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DISEASES OF EXTERNAL EAR

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May 23, 2026 PDF Available

Topic Overview

DISEASES OF EXTERNAL EAR

INTRODUCTION

Definition

External ear consists of:

  • Auricle (pinna)

  • External auditory canal (EAC)

  • Outer surface of tympanic membrane

It functions mainly in:

  • Collection of sound

  • Transmission of sound to middle ear

  • Protection of middle and inner ear structures

COMPONENTS OF EXTERNAL EAR

Auricle (Pinna)

  • Fibrocartilaginous structure except lobule

  • Covered by skin

  • Projects from side of head

Parts of pinna

  • Helix

  • Antihelix

  • Tragus

  • Antitragus

  • Concha

  • Lobule

  • Scaphoid fossa

  • Triangular fossa

External Auditory Canal (EAC)

Length

  • About 24 mm in adults

Direction

  • S-shaped canal

  • Runs:

    • Inward

    • Forward

    • Downward

Parts

Part Length Features
Cartilaginous part Outer 1/3 Hair follicles, ceruminous glands
Bony part Inner 2/3 Thin tightly adherent skin

FUNCTIONS OF EXTERNAL EAR

Sound conduction

  • Collects and funnels sound waves toward tympanic membrane

Sound localization

  • Helps identify direction of sound

Resonance

  • EAC amplifies sounds between:

    • 2000–4000 Hz

Protection

  • Cerumen traps dust/insects

  • Hair follicles protect canal

  • Acidic pH inhibits bacterial growth

APPLIED ANATOMY

Clinical importance

  • Narrow bony canal → painful swelling in infections

  • Loose skin in cartilaginous canal → furunculosis common

  • Thin skin over bone → severe pain in otitis externa

  • Fissures of Santorini allow spread of infection to parotid region

  • Foramen of Huschke may communicate with TMJ

SKIN LINING OF EAC

Cartilaginous canal

  • Thick skin

  • Hair follicles present

  • Sebaceous glands present

  • Ceruminous glands present

Bony canal

  • Very thin skin

  • Firmly adherent to periosteum

  • No subcutaneous tissue

Clinical importance

  • Infection in bony canal causes severe pain

  • Instrumentation may easily traumatize skin

CERUMINOUS GLANDS

Definition

Modified apocrine sweat glands present in cartilaginous EAC.

Functions

  • Produce cerumen (ear wax)

  • Lubrication

  • Antibacterial action

  • Antifungal protection

  • Prevent dryness

CARTILAGINOUS VS BONY EAC

Feature Cartilaginous EAC Bony EAC
Length Outer 1/3 Inner 2/3
Skin Thick Thin
Hair follicles Present Absent
Glands Present Absent
Pain sensitivity Less More
Infection Furunculosis common Severe pain common

ISTHMUS OF EAC

Definition

Narrowest part of EAC located at junction of cartilaginous and bony canal.

Clinical importance

  • Foreign bodies may lodge here

  • Difficult instrumentation

  • Wax impaction common

SELF-CLEANSING MECHANISM

Mechanism

  • Epithelium migrates outward from tympanic membrane toward meatus

  • Jaw movements assist migration

Importance

  • Removes wax/debris naturally

  • Disturbance predisposes to wax accumulation

CERUMEN MIGRATION

  • Begins at umbo

  • Moves radially outward

  • Travels laterally along EAC

  • Finally expelled from canal

FISSURES OF SANTORINI

Definition

Small fissures in cartilaginous EAC.

Importance

  • Permit spread of:

    • Infection

    • Tumor

  • Communication with:

    • Parotid gland

    • Infratemporal fossa

FORAMEN OF HUSCHKE

Definition

Developmental defect in anterior wall of EAC.

Importance

  • May communicate with TMJ

  • Salivary leakage into ear possible

  • TMJ herniation may occur

BLOOD SUPPLY

Structure Blood Supply
Auricle Superficial temporal artery, posterior auricular artery
EAC Deep auricular artery

NERVE SUPPLY

Nerve Area Supplied
Auriculotemporal nerve Anterosuperior canal
Arnold nerve (vagus) Posteroinferior canal
Facial nerve Small area
Great auricular nerve Lobule

Clinical importance

  • Arnold nerve stimulation may cause cough during ear cleaning

LYMPHATIC DRAINAGE

Region Drainage
Upper anterior auricle Preauricular nodes
Posterior auricle Mastoid nodes
Lower auricle Deep cervical nodes

EMBRYOLOGY OF EXTERNAL EAR

DEVELOPMENT OF PINNA

Hillocks of His

  • Six mesenchymal hillocks develop around first branchial groove

Derived from:

Arch Hillocks
First branchial arch 1st, 2nd, 3rd hillocks
Second branchial arch 4th, 5th, 6th hillocks

DEVELOPMENT OF EAC

  • Develops from:

    • First branchial cleft

Meatal plug

  • Canal initially filled with ectodermal plug

  • Canalization occurs later

Failure of canalization → congenital atresia

DEVELOPMENTAL ANOMALIES

Embryological basis

  • Defective hillock fusion

  • Branchial arch developmental defects

  • Failure of canalization

CONGENITAL DISORDERS OF EXTERNAL EAR

CONGENITAL ANOMALIES OF PINNA

MICROTIA

Definition

Congenital underdevelopment of pinna.

Types

Grade Features
I Small pinna
II Partially developed
III Peanut ear
IV Anotia

Clinical features

  • Cosmetic deformity

  • Conductive hearing loss

  • Associated canal atresia

Diagnosis

  • Clinical examination

  • Audiological evaluation

  • HRCT temporal bone

Management

Reconstructive surgery

  • Usually after 6–8 years age

  • Rib cartilage graft

Hearing rehabilitation

  • Bone conduction hearing aid

  • BAHA

ANOTIA

Complete absence of pinna.

MACROTIA

Abnormally large pinna.

BAT EAR

Features

  • Prominent ears

  • Poor antihelical fold

  • Large conchal bowl

Treatment

  • Otoplasty

LOP EAR

Folded upper helix.

CUP EAR

Constricted ear deformity with folded helix.

CRYPTOTIA

Upper auricle buried beneath scalp skin.

POLYOTIA

Accessory auricular tissue resembling additional pinna.

MELOTIA

Abnormal displacement of ear.

DARWIN’S TUBERCLE

Small nodular thickening on helix.

CONGENITAL ANOMALIES OF EAC

CONGENITAL ATRESIA

Definition

Failure of development/canalization of EAC.

Features

  • Conductive deafness

  • Associated microtia

  • Abnormal middle ear ossicles

Investigations

  • Audiometry

  • HRCT temporal bone

Treatment

  • Canaloplasty

  • BAHA

CANAL STENOSIS

Abnormally narrow EAC.

CONGENITAL SINUSES & APPENDAGES

PREAURICULAR SINUS

Definition

Congenital epithelial tract near ascending helix.

Etiology

Incomplete fusion of hillocks.

Clinical features

  • Small pit near ear

  • Recurrent infection

  • Discharge/abscess

Treatment

  • Complete excision of tract

PREAURICULAR TAG / ACCESSORY AURICLE

Features

  • Skin appendages near tragus

  • May contain cartilage

Treatment

  • Excision

COLLAURAL FISTULA

Fistulous communication between neck and EAC.

AURICULAR CYSTS

Congenital cystic lesions around pinna.

SYNDROMIC ASSOCIATIONS

Syndrome Ear Abnormality
Treacher Collins syndrome Microtia
Goldenhar syndrome Facial asymmetry + ear anomalies
Pierre Robin sequence Craniofacial anomalies
Down syndrome ET dysfunction

HEARING ASSESSMENT

Tests

  • OAE

  • BERA

  • Pure tone audiometry

  • Behavioral audiometry

RADIOLOGICAL EVALUATION

HRCT Temporal Bone

Assesses:

  • Canal anatomy

  • Middle ear

  • Facial nerve

  • Cochlea

HEARING REHABILITATION

BAHA (Bone Anchored Hearing Aid)

Indications

  • Congenital aural atresia

  • Chronic ear discharge

  • Conductive hearing loss

INFLAMMATORY & INFECTIVE DISORDERS

FURUNCULOSIS

Definition

Localized infection of hair follicle in cartilaginous EAC.

Etiology

  • Trauma from ear picking

  • Dirty instrumentation

Predisposing factors

  • Diabetes mellitus

  • Poor hygiene

  • Humid climate

Organism

Most common

  • Staphylococcus aureus

Clinical features

  • Severe throbbing ear pain

  • Pain aggravated by chewing

  • Tender tragus

  • Swelling in canal

  • Conductive hearing loss

Complications

  • Abscess formation

  • Cellulitis

Treatment

Medical

  • Systemic antibiotics

  • Analgesics

  • Local antibiotic pack

Surgical

  • Incision and drainage when fluctuant

DIFFUSE OTITIS EXTERNA

Definition

Diffuse inflammation of skin lining entire EAC.

Etiology

  • Bacterial infection

  • Excess moisture

  • Trauma

Predisposing factors

  • Swimming

  • Humidity

  • Diabetes

  • Ear instrumentation

SWIMMING EAR

Otitis externa associated with excessive water exposure.

ROLE OF HUMIDITY & pH

  • Moisture removes protective cerumen

  • Alkaline pH promotes bacterial growth

Organisms

Organism Frequency
Pseudomonas aeruginosa Most common
Staphylococcus aureus Common

Clinical features

  • Ear pain

  • Ear fullness

  • Itching

  • Discharge

  • Tenderness on tragal pressure

Otoscopic findings

  • Edematous canal

  • Debris

  • Narrow canal

  • Erythema

Treatment

Aural toilet

Topical antibiotic-steroid drops

Wick insertion

Systemic antibiotics in severe cases

ACUTE OTITIS EXTERNA

Features

  • Acute painful inflammation

  • Edema and erythema

  • Purulent discharge possible

CHRONIC OTITIS EXTERNA

Features

  • Itching predominant

  • Thickened canal skin

  • Mild discharge

  • Canal stenosis possible

DERMATOLOGICAL DISORDERS OF EAC

ECZEMATOUS OTITIS EXTERNA

Features

  • Itching

  • Scaling

  • Crusting

  • Mild watery discharge

SEBORRHEIC DERMATITIS

Associated with scalp dandruff.

