
• Bullous myringitis
• CGM (Chronic granular myringitis)
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Bullous Myringitis
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Chronic granular myringitis (CGM)• A tongue of granulation tissue can be seen by the umbo and extending to the posterior margin of the tympanic membrane.
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Otomycosis
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The End
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EAC Fig Quiz 1
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EAC Fig Quiz 2
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Overview
Symptoms TM Audiometry
Disease of Middle ear perforation … Conductive
- External ear ? normal normalcf. pain on TM exam
- Inner ear (cochlea) normal Sensorineural
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Aural Speculum
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Endaural incision
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Auricle cartilage for Rhinoplasty
• Anteriorly based skin/perichondrium flap is reflected anteriorly, exposing the conchal bowl. The optimal site for harvesting the graft is from the ascending portion, or "shoulder," of the conchal bowl, as demonstrated.