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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4440_Библиотеки_им_академика_М_И_Перельмана.pdf
108
Low set ear
astube ce
3 History andExamination ofEar
Darwin’s tubercle
Fig. 3.15 Darwin’s tubercle
Fig. 3.13 Ear tag
Fig. 3.14 Low-set ear
Low-set ears: A below positioned
ear compared to normal position is
known as low-set ear. In low-set
ears, the top of the pinna is positioned below the horizontal line
connecting the outer corners of the
eyes. This abnormality is associated
with a number of genetic syndromes
and often with developmental
delays (Fig.3.14).
Darwin’s tubercle: It is a congenital
ear condition, which often presents
as a thickening on the helix at the
junction of the upper and middle
thirds (Fig.3.15).
Showing congenital deformities
of pinna
Acquired deformities of pinna
Earlobe deformities—These come
in a variety of shapes, including ear-
lobes with clefts (Fig.3.16b), duplicate earlobes, earlobes with skin
tags (Fig. 3.16a), protruding earlobe (Fig.3.16c) and enlarged earlobe (Fig.3.16d).
Traumatic ear deformities—These
deformities are lacerations, tears and
bite injuries, loss of part of pinna and
total avulsion of pinna (Fig.3.17).
Cauliower ear: Abnormal carti-
lage forms on top of the normal cartilage, resulting in bulky misshapen
ears (Fig.3.18).
Showing acquired deformities of
pinna
Ear keloids: It is caused by exces-
sive scar tissue formation after
minor trauma, most commonly after
ear piercing (Fig.3.19).
Ear haemangiomas: This is most
common benign tumour of infancy,
can occur anywhere on the body,
including the external ear and the
salivary gland in front of the ear
(Fig.3.20).
Hypertrichosis—hypertrichosis
lanuginosa acquisita, a hairy pinna
(Fig.3.21).
Wart, mole, birthmark, scars, skin
tag.
Sunburn (Fig. 3.22a) and
frostbite(Fig. 3.22b)
Pressure ulcer—It is often due to a
poorly tting hearing aid and pressure bandage (Fig.3.23).
3.2 Examination ofEar
109
a
Fig. 3.16 Deformities of pinna. (a) Duplicate earlobe; (b) split ear or earlobe with cleft; (c) protruding earlobe; and (d)
enlarged earlobe
Fig. 3.17 Traumatic deformity of pinna
b c
d
Fig. 3.19 Keloid over pinna
Fig. 3.18 Cauliower ear
Fig. 3.20 Haemangioma
110
Fig. 3.21 Hypertrichosis
3 History andExamination ofEar
a
Fig. 3.22 (a) Sunburn and (b) frostbite
Tophus—nodule on the pinna
related to gout (Fig.3.24).
Actinic keratosis and cutaneous
horn, premalignant lesions caused
by solar damage (Fig.3.25).
Benign and malignant neoplasm—
including tumours, keratoacan-
thoma, carcinoma.
Chondrodermatitis nodularis chronica helicis (Winkler’s nodule)—a
nodule initiated by solar damage
(Fig.3.26).
– Palpation of pinna
Tenderness
b
Fig. 3.23 Pressure ulcer
Fig. 3.24 Tophus
Tragal tenderness—elicited by
pressing the tragus towards the
EAC.This is cardinal sign of acute
otitis externa, furunculosis of EAC
(Fig.3.27a).
3.2 Examination ofEar
Fig. 3.25 Actinic keratosis and cutaneous horn
111
Fig. 3.26 Winkler’s nodule
a
Fig. 3.27 Showing how to elicit tenderness. (a) Tragal tenderness; (b) tenderness on pressing pinna; and (c) tenderness
on pulling pinna
Tenderness on pulling pinna
(Fig. 3.27b)—mastoid abscess,
acute otitis externa
Tenderness on pressing pinna
(Fig. 3.27c)—perichondritis, haematoma, abscess
Consistency
Hard—keloid, chondroma
Firm—cauliower pinna,
perichondritis
Soft—haematoma, abscess, cyst
b c
(d) Examination of external auditory canal—
The normal external auditory canal, extends
from the pinna (laterally) to the tympanic
membrane (medially), and is 24 mm in
length (outer 1/3 is cartilaginous and inner
2/3 is bony), 7mm in diameter (it may vary),
and S-shaped. For inspection of EAC, pinna
has to pull posteriorly, superiorly and laterally in adult, whereas in children, it has to be
pulled laterally and posteriorly to make EAC
straight. The examination of EAC is done
with and without speculum.