ALLERGIC / CONTACT DERMATITIS

Causes

  • Ear drops

  • Hearing aids

  • Cosmetics

PSORIASIS

  • Silvery scales

  • Chronic itching

LUPUS ERYTHEMATOSUS

Autoimmune involvement causing chronic lesions.

NEURODERMATITIS

Chronic itching due to habitual scratching.

ICHTHYOSIS

Abnormal keratinization involving EAC.

OTOMYCOSIS

Definition

Fungal infection of EAC.

Etiology

  • Humidity

  • Excess antibiotic drops

  • Immunocompromised states

Organisms

Organism Appearance
Aspergillus niger Black dots
Aspergillus fumigatus Greenish
Candida albicans Creamy white

Clinical features

  • Intense itching

  • Ear blockage

  • Mild pain

  • Fungal debris

Otoscopic appearance

  • Wet newspaper appearance

  • Black/white fungal masses

Differential diagnosis

  • Wax

  • Chronic otitis externa

  • CSOM

Treatment

Aural toilet

Suction clearance

Antifungal ear drops

  • Clotrimazole

  • Fluconazole

Keep ear dry

Prevention of recurrence

  • Avoid unnecessary drops

  • Avoid moisture

  • Proper diabetic control

MALIGNANT (NECROTIZING) OTITIS EXTERNA

Definition

Aggressive infective osteomyelitis of skull base arising from EAC infection.

Etiology

Usually occurs in:

  • Elderly diabetics

  • Immunocompromised patients

Organism

Most common

  • Pseudomonas aeruginosa

Pathogenesis

  • Infection spreads from EAC

  • Invades soft tissue

  • Causes skull base osteomyelitis

SKULL BASE OSTEOMYELITIS

Spread

  • Temporal bone

  • Skull base foramina

  • Cranial nerves

CRANIAL NERVE INVOLVEMENT

Nerve Manifestation
VII Facial palsy
IX, X, XI Jugular foramen syndrome
XII Tongue weakness

Clinical features

  • Severe deep ear pain

  • Persistent otorrhea

  • Granulation tissue at bone-cartilage junction

  • Hearing loss

  • Cranial nerve palsy

GRANULATION TISSUE

Important finding

Seen at:

  • Floor of EAC

  • Bone-cartilage junction

Highly suggestive of malignant otitis externa.

ESR / CRP MONITORING

Used for:

  • Disease activity

  • Treatment response

IMAGING

HRCT Temporal Bone

Shows:

  • Bone erosion

  • Skull base involvement

MRI

Shows:

  • Soft tissue spread

  • Intracranial extension

RADIONUCLIDE SCANS

Scan Use
Tc-99 bone scan Osteomyelitis detection
Gallium scan Disease activity monitoring

DIFFERENTIAL DIAGNOSIS WITH MALIGNANCY

| Feature | Malignant OE | Malignancy |
|---|---|
| Pain | Severe | Variable |
| Granulation tissue | Common | Possible |
| Diabetes | Common | Rare |
| Response to antibiotics | Good | Poor |

TREATMENT

Medical

Glycemic control

Long-term antipseudomonal antibiotics

  • Ciprofloxacin

  • Piperacillin-tazobactam

  • Ceftazidime

Aural toilet

Surgical

Limited role.
Used for:

  • Abscess drainage

  • Debridement

PROGNOSIS

Depends on:

  • Early diagnosis

  • Diabetic control

  • Cranial nerve involvement

COMPLICATIONS

  • Skull base osteomyelitis

  • Facial nerve palsy

  • Multiple cranial neuropathies

  • Intracranial spread

  • Death

 

VIRAL DISORDERS OF EXTERNAL EAR

HERPES ZOSTER OTICUS

RAMSAY HUNT SYNDROME

Definition

Herpes zoster oticus is reactivation of varicella-zoster virus in the geniculate ganglion of facial nerve, producing ear vesicles with lower motor neuron facial palsy.

Etiology

  • Varicella-zoster virus reactivation

  • Reactivation occurs in:

    • Geniculate ganglion

    • Facial nerve sensory ganglion

Predisposing factors

  • Old age

  • Diabetes mellitus

  • Immunosuppression

  • Stress

  • Malignancy

  • Steroid therapy

STAGES / CLINICAL PATTERN

Prodromal stage

  • Deep ear pain

  • Burning sensation

  • Malaise

  • Fever may occur

Vesicular stage

  • Vesicles appear over:

    • Pinna

    • External auditory canal

    • Concha

    • Tympanic membrane

    • Soft palate sometimes

Neurological stage

  • LMN facial nerve palsy

  • Vestibulocochlear symptoms may occur

FACIAL PALSY

Type

  • Lower motor neuron facial palsy

Features

  • Inability to close eye

  • Drooping angle of mouth

  • Loss of forehead wrinkling

  • Hyperacusis if stapedius involved

  • Loss of taste from anterior two-thirds of tongue

  • Reduced lacrimation or salivation may occur

CRANIAL NERVE INVOLVEMENT

Cranial nerve Manifestation
VII Facial palsy
VIII Hearing loss, tinnitus, vertigo
IX, X Dysphagia, palatal weakness
V Facial pain
VI Rare ocular movement defect

VESICULAR LESIONS

Sites

  • Concha

  • External auditory canal

  • Pinna

  • Tympanic membrane

  • Sometimes oral cavity and palate

Character

  • Painful grouped vesicles

  • Later crusting may occur

CLINICAL FEATURES

Ear symptoms

  • Severe otalgia

  • Vesicles in ear canal/pinna

  • Ear discharge if secondary infection occurs

Facial nerve symptoms

  • LMN facial palsy

  • Hyperacusis

  • Taste disturbance

Audiovestibular symptoms

  • Sensorineural hearing loss

  • Tinnitus

  • Vertigo

  • Nausea/vomiting

General symptoms

  • Fever

  • Malaise

  • Headache

DIAGNOSIS

Clinical diagnosis

Based on:

  • Severe otalgia

  • Vesicles in concha/EAC

  • LMN facial palsy

Investigations

  • Pure tone audiometry → detects SNHL

  • Vestibular tests → if vertigo present

  • Viral PCR from vesicle fluid if diagnosis doubtful

  • MRI if atypical facial palsy or suspected intracranial pathology

TREATMENT

Antiviral therapy

Best started within 72 hours.

Drug Dose
Acyclovir 800 mg orally 5 times/day for 7–10 days
Valacyclovir 1 g orally 3 times/day for 7 days
Famciclovir 500 mg orally 3 times/day for 7 days

Steroids

  • Prednisolone 1 mg/kg/day, then taper

  • Helps reduce nerve edema

Eye care

  • Artificial tears

  • Eye ointment at night

  • Eye patch/taping

  • Ophthalmology referral if exposure keratitis risk

Pain control

  • NSAIDs

  • Neuropathic pain drugs if needed:

    • Gabapentin

    • Pregabalin

    • Amitriptyline

Ear care

  • Keep ear clean and dry

  • Treat secondary bacterial infection if present

Physiotherapy

  • Facial exercises

  • Electrical stimulation is not routinely required

HIGH-YIELD POINTS

  • Painful vesicles in ear + LMN facial palsy → Ramsay Hunt syndrome.

  • Prognosis is worse than Bell palsy.

  • Early antiviral + steroid improves recovery.

  • VIII nerve involvement causes SNHL and vertigo.

AURICULAR HERPES SIMPLEX

Definition

Viral infection of auricle/EAC caused by herpes simplex virus.

Etiology

  • HSV-1 commonly

  • HSV-2 occasionally

Clinical features

  • Painful grouped vesicles

  • Burning sensation

  • Recurrent lesions

  • Crusting after rupture

  • Usually less severe than herpes zoster

Diagnosis

  • Clinical

  • PCR/Tzanck smear if doubtful

Treatment

  • Acyclovir/valacyclovir

  • Analgesics

  • Local hygiene

  • Treat secondary infection

BULLOUS MYRINGITIS

Definition

Acute painful condition characterized by bullae formation on tympanic membrane, sometimes extending to adjacent external canal.

Etiology

  • Viral infection

  • Mycoplasma pneumoniae may be associated

  • May occur with acute otitis media

Clinical features

  • Sudden severe ear pain

  • Hearing loss

  • Fever may occur

  • Blood-stained discharge if bullae rupture

Otoscopic findings

  • Hemorrhagic or serous bullae on tympanic membrane

  • Congestion of TM

Treatment

  • Analgesics

  • Antibiotics if associated acute otitis media

  • Avoid unnecessary rupture of bullae

  • Follow-up hearing assessment if persistent hearing loss

MISCELLANEOUS INFLAMMATORY CONDITIONS

PERICHONDRITIS

Definition

Inflammation of perichondrium of auricular cartilage.

Etiology

  • Trauma

  • Ear piercing, especially high cartilage piercing

  • Surgery

  • Burns

  • Frostbite

  • Infected hematoma

  • Insect bite

Organisms

Organism Importance
Pseudomonas aeruginosa Common and important
Staphylococcus aureus Common
Streptococci May occur

Clinical features

  • Painful swollen pinna

  • Redness and warmth

  • Tenderness

  • Fever may occur

  • Lobule is usually spared because it has no cartilage

Perichondrial abscess

  • Pus collects between cartilage and perichondrium

  • Cartilage loses blood supply

  • Cartilage necrosis may occur

Complications

  • Cartilage necrosis

  • Cauliflower ear

  • Auricular deformity

  • Abscess formation

Treatment

Early perichondritis without abscess

  • Systemic antibiotics covering Pseudomonas and Staphylococcus

  • Analgesics

  • Local care

Perichondrial abscess

  • Incision and drainage

  • Drain placement

  • Pressure dressing

  • Culture and sensitivity

  • Antipseudomonal antibiotic

PERICHONDRITIS VS CELLULITIS

Feature Perichondritis Cellulitis
Main site Cartilaginous pinna Skin/subcutaneous tissue
Lobule Usually spared Usually involved
Pain Marked Variable
Risk Cartilage necrosis Usually no cartilage necrosis
Treatment Antipseudomonal antibiotics ± drainage Antibiotics

RELAPSING POLYCHONDRITIS

Definition

Autoimmune recurrent inflammation of cartilage.

