Diseases of the External and

Middle ear

Prof Hisham Khalil

Consultant ENT Surgeon
PUS Lecture
2 March, 2015
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Learning Objectives
Pertinent Anatomy and Physiology
Diagnostic approach to hearing loss
Common disorders of the external and
middle ear
Summary

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Pertinent Anatomy/ Physiology

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How do we hear?

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Diagnostic Approach to
Diseases of the External and
Middle ear

History
Examination
Investigations

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Symptoms of Ear Disease

Hearing loss
Ear Discharge (Otorrhoea)
Tinnitus
Vertigo
Ear Ache (Otalgia)
Facial Paralysis

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Otorrhoea

Purulent otitis externa / media

Mucopurulentotitis media
Clear.CSF
Blood stained.tumours
Bleeding per eartrauma/tumours

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Tinnitus
Perception of sound in the absence of
an acoustic stimulus
Common symptom with hearing loss

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Vertigo
A hallucination of movement
Symptom of a vestibular disorder
(peripheral or central)
Dizziness is a broader term referring to
a disorder of balance. It includes light
headedness, giddiness, unsteadiness,
vertigo etc
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Examination

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Otoscopy

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Tympanic Membrane

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Assessment of Hearing

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Subjective Assessment Of Hearing

in Adults
Free field speech tests
Tuning fork tests
Pure tone audiogram

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Free Field Speech Tests

Whisper test
Normal Conversational voice
Shouting
Tests performed 2ft/6inchs from
subject
Masking of contra-lateral ear

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Tuning Fork Tests

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Rinn Test
Compares Air
Conduction (AC)
with
Bone Conduction
(BC) in the same ear

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Rinn Test
Positive Rinn
AC > BCNormal
Negative Rinn
BC > AC.Conductive HL
Reduced Rinn
AC > BC but shortened
duration...Sensorineural HL
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Weber Test
Central.normal
hearing
Localised to
affected ear
conductive hearing
loss
Localised to normal
earsensorineural
hearing loss
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Tympanometry
Ear canal probe alters
pressure in ear canal
Ear canal volume,
middle ear pressure
and volume is
measured
Stapedial reflex can
be tested

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Tympanogram
Type A

Demonstrates
normal (eardrum) &
middle ear compliance

NB: ECV values must be

considered at the same
time to interpret the
tympanogram correctly

Normal ranges
Child 0.4/0.7 ml
Adult 0.7/1.2 ml

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Tympanogram
Type B
Flat tympanogram,
associated with
Otitis Media with
effusion

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Pure Tone Audiometry

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Conductive loss. Bilateral

Glue ears (OME) See
PDF Deaf.4 in this folder
for full document

Audiometer 3

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Disorders of the External and

Middle ear

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Congenital Anomalies
Aural atresia
Conductive or
mixed hearing loss

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External Ear Pathology

Impacted Wax
Can cause a mild
conductive
hearing loss
Foreign body

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Otitis Externa

Otorrhoea (purulent)
Itching
+ Otalgia
Oedema of ear canal

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Herpes Zoster Oticus

Ramsay-Hunt Syndrome

Caused by HZ virus
Vesicles in Concha
Sensorineual hearing loss
Facial paralysis
Dizziness
Treated with Acyclovir +/oral steroids

Necrotising(Malignant)
Otitis Externa
Caused by pseudomonas
species +/- Anaerobes
Elderly
immunpcopromised
patients e.g. Diabetic
Pain a prominent feature
Treatment with long term
antibiotics including i.V.
Triple therapy to avoid
drug resistance

Traumatic TM Perforation
Direct or Indirect
Trauma
(e.g. slap on the ear)
Usually heals
spontaneously

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Otitis Media-Classification
Otitis media is an inflammation of the
middle ear cleft.
1. Acute Otitis Media
2. Chronic Otitis Media
a) Non-Suppurative: Glue Ear, Otitis
media with effusion (OME)
b) Suppurative: Mucosal Disease
Cholesteatoma
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Acute Otitis Media

Fever
Otalgia
Congested,
Featureless TM
Organisms:
Strept pneumoniae
H Infleunza
M Catarrhalis
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Treatment of AOM
No evidence to support the routine use of
antibiotics
Analgesia
Rehydration
Antibiotics with increasing pain despite
conservative measures and with
complications
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Otitis Media with Effusion

(Glue Ear)
Commonest Cause of Childhood
Deafness
Eustachian tube dysfunction is the
principal pathology
URTI, Adenoidal hypertrophy, parental
smoking, allergy are risk factors
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Otitis Media with Effusion

(Glue Ear)
Conductive deafness
Fluctuating hearing
Spontaneous
resolution is common

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Treatment of OME
Watchful waiting for 3
months
Hearing aids
Ventilatio tubes (grommet
insertion)

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Chronic Otitis Media

Mucosal Disease
Tympanic membrane
perforation
Chronic Otorrhoea

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Myringoplasty/Tympan
oplasty

Chronic Otitis Media

Cholesteatoma
Squamous epithelium
(skin) growing into the
middle ear cleft
(normally lined by
mucosa)
Pathology: chronic
infection, osteitis,
destruction of middle
ear structures
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Chronic Otitis Media

Aural Polyp
Chronic Otorrhoea
Conductive
hearing loss
Underlying
osteitis

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Tympanomastoidectomy
Combined Approach
(CAT)

Modified radical

Tympanosclerosis
A sequel of
otitis media
or
grommet insertion

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Otosclerosis
Fixation of the footplate of the stapes in
the oval window
Normal ear drum
Conductive or mixed hearing loss

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Stapedectomy

Cancer of the External and

Middle Ear

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Discussion

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