112
• Examination with headlight or head
mirror—The external auditory canal is
24 mm long and S-shaped. This part of
examination is done either by headlight or
by head mirror, to know the diameter of
EAC (normal, wide or stenosis or atresia),
collection (secretion, debris, wax), swelling (osteoma, furunculosis, exostosis),
growth (granulation, haemangioma,
tumours, polyp).
• Otoscopic examination—This is done to
conrm the ndings of examination done
with head mirror.
• Differential diagnosis of EAC diseases/
ndings.
– Opening of EAC (external auditory
meatus)
Normal—The external opening is
round in shape and 7 mm in
diameter.
Abnormal
3 History andExamination ofEar
Narrow—meatal stenosis (brous), infec-
tion, mass or growth, oedema, swelling
Wide—post-MRM
Absent—meatal atresia
– Shape of EAC
– Normal—EAC is of cylindrical shape.
– Lumen of EAC
Normal—Diameter of lumen of
EAC is around 9mm but may vary.
Abnormal (Fig.3.28)
Narrow—The diameter less than normal is
indicative of large mastoid (Fig.3.28b).
Wide—A wide EAC is indicative of small
mastoid (Fig.3.28a).
Absent (atresia)—Its abnormal and absent
meatal atresia (Fig.3.28c).
a b c
Fig. 3.28 Sizes of external auditory canal and its opening. (a) Wide canal; (b) stenosed canal; and (c) canal atresia
Colour of ear wax
W
x
3.2 Examination ofEar
113
– Curvature of EAC
Normal—extended S-shaped
Abnormal—straight/curved
– Walls of external auditory canal
Painful swelling limited to cartilaginous part of EAC caused by
furunculosis.
Sagging of posterosuperior bony
wall—cholesteatoma, mastoid
abscess.
Absent sensation in posterosuperior
cartilaginous part of EAC is known as
Hitzelberger’s sign—CP angle lesion.
Swelling on oor of bony EAC—
exostosis.
Oedema of EAC—caused by infection/inammation, diffuse otitis
externa.
Fig. 3.29 Colour chart
of wax
Yellow
Fresh wax
Erythema of skin—otitis externa.
Laceration and other signs of trauma.
– Presence of specic sign, wax or
discharge.
Wax—It usually appears brown in
colour; consistency may vary
(Fig.3.29).
Discharge—The colours of discharge in EAC indicate diagnosis
(Table3.48 and Fig.3.30).
Mass/growth/granulation—It may
be due to infection of EAC, benign
or malignant tumour of EAC
(Table3.49).
Showing clinical images of
tumours of external ear (Fig.
3.31)
Swelling in EAC (Table 3.50)
Yellow to green
Pus mixed with wax
Yellow to orange
Fresh wax
Darkorange
ax + dust particle
Table 3.48 Causes of ear discharge
Colour of discharge Probable diagnosis
Brown Wa x
Black Otomycosis (Aspergillosis) (Fig.3.30a)
White Otomycosis (mucormycosis) (Fig.3.30b), CSOM
Colourless (watery, serous) Acute otitis media, CSF otorrhoea
Yellow Bacterial infection in CSOM, ASOM, furunculosis
Reddish (blood stained or serosanguinous) CSOM attic antral type, acute infection in CSOM, ASOM
Blood Trauma, haemangioma, bleeding disorder
Brown
Very old wax
Pale orange
Dry wax
GREEN
Ear infection + wax
Blood mixed wax
Infection or Trauma
Gray
DUST in EAC +/- wa
Black
Impacted wax
114
3 History andExamination ofEar
Fig. 3.30 Otomycosis.