Sites involved

  • Pinna

  • Nose

  • Larynx

  • Trachea

  • Joints

  • Eyes

Clinical features

  • Recurrent painful red swollen pinna

  • Lobule spared

  • Saddle nose deformity

  • Hoarseness/airway symptoms

  • Arthralgia

  • Ocular inflammation

Diagnosis

  • Clinical

  • Raised inflammatory markers

  • Autoimmune workup

  • Biopsy if doubtful

Treatment

  • NSAIDs in mild cases

  • Systemic corticosteroids

  • Immunosuppressants in severe disease

  • Airway monitoring

CHONDRODERMATITIS NODULARIS HELICIS

Definition

Painful inflammatory nodule on helix or antihelix, usually due to pressure-induced cartilage inflammation.

Etiology

  • Chronic pressure during sleep

  • Local trauma

  • Ischemia of cartilage

  • More common in elderly males

Clinical features

  • Small painful nodule on helix

  • Tender on pressure

  • Central crust/ulcer may be present

  • Pain while sleeping on affected side

Differential diagnosis

  • Squamous cell carcinoma

  • Basal cell carcinoma

  • Actinic keratosis

Treatment

  • Avoid pressure

  • Protective pillow

  • Topical steroid

  • Intralesional steroid

  • Surgical excision if persistent

PRURITUS AURIS

Definition

Itching of external auditory canal.

Causes

  • Wax

  • Otomycosis

  • Eczema

  • Seborrheic dermatitis

  • Allergic dermatitis

  • Psoriasis

  • Diabetes

  • Overcleaning of ear

  • Hearing aid irritation

Clinical features

  • Itching

  • Scratching habit

  • Excoriation

  • Secondary otitis externa

Treatment

  • Treat underlying cause

  • Avoid ear picking

  • Keep ear dry

  • Mild topical steroid for eczema

  • Antifungal if otomycosis present

IDIOPATHIC PRURITUS AURIS

Definition

Chronic itching of EAC without obvious infective or dermatological cause.

Management

  • Reassurance

  • Avoid cotton buds

  • Emollient drops

  • Short course mild steroid drops if inflammation

  • Rule out diabetes and fungal infection

OBSTRUCTIVE LESIONS OF EAC

WAX / CERUMEN

Definition

Cerumen is a mixture of secretions from ceruminous and sebaceous glands with desquamated epithelial cells.

COMPOSITION

  • Ceruminous gland secretion

  • Sebaceous secretion

  • Desquamated keratin

  • Dust particles

  • Hair

TYPES

Type Feature
Wet wax Soft, brown, sticky
Dry wax Grey, flaky
Hard wax Firm impacted wax
Soft wax Easily removable

FUNCTIONS OF CERUMEN

  • Lubricates EAC

  • Traps dust and foreign particles

  • Antibacterial action

  • Antifungal action

  • Maintains acidic pH

  • Prevents insect entry

IMPACTED WAX

Definition

Accumulation of cerumen causing obstruction of EAC with symptoms.

Causes

  • Narrow canal

  • Excessive production

  • Failure of self-cleaning

  • Use of cotton buds

  • Hearing aid use

  • Elderly patients

  • Canal stenosis

Clinical features

  • Ear blockage

  • Conductive hearing loss

  • Tinnitus

  • Earache

  • Reflex cough due to Arnold nerve stimulation

  • Vertigo rarely

Diagnosis

  • Otoscopy

  • Wax seen occluding canal

  • Hearing improves after removal

CERUMINOLYTICS

Common agents

Agent Use
Sodium bicarbonate drops Softens wax
Hydrogen peroxide Effervescent wax loosening
Olive oil Lubrication and softening
Glycerine Softening
Carbamide peroxide Wax breakdown

TREATMENT

Methods

  • Ceruminolytic drops

  • Ear syringing/irrigation if TM intact

  • Microsuction

  • Instrumental removal under vision

Avoid syringing if:

  • TM perforation

  • CSOM

  • Ear surgery history

  • Grommet

  • Only hearing ear

  • Active otitis externa

COMPLICATIONS OF SELF-CLEANING

  • Wax pushed deeper

  • Canal abrasion

  • Otitis externa

  • TM perforation

  • Bleeding

  • Foreign body retention

FOREIGN BODIES IN EAR

Types

Type Examples
Animate Insects
Non-animate Beads, stones, paper, cotton
Vegetable Seeds, peas
Hygroscopic Beans, sponge
Dangerous Button battery
Chemical/adhesive Superglue

ANIMATE FOREIGN BODY / LIVE INSECT

Clinical features

  • Severe discomfort

  • Buzzing sound

  • Pain

  • Panic

  • Scratching sensation

Management

  • Kill insect first using:

    • Mineral oil

    • Lidocaine

    • Alcohol if TM intact

  • Remove under vision

NON-ANIMATE FOREIGN BODY

Examples

  • Beads

  • Eraser

  • Cotton

  • Small toys

  • Stone

Management

  • Hook/curette/suction/forceps depending on object

  • Avoid pushing deeper

VEGETABLE / HYGROSCOPIC FOREIGN BODY

Examples

  • Seed

  • Pea

  • Bean

Important point

  • Swells with water

Management

  • Do not irrigate

  • Remove dry under vision

SUPERGLUE FOREIGN BODY

Features

  • Adhesive material stuck to canal skin/TM

  • Risk of epithelial injury

Management

  • ENT specialist removal

  • Avoid forceful extraction

  • Microscope-guided removal

BUTTON BATTERY INJURY

Importance

ENT emergency.

Mechanism of injury

  • Alkali leakage

  • Electrical burn

  • Pressure necrosis

  • Liquefaction necrosis

Management

  • Immediate removal

  • Do not irrigate

  • Examine TM and canal after removal

  • Treat burns/necrosis

CLINICAL FEATURES OF FOREIGN BODY

  • Ear blockage

  • Pain

  • Discharge

  • Bleeding

  • Hearing loss

  • Tinnitus

  • Child may be asymptomatic

DIAGNOSIS

  • Otoscopy

  • Microscopy

  • Assess:

    • Type of foreign body

    • Site

    • TM status

    • Canal trauma

REMOVAL TECHNIQUES

Method Suitable for
Hook Round objects
Forceps Graspable objects
Suction Smooth/light objects
Irrigation Small inert objects if TM intact
Microsuction Debris/small FB
General anaesthesia Children/uncooperative

ANAESTHESIA INDICATIONS

  • Uncooperative child

  • Deeply impacted foreign body

  • Failed previous attempt

  • Sharp foreign body

  • Foreign body near TM

  • Canal trauma/bleeding

PRECAUTIONS IN CHILDREN

  • Avoid repeated blind attempts

  • Proper immobilization

  • Early GA if uncooperative

  • Remove under microscope when needed

COMPLICATIONS

  • Canal abrasion

  • Bleeding

  • Otitis externa

  • TM perforation

  • Ossicular injury

  • Foreign body pushed deeper

KERATOSIS OBTURANS

Definition

Accumulation of desquamated keratin plug in deep EAC causing canal widening and severe pain.

TYPES

Inflammatory type

  • Associated with infection

  • Painful

Silent type

  • Less symptomatic

  • May recur

ETIOPATHOGENESIS

  • Faulty epithelial migration

  • Keratin accumulation

  • EAC plug formation

  • Pressure causes canal widening

ASSOCIATION

May be associated with:

  • Sinusitis

  • Bronchiectasis

CLINICAL FEATURES

  • Severe otalgia

  • Conductive hearing loss

  • Ear blockage

  • Usually bilateral in younger patients

  • Recurrent keratin plug

OTOSCOPIC FINDINGS

  • Keratin plug in deep canal

  • Widened bony canal

  • Intact tympanic membrane

DIFFERENTIAL DIAGNOSIS

  • Impacted wax

  • EAC cholesteatoma

  • Foreign body

  • Chronic otitis externa

TREATMENT

  • Removal of keratin plug

  • Aural toilet

  • Regular follow-up cleaning

  • Treat associated sinusitis/bronchiectasis

  • Canalplasty rarely

EXTERNAL AUDITORY CANAL CHOLESTEATOMA

Definition

Localized collection of keratinizing squamous epithelium in EAC associated with bone erosion.

ETIOPATHOGENESIS

  • Primary spontaneous disease

  • Post-traumatic

  • Post-surgical

  • Canal stenosis

  • Chronic inflammation

  • Faulty epithelial migration

BONE EROSION

Common site

  • Inferior wall of bony EAC

Mechanism

  • Pressure necrosis

  • Chronic inflammation

  • Enzymatic bone erosion

HRCT FINDINGS

  • Soft tissue mass in EAC

  • Focal bony erosion

  • Sequestrum may be present

  • Middle ear usually spared unless advanced

CLINICAL FEATURES

  • Chronic dull otalgia

  • Otorrhea

  • Conductive hearing loss

  • Keratin debris

  • Usually unilateral

  • Older age group

DIFFERENTIAL DIAGNOSIS WITH KERATOSIS OBTURANS

Feature Keratosis Obturans EAC Cholesteatoma
Age Younger Older
Laterality Often bilateral Usually unilateral
Pain Severe Dull pain
Canal Generalized widening Localized bone erosion
Keratin Plug Localized sac/debris
Association Sinusitis/bronchiectasis Trauma/surgery/inflammation

TREATMENT

Conservative

  • Regular microscopic cleaning

  • Topical antibiotics if infected

Surgical

  • Canalplasty

  • Excision of cholesteatoma

  • Reconstruction if extensive erosion

TRAUMATIC CONDITIONS

HEMATOMA AURIS

Definition

Collection of blood between auricular cartilage and perichondrium.

Etiology

  • Blunt trauma

  • Wrestling/boxing

  • Road traffic injury

  • Sports injury

Pathogenesis

  • Trauma separates perichondrium from cartilage

  • Blood collects in subperichondrial space

  • Cartilage loses nutrition

  • Fibrosis and cartilage deformity follow

CAULIFLOWER EAR

Definition

Deformed thickened auricle due to untreated or recurrent auricular hematoma.

