Ear

external middle inner

External meatus

3 cm long cartilaginous part bony part

Innervation

sensory is supplied by trigeminal nerve great auricular nerve vagus nerve sensory fibers of the facial nerve

Middle ear cavity

Eustachian tube tympanic cavity mastoid antrum pneumatic system of the temporal bone

 Middle ear cavity (film)

Eustachian tube consists of

mobile cartilaginous portion (2/3) bony portion (1/3)

Middle ear cavity

is an air containing space divided into

epitympanic recess or attic mesotympanum hypotympanic recess

Tympanic membrane consists of the

pars tensa pars flacida

Clinical tympanic membrane

is divided into four quadrants

anterosuperior anteroinferior posteroinferior posterosuperior

Investigation

palpation otoscopy

X-ray investigation

Schueller view present pneumatic system temporal bone: mastiod process, the antrum, the sigmoid sinus, the mastoid emissary foramen Indication: mastoiditis, cholesteatoma, longitudinal fracture of the petrous pyramid

Stenvers view present the apex of the petrous pyramid the labyrinth, the internal auditory meatus

CT

The pathologic of the tympanic membrane

injection of the vessels and inflammation haemorrhage serous exudate retraction of the tympanic membrane decreased pressure in the middle ear

The pathologic of the tympanic membrane

bulging due to formation of exudate behind the tympanic membrane

atrophy of the tympanic membrane thickening of the tympanic membrane scars of the tympanic membrane tympanic membrane perforations central or peripheral

Extensive tympanic membrane perforation (angular edges) exposing the tympanic cavity and incudostapedial joint

Adhesive process with atelectasis of the middle ear cleft, a retraction pocket, and destruction of the long process of the incus (arrow)

Hematotympanum following a transverse petrous bone fracture

Wax and foreign body

yellowish-brown mass consisting of secretion of the sebaceous and ceruminous glands, desquamated epithelium hair dirt

Differential diagnosis foreign body, dried blood, purulent exudate

Treatment ear irrigated with water at temp. 37C, removed by hook

Subepithelial hematoma (H) and cerumen on the tympanic membrane caused by attempted self-cleaning of the ear

External otitis

diffuse bacterial and viral circumscribed bacterial and viral furuncule Symptoms: swelling of external meatus, redness pain on pulling on the auricle or pressure on the tragus

External otitis

Treatment systematic antibiotics, local antibiotics, alcohol drops

Herpes zoster oticus multiple herpetic vesicels arranged in groups on the auricule, the external meatus

in same cases hearing and balance, facial paralysis may occur

Bullous myringitis

usually occurs in association with an influenzal infection

conductive deafness bluish-livid bullous inflammation witch can extend to the tympanic membrane

After a few days the haemorrhagic vesicles dry out and heal without complications

Acute hemorrhagic otitis media (influenzal otitis) with loss of differentiation of the tympanic membrane

Malignant otitis externa

in diabetes patients Etiopathology Pseudomonas aeruginosa Infection extends cartilaginous meatus retromandibular fossa base of the skull to jugular foramen

Treatment treatment of diabetes and intensive antibiotic therapy

Eustachian tube occlusion

Pathogenesis

an inadequate tensor palati molle swelling of the tubal mucosa obstruction of the ostium of the tube by hypertrophied adenoids

malignant infiltration of the tube

acute tubal occlusion

symptoms stabbing pain, deafness and cracling noise feeling pressure in the ear

otoscopy retracted tympanic membrane, injection of the handle of the malleus and of the vessels of the tympanic membrane

treatment decongestant nose drops, vasoconstrictors, antihistamines

Eustachian tube occlusion

tympanic membrane with localized protrusion, an exudate in the middle ear

conductive deafness treatment paracentesis and drainage of the middle ear

paracentesis anteroinferior quadrant effusion is aspirated out and long-term drainage is provided grommet

Serrous middle ear effusion (acute serous otitis media) with a fluid level (arrow) and retraction of the tympanic membrane

OMS

OMS

Transtympanic drainage of the middle ear (myringotomy tube)

OMS

Acute otitis media

increase of the temperature 39-40C, pulsating pain worse by night than by day,

deafness, sensitivity of the the mastoid process to pressure

pathogenesis Streptococci in adults, Pneumococci in children, Hemophilus influenze

Acute otitis media

Diagnosis handle of the malleus and its shorts process disappear, the tympanic membrane is redness

Treatment paracentesis, systematic antibiotics 10 days, nasal drops

Drops containing cortisone and antibiotic solution should not be used locally for aural discharge

Incipient acute otitis media with radial vascular congestion

Acute otitis media

in infants and children characterised by

general symptoms high fever, vomiting refusal to eat disturbance of sleep.

Infants and young children have predisposition to tubal middle ear infection because of the short stright, wide tube, the uniform character of mucosa.

Mastoiditis

extension infection from the middle ear cavity to the pneumatic system of the temporal bone

Symptoms increase discharge, hearing loss, increasing pain in the ear

Mastoiditis
Diagnosis

aural discharge tenderness to pressure over the mastoid retroauricular swelling with a protruding ear

swelling of the zygomatic process with extension to the cheek and eyelids (common in children)

Mastoiditis

Bezolds mastoiditis abscess tracking from mastoid apex in the fascial spaces of the digastric, sternocleidomastoid

Mastoiditis extended to the bone should be treated by surgery

Mastoiditis
Indications for mastoidectomy

symptoms of otogenic intracranial complications signs of a subperiosteal collection a facial paralysis Mastoidectomy under general anaesthesia wide connection is created between the mastoid antrum and mastoid cavity and thus from the latter to the middle ear cavity.