(a) Aspergillosis and (b)
candidiasis
Table 3.49 Causes of mass/growth in EAC and their presentation
Type/characteristics of growth/mass Differential diagnosis
Benign tumour
A bilateral, broad-based mounds of bone that arise from the anterior and posterior
canal walls. This is a most common benign tumour. Present in deep part of EAC
(Fig.3.31a)
A solitary and unilateral, pedunculated bony growth, arises from lateral part (bony
cartilaginous junction) of EAC (Fig.3.31b)
A round or irregularly shaped lesions that are scaly, keratotic and at topped. The
colour varies from grey to deep brown. It is the most common premalignant lesion
A warty, verrucous and elevated lesion that may be pigmented. It may have an
overlying, thickened keratin layer (Fig.3.31c)
It is a smooth, elevated, pedunculated, rm-to-soft lesion which is usually solitary and
smaller than 0.5cm and bleed of touch. The colour varies; tan, skin-coloured, pink and
red lesions have been observed
It is slow-growing, bluish, solitary and well-circumscribed nodule within the dermis of
the auricle or preauricular region presented in rst two decades of life
It is a rare, slow-growing presented as skin-covered, non-ulcerated masses located in
the lateral half of the EAC
Arise from hair follicle, an elevated mass eshy covered or pinkish, relatively
uncommon
It is adnexal tumour of skin present as skin mass Benign cylindroma
It is a at or cicatricial, verrucose or nodular form, slowly growing Haemangioma/congenital
It is smooth surface mass white to pink in colour (Fig.3.31d) Aural polyp
Granulations are inammatory tissue that may arise from infected bone of ear canal or
middle ear
Malignant tumour
It is an aggressive malignant tumour of childhood, and second most common primary
bone tumour. It can involve almost any bone in the body; however, trunk and long
bones are more commonly affected
A tumour also might start inside the ear canal. The patient might notice drainage from
the canal or pain inside the ear. Present with earache, mass and redness at site of
tumour
Basal skin carcinoma is the most common type of ear and temporal bone cancer. A
scaly area of skin on the ear, which does not improve with the application of
moisturizer, is usually the rst sign. Then, a pearly white bump appears which grows
slowly
a b
Exostosis
(osteochondroma)
Osteoma, bone island and
osteoid osteoma
Actinic keratosis
Squamous papilloma
Sebaceous adenoma
Pilomatricoma
Ceruminous gland
tumour (adenoma)
(ceruminoma)
Keratoacanthoma
(Turban tumour)
hamartoma
Granulation
Ewing sarcoma
Osteosarcoma
Basal cell carcinoma
(continued)
3.2 Examination ofEar
Table 3.49 (continued)
Type/characteristics of growth/mass Differential diagnosis
Bloody discharge from the inner ear is the most common symptom for middle ear
cancer, but other symptoms include inability to move the face on the affected side of
ear, earache (pain) inside the ear and hearing loss (Fig.3.31h)
Adenoid cystic carcinoma is extremely rare tumour of EAC accounting for
approximately 5%. Majority of the patients presents with unilateral severe or dull
aching constant ear pain of prolonged duration, reduced hearing and mass in the
external ear (Fig.3.31g)
Firm, red nodules and sores on skin of the ear with a scaly crust are among the
most common visible signs of squamous cell carcinoma (Fig.3.31e, f)
Adenocarcinoma
Adenoid cystic carcinoma
Squamous cell carcinoma
115
Fig. 3.31 Tumour of
EAC. (a) Exostosis; (b)
osteoma; (c) squamous
papilloma; (d) aural
polyp shows malignant
tumour of EAC, (e, f)
squamous cell
carcinoma; (g) adenoid
cystic carcinoma; and
(h) adenocarcinoma
a
c
e
b
d
f
g
h
116
Table 3.50 Differential diagnosis of swelling of EAC
Denition/signs Diagnosis
Infection of a hair follicle (Fig.3.32d) Acute localized OE/furunculosis
Most common, seen in swimmer, tragal tenderness present, diffuse oedema
(Fig.3.32a)