CLINICAL FEATURES

  • Painful swelling of pinna

  • Fluctuant swelling

  • Commonly over scaphoid fossa/antihelix

  • History of trauma

TREATMENT

Early small hematoma

  • Aspiration

  • Pressure dressing

Large hematoma

  • Incision and drainage

  • Remove clots

  • Pressure dressing/bolster dressing

  • Antibiotics

  • Follow-up to prevent recurrence

LACERATIONS OF PINNA

Management

  • Clean wound

  • Preserve cartilage

  • Approximate skin carefully

  • Antibiotic cover

  • Tetanus prophylaxis

  • Avoid excessive cartilage removal

AVULSION INJURIES

Management principles

  • Preserve avulsed part

  • Microvascular repair if possible

  • Reimplantation/reconstruction

  • Control infection

PINNA FRACTURES

  • Usually cartilage fracture

  • May be associated with hematoma

  • Treat hematoma and deformity early

BLAST INJURIES

Ear effects

  • TM perforation

  • EAC injury

  • Ossicular disruption

  • Inner ear damage

Management

  • Otoscopic evaluation

  • Audiometry

  • Treat associated trauma

BURNS

Types

  • Thermal burns

  • Chemical burns

  • Electrical burns

Complications

  • Perichondritis

  • Cartilage necrosis

  • Contracture deformity

Treatment

  • Wound care

  • Antibiotics if infected

  • Prevent pressure

  • Reconstruction later if needed

FROSTBITE

Features

  • Cold injury to pinna

  • Pallor, numbness

  • Blistering/necrosis in severe cases

Treatment

  • Gradual rewarming

  • Analgesics

  • Avoid rubbing

  • Treat necrosis/infection

HUMAN BITE INJURIES

Importance

  • High infection risk

  • Cartilage involvement common

Management

  • Thorough irrigation

  • Debridement

  • Antibiotics

  • Tetanus prophylaxis

  • Consider rabies risk where relevant

EAR PIERCING COMPLICATIONS

Complications

  • Infection

  • Perichondritis

  • Keloid

  • Split lobule

  • Embedded earring

  • Allergic dermatitis

KELOID OF PINNA

Definition

Excessive fibrocollagenous scar growth extending beyond original wound margin.

Etiology

  • Ear piercing

  • Trauma

  • Burns

  • Surgery

  • Genetic predisposition

Clinical features

  • Firm raised swelling

  • Common over lobule

  • Itching

  • Cosmetic concern

  • Recurrence after excision

Prevention

  • Avoid unnecessary piercing in prone individuals

  • Aseptic piercing

  • Early treatment of hypertrophic scars

  • Pressure earrings after excision

Treatment

Method Use
Intralesional steroid First-line small lesions
Surgical excision Large keloid
Pressure therapy Prevent recurrence
Silicone gel sheet Adjunct
Radiotherapy Recurrent selected cases
Cryotherapy/laser Selected cases

TUMORS OF EXTERNAL EAR

BENIGN TUMORS

OSTEOMA

Definition

Solitary benign bony tumor of EAC.

Features

  • Usually single

  • Pedunculated

  • Near bony-cartilaginous junction

  • Slow growing

Clinical features

  • Usually asymptomatic

  • Wax retention

  • Conductive hearing loss if obstructive

Treatment

  • Observation if asymptomatic

  • Surgical removal if symptomatic

EXOSTOSIS / SURFER’S EAR

Definition

Multiple broad-based bony outgrowths of EAC due to chronic cold water exposure.

Features

  • Usually multiple

  • Bilateral

  • Broad based

  • Medial bony canal

Clinical features

  • Water trapping

  • Recurrent otitis externa

  • Conductive hearing loss

Treatment

  • Prevention from cold water exposure

  • Canalplasty if severe obstruction

OSTEOMA VS EXOSTOSIS

Feature Osteoma Exostosis
Number Single Multiple
Base Pedunculated Broad-based
Laterality Usually unilateral Often bilateral
Cause Idiopathic Cold water exposure
Site Lateral bony canal Medial bony canal

PAPILLOMA

Etiology

  • HPV infection

Features

  • Warty growth in EAC/pinna

  • May bleed if traumatized

Treatment

  • Excision

  • Histopathology

CERUMINOUS ADENOMA

Definition

Benign tumor of ceruminous glands.

Features

  • EAC mass

  • Ear blockage

  • Conductive hearing loss

  • May mimic malignancy

Treatment

  • Complete excision

  • Histopathological confirmation

CERUMINOUS GLAND TUMORS

Types

  • Ceruminous adenoma

  • Ceruminous adenocarcinoma

  • Adenoid cystic carcinoma

  • Pleomorphic adenoma-like tumor

SEBACEOUS CYST

Features

  • Smooth cystic swelling

  • Common behind ear/lobule

  • May become infected

Treatment

  • Excision with capsule

NEVUS

Features

  • Pigmented lesion

  • Monitor for malignant change

Treatment

  • Excision if suspicious/cosmetic

HEMANGIOMA

Features

  • Vascular lesion

  • Compressible swelling

  • Bleeding risk

Treatment

  • Observation/sclerotherapy/excision depending size

FIBROMA

  • Benign fibrous tumor

  • Firm swelling

  • Excision if symptomatic

CHONDROMA

  • Benign cartilage tumor

  • Rare in pinna/EAC

  • Excision if symptomatic

MALIGNANT TUMORS

SQUAMOUS CELL CARCINOMA

Most common malignant tumor of external ear.

Risk factors

  • Chronic sun exposure

  • Chronic otitis externa

  • Radiation

  • Immunosuppression

  • Chronic ulcer

  • HPV sometimes

Clinical features

  • Non-healing ulcer

  • Bleeding lesion

  • Pain

  • Discharge

  • Granulation tissue

  • Facial palsy if advanced

  • Cervical lymphadenopathy

Diagnosis

  • Biopsy

  • HRCT temporal bone

  • MRI for soft tissue spread

  • Nodal evaluation

Treatment

  • Wide local excision

  • Temporal bone resection if EAC/middle ear involved

  • Neck dissection if nodes

  • Radiotherapy in selected cases

BASAL CELL CARCINOMA

Features

  • Common on sun-exposed pinna

  • Slow growing

  • Locally invasive

  • Rare metastasis

Clinical features

  • Pearly nodule

  • Rolled edge ulcer

  • Telangiectasia

  • Non-healing lesion

Treatment

  • Surgical excision

  • Mohs surgery where available

  • Radiotherapy if unfit

BASOSQUAMOUS CARCINOMA

Features

  • Has features of both BCC and SCC

  • More aggressive than BCC

  • Higher recurrence/metastatic potential

Treatment

  • Wide excision

  • Careful follow-up

MELANOMA

Risk factors

  • UV exposure

  • Pigmented nevus

  • Fair skin

  • Family history

Clinical warning signs

ABCDE:

  • Asymmetry

  • Border irregularity

  • Color variation

  • Diameter >6 mm

  • Evolution

Treatment

  • Wide excision

  • Sentinel lymph node biopsy where indicated

  • Oncology management

CERUMINOUS ADENOCARCINOMA

Definition

Malignant tumor of ceruminous glands of EAC.

Clinical features

  • EAC mass

  • Pain

  • Bleeding

  • Discharge

  • Conductive hearing loss

  • Facial palsy if advanced

Diagnosis

  • Biopsy

  • HRCT/MRI

Treatment

  • Wide excision/temporal bone resection

  • Radiotherapy depending extent

TEMPORAL BONE MALIGNANCY EXTENSION

Routes of spread

  • Along EAC

  • Middle ear

  • Mastoid

  • Parotid gland

  • TMJ

  • Facial nerve canal

  • Skull base

Clinical features of advanced disease

  • Severe otalgia

  • Persistent otorrhea

  • Facial palsy

  • Trismus

  • Vertigo

  • Lower cranial nerve palsy

TNM STAGING OVERVIEW

Used for

  • External ear cancers

  • EAC/temporal bone malignancy staging varies by system

Important staging factors

  • Tumor size

  • Cartilage invasion

  • Bone erosion

  • Middle ear involvement

  • Facial nerve involvement

  • Parotid/TMJ/skull base spread

  • Nodal metastasis

GENERAL CLINICAL FEATURES OF EXTERNAL EAR TUMORS

  • Mass in pinna/EAC

  • Ear blockage

  • Pain

  • Bleeding

  • Non-healing ulcer

  • Otorrhea

  • Hearing loss

  • Facial palsy in advanced lesions

  • Neck nodes

DIAGNOSIS

Clinical examination

  • Inspect lesion

  • Palpate pinna

  • Otoscopy/microscopy

  • Examine parotid and neck nodes

Biopsy

  • Required for suspicious lesion

  • Histopathology confirms diagnosis

Audiology

  • PTA if EAC obstruction or temporal bone involvement

IMAGING

Imaging Use
HRCT temporal bone Bone erosion
MRI Soft tissue, facial nerve, intracranial spread
PET-CT Advanced/metastatic disease staging

HISTOPATHOLOGY

Important slides

  • SCC → keratin pearls/intercellular bridges

  • BCC → basaloid cells with peripheral palisading

  • Melanoma → atypical melanocytes

  • Ceruminous adenoma/adenocarcinoma → glandular tumor pattern

TREATMENT PRINCIPLES

Benign tumors

  • Observe if asymptomatic

  • Excision if obstructive, recurrent infection, cosmetic issue, or diagnostic doubt

Malignant tumors

  • Biopsy confirmation

  • Imaging for extent

  • Wide local excision

  • Temporal bone resection if EAC/temporal bone involved

  • Parotidectomy if parotid involved

  • Neck dissection if nodal disease

  • Radiotherapy/chemoradiotherapy when indicated

  • Long-term follow-up for recurrence

 

 

OTHER CONDITIONS

OSTEONECROSIS OF EAC

Definition

Necrosis of bony external auditory canal due to reduced vascularity, trauma, infection, surgery, radiotherapy, or antiresorptive drugs.

Causes

  • Radiotherapy to head and neck

  • Bisphosphonate therapy

  • Denosumab therapy

  • Chronic trauma from instrumentation

  • Chronic otitis externa

  • Diabetes/immunosuppression

  • Post-surgical bony canal exposure

Clinical features

  • Chronic otalgia

  • Persistent otorrhea

  • Exposed bone in EAC

  • Foul smell

  • Granulation tissue

  • Conductive hearing loss if canal obstructed

Diagnosis

  • Otoscopy/microscopy → exposed necrotic bone

  • HRCT temporal bone → bony erosion/sequestrum

  • Biopsy if malignancy suspected

Treatment

  • Aural toilet

  • Topical antibiotic drops if infected

  • Avoid repeated trauma

  • Analgesics

  • Control diabetes/immunosuppression

  • Sequestrectomy/debridement if persistent

  • Rule out malignancy in non-healing granulation

RADIATION-INDUCED EAC STENOSIS

Definition

Narrowing of external auditory canal due to fibrosis after radiotherapy.

Causes

  • Radiotherapy for nasopharyngeal carcinoma

  • Parotid malignancy treatment

  • Temporal bone/skull base tumors

  • Post-radiation chronic inflammation

Pathogenesis

  • Radiation injury to skin and soft tissue

  • Chronic inflammation

  • Fibrosis

  • Canal narrowing

  • Wax/debris retention

  • Secondary infection

Clinical features

  • Ear blockage

  • Conductive hearing loss

  • Recurrent otitis externa

  • Wax retention

  • Difficult otoscopic examination

Treatment

  • Regular aural toilet

  • Topical treatment for infection

  • Ear mold/stent in selected cases

  • Canalplasty if severe stenosis

IMPACTED HEARING AID MOLD

Definition

Accidental retention or impaction of hearing aid mold or its broken part inside EAC.

Causes

  • Old or cracked hearing aid mold

  • Improper fitting

  • Forceful removal

  • Elderly patients with poor handling

  • Narrow EAC

Clinical features

  • Ear blockage

  • Sudden reduced hearing

  • Pain

  • Foreign body sensation

  • Otitis externa if delayed

Diagnosis

  • Otoscopy

  • Microscopic examination

Treatment

  • Remove under vision

  • Use hook/forceps/suction as appropriate

  • Avoid blind attempts

  • Treat canal abrasion or otitis externa

  • Replace with properly fitted mold

EXAMINATION OF EXTERNAL EAR

INSPECTION

Method

Inspect both ears from:

  • Front

  • Side

  • Behind

Look for

  • Size of pinna

  • Shape deformity

  • Position of ear

  • Congenital anomalies

  • Swelling

  • Redness

  • Ulcer

  • Discharge

  • Sinus opening

  • Scar

  • Keloid

  • Trauma

  • Skin lesions

  • Preauricular pit/tag

  • Postauricular swelling

Important observations

  • Microtia/anotia

  • Bat ear

  • Preauricular sinus

  • Perichondritis

  • Hematoma auris

  • Cauliflower ear

  • Malignancy

PALPATION

Method

Palpate:

  • Pinna

  • Tragus

  • Mastoid region

  • Preauricular region

  • Postauricular region

  • Parotid region

  • Neck nodes

Assess

  • Tenderness

  • Temperature

  • Fluctuation

  • Consistency

  • Mobility

  • Cartilage thickening

  • Lymph nodes

Clinical importance

  • Tragal tenderness → otitis externa/furunculosis

  • Pinna movement pain → otitis externa

  • Lobule sparing → perichondritis

  • Fluctuant swelling → hematoma/abscess

  • Hard fixed ulcer → malignancy

OTOSCOPIC EXAMINATION

Definition

Visual examination of EAC and tympanic membrane using otoscope.

Steps

  • Explain procedure

  • Use proper size speculum

  • Hold otoscope like a pen

  • Stabilize hand against patient’s cheek

  • Straighten EAC

  • Examine canal first

  • Then examine tympanic membrane

Pulling pinna

Age group Direction
Adult Upward, backward, outward
Child Downward, backward

Structures assessed in EAC

  • Wax

  • Foreign body

  • Edema

  • Furuncle

  • Discharge

  • Fungal debris

  • Granulation

  • Polyp

  • Exostosis/osteoma

  • Canal stenosis

  • Trauma

Tympanic membrane assessment

  • Color

  • Position

  • Mobility

  • Perforation

  • Retraction

  • Bulging

  • Cone of light

  • Handle of malleus

  • Pars tensa

  • Pars flaccida

PNEUMATIC OTOSCOPY

Definition

Otoscopy with air pressure variation to assess tympanic membrane mobility.

Uses

  • Detect middle ear effusion

  • Assess ET function indirectly

  • Differentiate TM retraction from perforation

  • Assess adhesive otitis

Findings

Finding Suggests
Normal mobility Normal middle ear
Reduced mobility OME, thick TM, adhesive otitis
Increased mobility Atrophic TM
No mobility Fluid, perforation seal issue, severe retraction

MICROSCOPE EXAMINATION

Uses

  • Better visualization of EAC/TM

  • Foreign body removal

  • Wax removal

  • Aural toilet

  • Otomycosis cleaning

  • Assessment of granulation tissue

  • Minor procedures

Advantages

  • Magnification

  • Binocular vision

  • Safer instrumentation

  • Useful in children/uncooperative cases with proper support

APPLIED CLINICAL POINTS

REFERRED OTALGIA

Definition

Ear pain due to pathology outside ear because of shared sensory nerve supply.

Nerve pathways

Nerve Referred pain source
Trigeminal nerve Teeth, TMJ, oral cavity
Glossopharyngeal nerve Tonsil, pharynx, base of tongue
Vagus nerve Larynx, hypopharynx, esophagus
C2–C3 nerves Cervical spine, neck muscles
Facial nerve Deep ear region

Common causes

  • Dental caries

  • Impacted molar

  • TMJ arthritis

  • Tonsillitis

  • Peritonsillar abscess

  • Pharyngitis

  • Laryngeal carcinoma

  • Hypopharyngeal carcinoma

  • Cervical spondylosis

  • Neuralgia

Exam pearl

Normal otoscopy + persistent otalgia in adult → examine oral cavity, tonsil, base of tongue, larynx, hypopharynx and neck.

DIFFERENTIAL DIAGNOSIS OF OTALGIA

Cause group Examples
External ear Furunculosis, otitis externa, perichondritis, trauma, wax, foreign body
Middle ear Acute otitis media, barotrauma, mastoiditis
Inner ear/nerve Ramsay Hunt syndrome, neuralgia
Dental Caries, impacted molar
TMJ TMJ dysfunction, arthritis
Throat Tonsillitis, peritonsillar abscess, pharyngitis
Malignancy Oral cavity, oropharynx, hypopharynx, larynx
Cervical Cervical spondylosis

DIFFERENTIAL DIAGNOSIS OF PAINFUL PINNA

Condition Key clue
Perichondritis Painful red pinna, lobule spared
Cellulitis Lobule involved
Hematoma auris Post-traumatic fluctuant swelling
Relapsing polychondritis Recurrent painful cartilage inflammation
Chondrodermatitis nodularis helicis Painful nodule on helix
Herpes zoster oticus Vesicles + severe pain
Frostbite/burns Exposure history
Keloid infection Piercing history

DIFFERENTIAL DIAGNOSIS OF EAC GRANULATIONS

Cause Important clue
Malignant otitis externa Elderly diabetic, severe pain, floor granulation
Squamous cell carcinoma Bleeding, non-healing mass, severe pain
EAC cholesteatoma Keratin debris + focal bony erosion
Chronic otitis externa Recurrent discharge/itching
Foreign body reaction History of retained foreign body
Tuberculosis/fungal infection Chronicity, poor response
Post-surgical granulation Surgery history

Exam pearl

Granulation tissue in EAC of elderly diabetic is malignant otitis externa until proved otherwise.

DIFFERENTIAL DIAGNOSIS OF EAR DISCHARGE

Type of discharge Possible causes
Watery Eczema, CSF leak, otitis externa
Purulent Otitis externa, acute otitis media with perforation, CSOM
Foul-smelling Cholesteatoma, foreign body, malignant otitis externa
Blood-stained Trauma, bullous myringitis, malignancy
Black/white debris Otomycosis
Mucoid Middle ear disease

DIFFERENTIAL DIAGNOSIS OF EAR SWELLING

Site Causes
Pinna Hematoma, perichondritis, keloid, cyst, tumor
Preauricular Preauricular sinus abscess, lymph node, parotid lesion
Postauricular Mastoiditis, lymph node, sebaceous cyst
EAC Furuncle, osteoma, exostosis, foreign body, tumor, cholesteatoma

PROCEDURES

AURAL TOILET

Definition

Cleaning of EAC and ear discharge/debris under vision using suction, cotton, mop, or instruments.

Indications

  • Otitis externa

  • Otomycosis

  • CSOM discharge

  • Wax/debris

  • Before topical medication

  • Foreign body-associated debris

  • Malignant otitis externa monitoring

Methods

  • Dry mopping

  • Suction clearance

  • Microscope-assisted cleaning

  • Removal of crusts/debris

  • Cleaning fungal masses

Precautions

  • Avoid trauma to canal skin

  • Avoid deep blind instrumentation

  • Confirm TM status

  • Use microscope in painful/narrow canal

  • Diabetics need gentle handling

Importance

  • Improves penetration of ear drops

  • Reduces microbial load

  • Helps diagnosis by clearing view

EAR WICK INSERTION

Definition

Placement of expandable wick in swollen EAC to deliver topical medication.

Indications

  • Severe otitis externa with canal edema

  • Narrowed EAC preventing drop entry

  • Painful diffuse otitis externa

Material

  • Compressed sponge wick

  • Ribbon gauze wick

Technique

  • Clean canal gently

  • Insert wick under vision

  • Soak with antibiotic-steroid drops

  • Review after 24–48 hours

  • Remove/replace depending edema

Advantages

  • Delivers drug deep into canal

  • Reduces edema

  • Avoids repeated instrumentation

Complications

  • Pain

  • Canal abrasion

  • Retained wick

  • Secondary infection if forgotten

MICROSuction

Definition

Removal of wax, discharge, fungal debris, or foreign material from ear under microscope/endoscope using suction.