Skin of EAC is shiny, erythematous, hyperaemia and covered with white
patchy and purulent exudate, normal cerumen absent (Fig.3.32b)
Granulation tissue on the oor of EAC at the junction of bony and
cartilaginous junction, and meatus is lled with purulent discharge
(Fig.3.32c)
Encompasses various dermatologic conditions (e.g. atopic dermatitis,
psoriasis, systemic lupus erythematosus and eczema) that may infect the
EAC and cause OE (Fig.3.32g)
Infection of the ear canal from a fungal species (e.g. Candida, Aspergillus)
(Fig.3.32f)
Sagging and swelling in posterosuperior bony wall of EAC (Fig.3.32e) Luc’s abscess
White keratin debris with cerumen accompanied by granulation and
widening of EAC (Fig.3.32h)
Herpetic vesicle in EAC and concha with facial nerve paralysis Ramsay Hunt syndrome
3 History andExamination ofEar
Acute diffused OE
Chronic otitis externa
Necrotizing (malignant) otitis
externa
Eczematous/seborrhoeic otitis
externa
Otomycosis
Keratosis obturans
Showing clinical images of diseases of external auditory canal
(Fig. 3.32)
(e) Examination of tympanic membrane
• Clinical anatomy of normal tympanic
membrane—The normal tympanic membrane is pearly white, glistening, ovoid
and semitransparent. It is comprised of
two parts, the pars tensa inferiorly and the
pars accida superiorly. The cone of light
presents in anteroinferior quadrants of
TM at the 5 o’ clock position in right tympanic membrane and 7 o’clock position in
left tympanic membrane. TM is divided
into four quadrants by two lines, one
drawn vertically from handle of malleus
and another horizontally from umbo.
These quadrants are anterosuperior,
anteroinferior, posteroinferior and posterosuperior (Fig.3.33).
• Inspection of tympanic membrane—
This is done by headlight or head mirror.
– Position of tympanic membrane
Normal—The tympanic membrane
is oriented obliquely in the antero-
posterior, mediolateral and supero-
inferior planes. Consequently, its
superoposterior end lies lateral to
its anteroinferior end (Fig.3.33).
Bulging/lateralized—This is caused
by collection of uid or pus in middle ear in SOM and AOM
(Fig.3.34).
Medialized/retracted pars tensa of
TM (retraction caused by negative
pressure)—The retraction of tympanic membrane is classied
depending upon that the part of
tympanic membrane is retracted.
Sade’s classication of pars tensa
retraction (Table 3.51 and
Fig.3.35).
Adhesive otitis media—It is a form
of chronic otitis media where there
is an adhesion of medial ear structures as a result of chronic inammation. In adhesive otitis media,
tympanic membrane is adhered to
medial wall of middle ear and
immobile (Fig.3.36).
Retraction of pars accida—Pars
accida is located above pars
tensa or malleolar folds.
Retraction of pars accida is the
rst reaction to negative pressure
in middle ear. The retraction of
pars accida has been classied
by TOSS into four grades, which
3.2 Examination ofEar
a b c
d e f
117
g h
Fig. 3.32 Infection (otitis externa). (a) Diffused OE; (b) chronic OE; (c) malignant OE; (d) furunculosis (acute local-
izing OE); (e) Luc’s abscess; (f) otomycosis; (g) seborrhoeic otitis externa; and (h) keratosis obturans
is known as TOSS classication
of pars accida retraction
(Table3.52 and Fig.3.37).
– Colour of tympanic membrane
White—The white colour of TM is
due to tympanosclerosis. It is
dened as opaque or patchy white
appearance of the eardrum. The
amount of eardrum involvement
can vary considerably between
cases (Fig.3.38).
Yellow (SOM, glue ear)—A yellow
or greyish middle ear effusion can
be seen behind the tympanic membrane in either condition (Fig.3.39).
Blue—haemotympanum—It is the
presence of blood in your middle
ear, which is the area behind your
eardrum (Fig.3.40).
Red
Dark red—It indicates a recent
trauma or blood behind the TM.
Dark pink or lighter red—It indicates AOM or hyperaemia of the
TM caused by crying, coughing or
nose blowing (Fig.3.41).