Indications

  • Wax removal when syringing contraindicated

  • Otomycosis

  • Otitis externa debris

  • Postoperative cavity cleaning

  • Foreign body removal

  • Perforated TM with discharge

Advantages

  • Direct visualization

  • Safer in TM perforation

  • Avoids water exposure

  • Useful in diabetics and post-surgical ears

Precautions

  • Explain loud suction noise

  • Avoid touching canal wall/TM

  • Use appropriate suction tip

  • Stop if severe vertigo/pain

Complications

  • Noise discomfort

  • Vertigo

  • Canal abrasion

  • Bleeding

  • Rare TM trauma

DRESSING AFTER EAR PROCEDURES

Indications

  • Hematoma auris drainage

  • Perichondrial abscess drainage

  • Pinna laceration repair

  • Post-auricular surgery

  • Keloid excision

Types

  • Pressure dressing

  • Bolster dressing

  • Ribbon gauze dressing

  • Antibiotic dressing

Goals

  • Prevent recollection of blood/pus

  • Maintain contour of pinna

  • Reduce edema

  • Protect wound

  • Prevent infection

Precautions

  • Do not apply excessive pressure causing ischemia

  • Check for pain, discoloration, swelling

  • Keep dressing dry

  • Review early after procedure

IMPORTANT TABLES

ANATOMY TABLES

Cartilaginous vs Bony EAC

Feature Cartilaginous EAC Bony EAC
Part Outer one-third Inner two-thirds
Skin Thick Thin
Hair follicles Present Absent
Ceruminous glands Present Absent
Sebaceous glands Present Absent
Subcutaneous tissue Present Minimal/absent
Common disease Furunculosis Severe otitis externa pain, exostosis
Sensitivity Less More painful

Blood Supply of External Ear

Region Arterial supply
Auricle Posterior auricular artery
Anterior auricle Superficial temporal artery
EAC Deep auricular artery
Lobule Branches of posterior auricular/superficial temporal

Nerve Supply of External Ear

Nerve Area supplied Clinical importance
Auriculotemporal nerve Anterosuperior auricle/EAC TMJ-related referred pain
Great auricular nerve Lobule and lower auricle Pain in lobule lesions
Lesser occipital nerve Upper medial auricle Cervical referred pain
Auricular branch of vagus Posteroinferior EAC Ear-cough reflex
Facial nerve contribution Concha/posterior canal small area Ramsay Hunt lesions

Lymphatic Drainage

Region Lymph nodes
Anterior auricle Preauricular/parotid nodes
Posterior auricle Postauricular/mastoid nodes
Lobule/lower auricle Upper deep cervical nodes
EAC Parotid and deep cervical nodes

Functions of Cerumen

Function Explanation
Lubrication Prevents dryness/cracking
Protection Traps dust and insects
Antibacterial Acidic pH and enzymes inhibit bacteria
Antifungal Reduces fungal colonization
Self-cleaning aid Migrates outward with epithelium

EMBRYOLOGY TABLES

First vs Second Branchial Arch Contribution

Arch Contribution
First arch Tragus, anterior auricular elements
Second arch Majority of pinna including helix, antihelix, lobule
First branchial cleft External auditory canal
Meatal plug Canalizes to form EAC lumen

Congenital Ear Anomalies

Anomaly Meaning
Microtia Small malformed pinna
Anotia Absence of pinna
Macrotia Large pinna
Bat ear Prominent ear
Lop ear Folded upper ear
Cryptotia Buried upper auricle
Preauricular sinus Congenital epithelial tract
Accessory auricle Extra auricular appendage
EAC atresia Absent canal
EAC stenosis Narrow canal

INFECTION TABLES

Furunculosis vs Diffuse Otitis Externa

Feature Furunculosis Diffuse Otitis Externa
Site Hair follicle, cartilaginous canal Entire EAC skin
Organism Staphylococcus aureus Pseudomonas, Staph aureus
Pain Severe localized Diffuse pain
Swelling Localized boil Diffuse canal edema
Discharge Usually absent initially Common
Treatment Antibiotics ± I&D Aural toilet + topical drops

Acute vs Chronic Otitis Externa

Feature Acute OE Chronic OE
Duration Short Long/recurrent
Pain Prominent Less prominent
Itching Variable Prominent
Canal Red, edematous Thickened, scaly
Discharge Purulent/debris Mild chronic discharge
Treatment Topical antibiotic-steroid Treat dermatitis/allergy + hygiene

Bacterial vs Fungal Otitis Externa

Feature Bacterial OE Otomycosis
Main symptom Pain Itching
Discharge Purulent Fungal debris
Common organism Pseudomonas Aspergillus
Otoscopy Edema, pus Black/white fungal masses
Treatment Antibiotic drops Aural toilet + antifungal

Benign vs Malignant Otitis Externa

Feature Benign OE Malignant OE
Patient Any age Elderly diabetic/immunocompromised
Pain Mild-moderate Severe deep nocturnal pain
Bone involvement Absent Skull base osteomyelitis
Granulation Uncommon Common at bone-cartilage junction
Cranial nerve palsy Absent May occur
Treatment Topical therapy Long-term systemic antipseudomonal therapy

Perichondritis vs Cellulitis

Feature Perichondritis Cellulitis
Structure involved Perichondrium/cartilage Skin/subcutaneous tissue
Lobule Spared Involved
Cause Piercing, trauma, burns Skin infection
Risk Cartilage necrosis Usually no cartilage necrosis
Treatment Antipseudomonal antibiotics ± drainage Antibiotics

Ramsay Hunt Syndrome vs Bell Palsy

Feature Ramsay Hunt Syndrome Bell Palsy
Cause Varicella-zoster virus Idiopathic/HSV-related
Ear pain Severe Mild/absent
Vesicles Present Absent
Hearing loss/vertigo May occur Usually absent
Prognosis Worse Better
Treatment Antiviral + steroid Steroid ± antiviral

MICROBIOLOGY TABLES

Organisms Causing Otitis Externa

Condition Common organisms
Furunculosis Staphylococcus aureus
Diffuse otitis externa Pseudomonas aeruginosa, Staphylococcus aureus
Malignant otitis externa Pseudomonas aeruginosa
Perichondritis Pseudomonas, Staphylococcus
Secondary infected eczema Staphylococcus aureus

Fungi Causing Otomycosis

Fungus Typical appearance
Aspergillus niger Black spores/debris
Aspergillus fumigatus Greenish/grey debris
Aspergillus flavus Yellow-green debris
Candida albicans Creamy white debris

Organisms Causing Malignant Otitis Externa

Organism Importance
Pseudomonas aeruginosa Most common
Staphylococcus aureus Less common
Fungal organisms Immunocompromised patients
Aspergillus Rare but serious

Antibiotics and Antifungals Used

Drug group Examples Use
Topical quinolone Ciprofloxacin/ofloxacin drops Otitis externa
Antibiotic-steroid drops Ciprofloxacin + steroid Painful edematous OE
Antipseudomonal systemic Ciprofloxacin, ceftazidime, piperacillin-tazobactam Malignant OE
Antifungal drops Clotrimazole Otomycosis
Antiviral Acyclovir/valacyclovir Ramsay Hunt, herpes simplex

OBSTRUCTIVE LESION TABLES

Types of Wax

Type Feature
Wet wax Brown, sticky
Dry wax Grey, flaky
Hard wax Impacted, firm
Soft wax Easily removable

Types of Foreign Bodies

Type Examples Important precaution
Animate Insects Kill before removal
Non-animate Beads, stones Remove under vision
Vegetable Peas, seeds Do not irrigate
Hygroscopic Beans, sponge Swells with water
Button battery Battery Emergency removal; no irrigation
Sharp Pins Specialist removal

Keratosis Obturans vs EAC Cholesteatoma

Feature Keratosis Obturans EAC Cholesteatoma
Age Younger Older
Laterality Often bilateral Usually unilateral
Pain Severe Dull chronic pain
Canal change Generalized widening Localized bone erosion
Keratin Plug Localized sac/debris
Association Sinusitis, bronchiectasis Trauma, surgery, chronic inflammation
Treatment Regular cleaning Cleaning ± surgery

Exostosis vs Osteoma

Feature Exostosis Osteoma
Number Multiple Single
Laterality Bilateral common Unilateral common
Base Broad-based Pedunculated
Cause Cold water exposure Idiopathic
Site Medial bony EAC Lateral bony EAC
Synonym Surfer’s ear Ivory osteoma

TRAUMA TABLES

Ear Trauma Classification

Type Examples
Blunt trauma Hematoma auris, cartilage fracture
Sharp trauma Laceration, avulsion
Thermal injury Burns
Cold injury Frostbite
Pressure injury Chondrodermatitis
Blast injury TM perforation, EAC trauma
Piercing-related Perichondritis, keloid

Complications of Hematoma Auris

Complication Mechanism
Cauliflower ear Cartilage necrosis/fibrosis
Perichondritis Secondary infection
Abscess Infected hematoma
Cosmetic deformity Untreated cartilage damage
Recurrence Inadequate pressure dressing

TUMOR TABLES

Benign vs Malignant External Ear Tumors

Feature Benign Malignant
Growth Slow Progressive/rapid
Pain Usually absent Pain may be present
Ulceration Rare Common
Bleeding Rare Common
Bone invasion Absent May occur
Facial palsy Absent Advanced disease
Treatment Excision if symptomatic Biopsy + wide excision ± RT

Ceruminous Tumors Classification

Type Nature
Ceruminous adenoma Benign
Ceruminous pleomorphic adenoma-like tumor Benign
Ceruminous adenocarcinoma Malignant
Adenoid cystic carcinoma Malignant
Mucoepidermoid carcinoma Malignant

DIFFERENTIAL DIAGNOSIS TABLES

Painful Ear Conditions

Condition Key feature
Furunculosis Localized boil, tragal tenderness
Diffuse otitis externa Diffuse canal edema
Perichondritis Lobule spared
Ramsay Hunt syndrome Vesicles + facial palsy
Hematoma auris Post-traumatic swelling
Malignant otitis externa Elderly diabetic + severe nocturnal pain
EAC carcinoma Non-healing bleeding lesion

Causes of Otorrhea

Cause Discharge
Otitis externa Purulent/debris
Otomycosis Fungal debris
CSOM Mucoid/purulent
Cholesteatoma Foul-smelling
Bullous myringitis Blood-stained
Malignancy Blood-stained/foul
Foreign body Foul discharge in children

Ear Canal Masses

Mass Clue
Wax Brown/black plug
Foreign body History/visible object
Furuncle Painful localized swelling
Osteoma Hard single bony mass
Exostosis Multiple bony swellings
Polyp/granulation Discharge, chronic disease
Papilloma Warty growth
Carcinoma Ulcerative bleeding mass

Granulation Tissue Differentials

Cause Important clue
Malignant otitis externa Elderly diabetic
SCC Non-healing bleeding lesion
EAC cholesteatoma Keratin + bone erosion
Foreign body Retained FB
Chronic otitis externa Recurrent infection
Tuberculosis/fungal infection Chronic non-resolving lesion
Postoperative granulation

Surgery history

 

 

IMPORTANT FLOWCHARTS — DISEASES OF EXTERNAL EAR

Approach to Ear Pain

Ear pain
↓
Otoscopy abnormal?
↓
Yes → Identify ear cause

  • EAC tenderness + edema → Otitis externa

  • Localized boil → Furunculosis

  • Vesicles + facial palsy → Ramsay Hunt syndrome

  • Wax/foreign body → Obstructive cause

  • Red swollen pinna, lobule spared → Perichondritis

  • Granulation in diabetic → Malignant otitis externa

  • Non-healing ulcer/mass → Malignancy

↓
No / normal otoscopy → Suspect referred otalgia
↓
Examine:

  • Teeth

  • TMJ

  • Tonsil

  • Pharynx

  • Base of tongue

  • Larynx

  • Neck
    ↓
    Persistent unexplained otalgia in adult
    ↓
    Rule out head & neck malignancy

Approach to Ear Discharge

Ear discharge
↓
Assess type of discharge
↓

Purulent + painful EAC
→ Otitis externa

Fungal debris + itching
→ Otomycosis

Foul-smelling + keratin debris
→ Cholesteatoma / EAC cholesteatoma

Blood-stained discharge
→ Trauma / bullous myringitis / malignancy

Watery discharge
→ Eczema / CSF leak / otitis externa

↓
Perform otoscopy + microscopy
↓
Assess TM status
↓
TM intact → External ear source likely
TM perforated → Middle ear disease likely
↓
Treat cause + aural toilet

Approach to EAC Swelling

EAC swelling
↓
Painful?
↓
Yes

  • Localized swelling → Furunculosis

  • Diffuse edematous canal → Diffuse otitis externa

  • Elderly diabetic + granulation → Malignant otitis externa

  • Trauma history → Hematoma / canal injury

↓
No / painless

  • Hard bony swelling → Osteoma / exostosis

  • Warty growth → Papilloma

  • Keratin debris + erosion → EAC cholesteatoma

  • Ulcerative bleeding mass → Malignancy

↓
Need evaluation

  • Otoscopy/microscopy

  • Aural toilet

  • HRCT if bony lesion suspected

  • Biopsy if suspicious mass/granulation

Management of Otitis Externa

Otitis externa suspected
↓
Assess severity
↓

Mild
→ Aural toilet
→ Topical antibiotic ± steroid drops
→ Keep ear dry
→ Analgesics

Moderate with edema
→ Aural toilet
→ Ear wick insertion
→ Topical antibiotic-steroid drops
→ Review after 24–48 hours

Severe / cellulitis / diabetes / immunocompromised
→ Aural toilet
→ Topical therapy
→ Systemic antibiotics
→ Rule out malignant otitis externa

↓
No improvement
↓
Reassess diagnosis

  • Otomycosis

  • Foreign body

  • Malignancy

  • Malignant otitis externa

Management of Otomycosis

Itching + blocked ear + fungal debris
↓
Otoscopy/microscopy
↓
Aural toilet / suction clearance
↓
Keep ear dry
↓
Topical antifungal

  • Clotrimazole

  • Fluconazole

  • Other antifungal drops
    ↓
    Avoid unnecessary antibiotic-steroid drops
    ↓
    Treat predisposing factors

  • Diabetes

  • Moisture

  • Hearing aid irritation
    ↓
    Recurrent otomycosis
    ↓
    Repeat cleaning + culture if needed + rule out chronic otitis externa / immunosuppression

Management of Malignant Otitis Externa

Elderly diabetic / immunocompromised + severe otalgia + EAC granulation
↓
Suspect malignant otitis externa
↓
Urgent evaluation

  • Blood sugar

  • ESR / CRP

  • Ear swab culture

  • HRCT temporal bone

  • MRI if soft tissue / cranial nerve involvement

  • Radionuclide scan if needed
    ↓
    Start treatment

  • Strict glycemic control

  • Aural toilet

  • Long-term antipseudomonal antibiotic

  • Analgesia
    ↓
    Assess cranial nerves
    ↓
    Cranial nerve palsy / skull base spread
    → Admit + IV antipseudomonal therapy
    ↓
    Monitor response

  • Pain relief

  • ESR / CRP fall

  • Granulation reduction
    ↓
    Persistent granulation / suspicious lesion
    → Biopsy to rule out malignancy

Management of Foreign Body Ear

Foreign body in ear
↓
Assess type
↓

Live insect
→ Kill first with oil/lidocaine
→ Remove under vision

Vegetable / hygroscopic FB
→ Do not irrigate
→ Remove dry under vision

Button battery
→ Emergency removal
→ No irrigation
→ Assess chemical burn

Smooth round object
→ Hook behind object
→ Avoid forceps pushing deeper

Sharp / deep / near TM
→ ENT specialist removal

↓
Assess patient cooperation
↓
Uncooperative child / failed attempt / deep FB
→ Removal under GA
↓
After removal
→ Check EAC and TM
→ Treat abrasion/infection

Management of Impacted Wax

Symptoms of wax impaction

  • Ear blockage

  • Conductive hearing loss

  • Tinnitus

  • Earache
    ↓
    Confirm by otoscopy
    ↓
    Check contraindications to irrigation

  • TM perforation

  • CSOM

  • Previous ear surgery

  • Grommet

  • Only hearing ear

  • Active otitis externa
    ↓

No contraindication
→ Ceruminolytic drops
→ Ear irrigation / syringing
→ Recheck TM

Contraindication present
→ Microsuction / instrumental removal under vision

↓
Advise

  • Avoid cotton buds

  • Keep ear dry if canal irritated

  • Review if pain/discharge develops

Management of Diabetic Ear Pain

Diabetic patient with ear pain
↓
Otoscopy
↓

Simple wax / mild otitis externa
→ Treat carefully
→ Avoid trauma
→ Close follow-up

Severe deep pain / nocturnal pain / persistent otorrhea
↓
Look for EAC granulation
↓
Granulation at bone-cartilage junction
→ Suspect malignant otitis externa
↓
Investigations

  • Blood sugar

  • ESR / CRP

  • Ear swab culture

  • HRCT temporal bone

  • MRI if needed
    ↓
    Treatment

  • Admit if severe

  • Antipseudomonal antibiotics

  • Glycemic control

  • Aural toilet

  • Monitor ESR/CRP
    ↓
    No response / atypical lesion
    → Biopsy to rule out carcinoma

Management of Hematoma Auris

Trauma to pinna
↓
Fluctuant swelling on auricle
↓
Diagnose hematoma auris
↓
Small early hematoma
→ Aspiration
→ Compression dressing

Large / recurrent hematoma
→ Incision and drainage
→ Remove clots
→ Bolster / pressure dressing
→ Antibiotics
↓
Follow-up in 24–48 hours
↓
Reaccumulation?
↓
Yes → Repeat drainage + firm bolster dressing
↓
Untreated / recurrent
→ Cauliflower ear

Approach to Granulation Tissue in EAC

Granulation tissue in EAC
↓
Assess patient profile
↓

Elderly diabetic / immunocompromised
→ Malignant otitis externa until proved otherwise

Non-healing bleeding mass
→ Suspect carcinoma

Keratin debris + focal bone erosion
→ EAC cholesteatoma

History of foreign body
→ Foreign body granuloma

Chronic discharge
→ Chronic otitis externa / middle ear disease

↓
Investigations

  • Microscopy

  • Culture

  • Blood sugar

  • ESR / CRP

  • HRCT temporal bone

  • MRI if extensive disease

  • Biopsy if suspicious / non-resolving
    ↓
    Treat according to cause

Reconstruction of Microtia

Microtia diagnosed
↓
Assess severity

  • Grade I

  • Grade II

  • Grade III

  • Anotia
    ↓
    Assess hearing

  • OAE / BERA in children

  • PTA in older child
    ↓
    HRCT temporal bone when surgical planning required
    ↓
    Decide priority
    ↓

Bilateral atresia / significant hearing loss
→ Early hearing rehabilitation first

Unilateral microtia with good opposite ear
→ Cosmetic reconstruction planning

↓
Reconstruction options

  • Autologous rib cartilage framework

  • Porous polyethylene implant

  • Prosthetic ear
    ↓
    Timing

  • Usually after adequate auricular growth

  • Commonly around 6–8 years or later
    ↓
    Postoperative care

  • Protect framework

  • Prevent infection

  • Staged refinement if needed

Hearing Rehabilitation in Congenital Atresia

Congenital aural atresia
↓
Assess laterality
↓

Bilateral atresia
→ Early hearing rehabilitation essential
→ Bone conduction hearing aid / soft-band BAHA
→ Speech and language monitoring

Unilateral atresia
→ Assess functional hearing
→ School performance monitoring
→ Consider bone conduction device

↓
Audiological evaluation

  • BERA / ASSR in infant

  • PTA when possible
    ↓
    HRCT temporal bone
    → Assess middle ear, ossicles, facial nerve, cochlea
    ↓
    Management options

  • Bone conduction hearing aid

  • BAHA / bone conduction implant

  • Canaloplasty in selected cases
    ↓
    Canaloplasty suitable only if

  • Good middle ear anatomy

  • Favorable facial nerve course

  • Functional cochlea

  • Experienced surgical setup

 

 

COMBINED IMAGE GROUPS

Anatomy Diagrams

Image 1

  • Pinna anatomy

  • EAC anatomy

  • Cartilaginous vs bony EAC

Image

Image

Image

Image

Image

Image 2

  • Blood supply

  • Nerve supply

  • Self-cleansing mechanism

Image

Image

Image

Image 3

  • Fissures of Santorini

  • Foramen of Huschke

Image

Image

Embryology Diagrams

Image 1

  • Hillocks of His

  • Development of pinna

  • Congenital anomalies

Image

Image

Image

Disease Diagrams

Image 1

  • Furunculosis

  • Diffuse otitis externa

  • Otomycosis

Image

Image

Image 2

  • Malignant otitis externa

  • Skull base osteomyelitis spread

Image 3

  • Ramsay Hunt syndrome

  • Bullous myringitis

Image

Image

Image 4

  • Hematoma auris

  • Cauliflower ear

  • Perichondritis

Image

Image

Image

Image 5

  • Keratosis obturans

  • EAC cholesteatoma

  • Wax impaction

Image

Image

Image

Image 6

  • Exostosis

  • Osteoma

Image

Image

Procedure Diagrams

Image 1

  • Otoscopy

  • Ear wick insertion

  • Microsuction

Image

Image

Image

Image 2

  • Foreign body removal

  • Aural toilet

Image

Image

Image 3

  • Hematoma drainage

  • BAHA placement

Radiology Figures

Image 1

  • HRCT EAC cholesteatoma

  • HRCT temporal bone

Image

Image

 

 

 

EAR IRRIGATION

Definition

Ear irrigation (ear syringing) is the procedure of cleaning the external auditory canal by flushing fluid into the canal to remove wax, debris, discharge, or selected foreign bodies.

Principles of Ear Irrigation

  • Procedure should be performed only after proper otoscopic examination.

  • Tympanic membrane status must be known before irrigation.

  • Water should be at body temperature.

  • Direction of water jet should be along posterosuperior canal wall, not directly at tympanic membrane.

  • Procedure must be atraumatic.

  • Sterile/clean technique should be maintained.

  • Excessive pressure should be avoided.

  • Irrigation should stop immediately if:

    • Severe pain

    • Vertigo

    • Bleeding

    • Sudden hearing loss occurs

Mechanism of Irrigation

Wax removal mechanism

  • Water enters between wax and canal wall.

  • Wax softens and loosens.

  • Hydraulic pressure expels wax outward.

Foreign body removal mechanism

  • Water flows behind object and pushes it outward.

Importance of Water Temperature

Ideal temperature

  • Around body temperature:

    • 37°C

Cold water effects

  • Vertigo

  • Nystagmus

  • Nausea

Hot water effects

  • Similar vestibular stimulation

Caloric Stimulation Mechanism

Principle

Temperature difference creates endolymph movement in semicircular canals.

Cold water

  • Endolymph falls

  • Produces nystagmus to opposite side

Warm water

  • Endolymph rises

  • Produces nystagmus to same side

Mnemonic

COWS:

  • Cold → Opposite

  • Warm → Same

Sterility Precautions

  • Use clean sterilized instruments.

  • Avoid contaminated water.

  • Hand hygiene mandatory.

  • Use disposable tips/specula when possible.

  • Avoid cross contamination between patients.

  • Clean suction apparatus properly.

TYPES OF EAR CLEANING

Ear Syringing

Definition

Cleaning using manual syringe and water irrigation.

Commonly used for

  • Impacted wax

Electronic Irrigation

Definition

Machine-assisted controlled irrigation system.

Advantages

  • Controlled pressure

  • Reduced trauma risk

Microsuction

Definition

Removal of debris/wax using suction under microscope/endoscope visualization.

Advantages

  • Useful when syringing contraindicated

  • Safe in perforated TM

  • Better visualization

Instrumental Removal

Methods

  • Hook

  • Forceps

  • Curette

  • Probe

Indications

  • Foreign body

  • Hard wax

  • Objects near tympanic membrane

Aural Toilet

Definition

Cleaning of EAC using suction, mopping, or instrumentation.

Uses

  • Otitis externa

  • Otomycosis

  • CSOM

INDICATIONS

Impacted Wax

  • Most common indication

Debris Removal

  • Discharge

  • Crusts

  • Keratin

  • Blood clots

Otomycosis Cleaning

  • Removal of fungal debris before antifungal drops

Selected Foreign Body Removal

Suitable foreign bodies

  • Small inert smooth objects

  • Loose non-hygroscopic materials

CONTRAINDICATIONS

Contraindication Reason
Tympanic membrane perforation Water enters middle ear
CSOM Infection spread
Previous ear surgery Altered anatomy
Mastoid cavity Vertigo/infection
Grommet insertion Middle ear contamination
Active infection Pain and worsening infection
Suspected cholesteatoma Disease spread
Severe vertigo history Vestibular stimulation
Only hearing ear Risk of hearing loss
Button battery Chemical injury
Vegetable/hygroscopic FB Swelling with water

EQUIPMENT

Syringe

  • Metal or plastic syringe

  • Commonly 50–100 mL

Irrigation Apparatus

  • Electronic irrigation device

  • Controlled pressure system

Body Temperature Water

  • Sterile/clean water at ~37°C

Kidney Tray

  • Collects expelled debris and water

Otoscope

  • Pre- and post-procedure examination

Ear Speculum

  • Proper visualization of canal

Microsuction Setup

Components

  • Operating microscope/endoscope

  • Suction machine

  • Fine suction tips

PROCEDURE

Patient Preparation

  • Explain procedure

  • Obtain consent

  • Examine ear

  • Rule out contraindications

  • Seat patient comfortably

Positioning

  • Patient seated upright

  • Head tilted slightly toward opposite side

  • Kidney tray below ear

Direction of Water Jet

Correct direction

  • Along posterosuperior canal wall

Avoid

  • Direct jet toward tympanic membrane

Syringing Technique

Steps

  1. Fill syringe with body temperature water.

  2. Pull pinna:

    • Adult → upward, backward

    • Child → downward, backward

  3. Insert nozzle gently.

  4. Irrigate along canal wall.

  5. Allow water/debris to drain out.

  6. Re-examine ear.

Microsuction Technique

Steps

  1. Visualize canal under microscope.

  2. Select appropriate suction tip.

  3. Remove debris carefully.

  4. Avoid touching TM/canal wall repeatedly.

Post-Procedure Examination

Assess for

  • Canal trauma

  • Residual wax

  • Tympanic membrane integrity

  • Vertigo

  • Hearing improvement

CERUMINOLYTICS

Sodium Bicarbonate

Action

  • Softens wax

Advantages

  • Cheap

  • Effective

Hydrogen Peroxide

Action

  • Effervescence loosens wax

Side effects

  • Irritation possible

Olive Oil

Action

  • Lubricates and softens wax

Glycerine

Action

  • Softening and lubrication

Pretreatment Principles

  • Use drops for 3–5 days before syringing if wax hard.

  • Warm drops before use.

  • Avoid in suspected TM perforation unless safe preparation used.

FOREIGN BODY REMOVAL

Foreign Bodies Suitable for Irrigation

Suitable FB Examples
Small smooth inert FB Beads, plastic pieces
Loose non-hygroscopic objects Small stones

Foreign Bodies NOT Suitable

NOT suitable Reason
Button battery Chemical burn
Vegetable matter Swelling
Hygroscopic FB Expands with water
Sharp objects Trauma
Foam/sponge Swelling

Live Insect Management

Steps

  1. Kill insect first:

    • Mineral oil

    • Lidocaine

  2. Remove under visualization.

Instrumental Techniques

Instrument Use
Hook Round objects
Forceps Graspable FB
Suction Small smooth FB
Curette Wax/debris

COMPLICATIONS

Vertigo

Due to caloric stimulation.

Syncope

Vagal stimulation during procedure.

Pain

Due to:

  • Excess pressure

  • Infection

  • Canal trauma

Bleeding

From canal abrasion or trauma.

Canal Abrasion

Most common minor complication.

Tympanic Membrane Perforation

Due to forceful irrigation/instrumentation.

Otitis Externa

Secondary infection after trauma/moisture.

Otitis Media

Water enters middle ear through perforation.

Hearing Loss

Temporary conductive loss due to retained water/debris.
Rarely permanent injury.

Retained Fragments

Especially foreign bodies/wax fragments.

SPECIAL SITUATIONS

Children

Precautions

  • Proper immobilization

  • Avoid repeated attempts

  • Early GA if uncooperative

Elderly

Concerns

  • Narrow canal

  • Hard wax

  • Fragile skin

  • Vertigo susceptibility

Diabetics

Important

  • Avoid trauma

  • Increased infection risk

  • Beware malignant otitis externa

Mentally Disabled Patients

Issues

  • Poor cooperation

  • Sudden movement risk

Uncooperative Patients

Management

  • Gentle restraint

  • Sedation/GA if needed

IMPORTANT TABLES

Indications vs Contraindications

Indications Contraindications
Impacted wax TM perforation
Debris removal CSOM
Otomycosis cleaning Mastoid cavity
Selected FB Grommet
  Button battery

Syringing vs Microsuction

Feature Syringing Microsuction
Water used Yes No
TM perforation Contraindicated Safer
Visualization Limited Excellent
Noise Minimal Loud
Moisture risk Present Absent
Diabetic ear Less preferred Preferred

Ceruminolytics Comparison

Agent Action Advantage
Sodium bicarbonate Softens wax Cheap
Hydrogen peroxide Effervescence Rapid loosening
Olive oil Lubricates Gentle
Glycerine Softens Lubricating

Complications of Irrigation

Complication Cause
Vertigo Caloric effect
Pain Trauma
TM perforation Excess force
Bleeding Canal abrasion
Infection Moisture/contamination
Hearing loss Trauma or retained debris

Foreign Bodies Suitable for Irrigation

Suitable Not suitable
Plastic bead Button battery
Small stone Seed/pea
Loose inert object Sponge
  Sharp metal object

IMPORTANT FLOWCHARTS

Approach to Impacted Wax

Ear blockage/hearing loss
↓
Otoscopy
↓
Wax seen?
↓
Assess contraindications to irrigation
↓

No contraindication
→ Ceruminolytics
→ Syringing/irrigation
→ Re-examine TM

Contraindication present
→ Microsuction/instrumental removal

↓

Persistent symptoms
→ Reassess diagnosis

Ear Foreign Body Management

Foreign body identified
↓
Assess type
↓

Button battery
→ Emergency removal
→ No irrigation

Vegetable/hygroscopic
→ Dry removal only

Live insect
→ Kill first with oil/lidocaine
→ Remove

Smooth inert FB
→ Irrigation or hook/suction

↓
Uncooperative child/deep FB
→ Removal under GA

Decision-Making Before Irrigation

Need for irrigation
↓
Otoscopy
↓
Check:

  • TM status

  • Ear surgery history

  • Infection

  • Vertigo history

  • FB type

↓
Contraindication present?
↓

Yes
→ Avoid irrigation
→ Microsuction/instrumental removal

No
→ Proceed with irrigation

Post-Irrigation Complication Management

Pain/vertigo/bleeding after irrigation
↓
Stop procedure immediately
↓
Re-examine ear
↓

Canal abrasion
→ Topical antibiotic

TM perforation
→ Keep ear dry
→ ENT follow-up

Persistent vertigo
→ Vestibular assessment

Infection
→ Treat otitis externa/media

IMPORTANT DIAGRAMS / FIGURES

Ear syringing technique

Correct nozzle positioning

Water jet direction

Microsuction apparatus

Caloric stimulation mechanism

Foreign body extraction methods

Image

Image

Image

Image

Image

Image

IMPORTANT CLINICAL PHOTOGRAPHS

Syringing setup

Microsuction

Impacted wax before and after removal

Image

Image

Image

Post-irrigation otoscopic appearance

Image

Image

 

 

 

 

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