Otitis media acuta

cascade of events

Otitis media secretoria

Otitis media chronica

hearing loss

deafness extra-& intracranial complications

Chronic otitis media

Symptoms

chronic discharge purulent, odorless, mucoid Hearing conductive deafness perforation of tympanic membrane

Chronic otitis media

Pathogenetic factors

constitutional reduced mucosal (immunological) competence type, pathogenicity, virulence and resistance of the bacterial organisms anatomic conditions of the middle ear such as pneumatization, and the connections between the attic antrum, middle ear cavity and eustachin tube disordered function of the eustachin tube generalized diseases such as allergy, immune defects, cachexia, diabetes

Types of chronic otitis media

chronic mucosal inflammation mainly cofined to the mucosa, usually does not cause progressive bone detruction

Chronic otitis media with cholesteatoma

Chronic mucusal suppuration with a central perforation

Chronic otitis media

Diagnosis

otoscopy central or peripheral perforation X- ray Schller view shows reduced of pneumatization or bony destruction, formation of new bone

HRCT

Symptoms

fetid otorrhea progressive deafness, possibly dizziness dull headaches or feeling of pressure in the head

the development of a cholesteatoma is direct contact of the keratinizing squamous epithelium in the external meatus with mucoperiosteum of the middle ear which has been damaged by inflammation

CHOLESTEATOMA definition

bad skin in a bad place (Grote 2003) cholesteatoma is a benign keratinizing and hyperproliferative squamous epithelial lesion that dissolves extracellular matrix through proteolysis and invades surround stroma including bone (Olszewska 2004)

CHOLESTEATOMA definition (cont.)

It is a cystic formation in the middle ear, lined inside with some epithelial lining as skin, i.e. keratinizing stratified squamous epithelium (KSSE) lacking hair follicles and ceruminous glands (Sade 2006)

Chronic otitis media

Otoscopy marginal perforation retraction pocket of the pars tensa Cholesteatoma classified tensa cholesteatoma secondary middle ear cholesteatoma flacida cholesteatoma primary attic or epitympanic cholesteatoma occult cholesteatoma cholesteatoma behind an intact tympanic membrane

Chronic otitis media

Radical operation the attic middle ear cavity antrum, and infected pneumatic spaces of the mastoid process are exposed by retroauricular or endaural access

Otitis media chronica with cholesteatoma

Cholesteatoma

Cholesteatoma

Cholesteatoma

nerw_twarzowy.mpg

Radical operation

CHOLESTEATOMA cranial complications

ever present life threatening surgery in emergency multiple complications

Otogenic complications
Extracranial 1.Intartemporal:
Mastoiditis (retroauricular, temporozigomatic, Gelle, Bezolds, Gradenigo syndrome) Labyrinthitis nausea, vomiting, deafness, whistling noise in the ear Facial nerve palsy Fistule

2. Extratemporal

Otogenic complications
Intracranial

epidural empyema dull pulsating pain in the head, otorrhea, subfebrile temperature; pathogenesis chronic infection extends from the mastoid process into epidural space due to destruction of the inner table by infection

Otogenic meningitis headaches, sitffness of the neck, photophobia, restlessness, tonic-clonic convulsion and facial paralysis, otalgia, fever of 39 to 40, otorrhea, deafness Pathogenesis the infection spread by direct continuity due to inflammatory destruction of the bony walls via the perforating vessels and nerves by a thrombophlebitis extending the diplotic veins via the labyrinth

Epidural, subdural, brain abscess Sinus thrombosis and otogenic sepsis

Otogenic complications

Otogenic meningitis Diagnosis abnormalities of the cerebrospinal fluid X-ray investigation

Treatment antibiotics penicillin

Otogenic complications

Otogenic sinus trombosis sigmoid sinus Symptoms: chills a spiking temperature chart increased pulse rate vomiting somnolence neck stiffness septic lung metastases or pneumonia.

Otogenic complications

Otogenic sinus trombosis sigmoid sinus

Pathogenesis perisinus abscess forms with periphlebitis of the sigmoid sinus followed by sinus phlebitis

Otogenic complications

Diagnosis high fever swelling and sensitivity to pressure over the mastoid emissary foramen at the posterior border of the mastoid process Gresinger sign splenomegaly, septic coagulopathy

Treatment surgery radical operation, internal vein is ligated

Otogenic complications

Otogenic Brain Abscess

1) initial stage meningismus, nausea, headache, psychological changes, fever 2) latent stage epileptiform attacks, neurological sign 3) manifest stage papilledema, psychological changes, focal signs of aphasia, alexia, agraphia hemiplegia, cranial nerve paralysis: IIIrd,Vth, VIth, VIIth, IXth and Xth 4) termal stage stupor, coma, bradycardia and CheyneStokes respiration.

Mnire disease

tinnitus deafness vertigo

Mnire disease

Pathogenesis the disease is caused by disturbance of the quantitative relation between the volume of the peri- and endolymph, abnormal osmotic pressure regulation within the membranous labyrinth

Treatment during an attack intravenous antivertiginous and antiemetic drugs.

Otosclerosis

localized disease of the bony labyrinthine capsule the cause of witch has still not been explained Symptoms
conductive deafness of the middle ear type in about 80% of patients mixed conductive and sensorineural deafness in about 15% patients pure sensorineural deafness in about 5% patients

Treatment stapedotomy

STAPEDOTOMIA

STAPEDOTOMIA

STAPEDOTOMIA

STAPEDOTOMIA

STAPEDOTOMIA

STAPEDOTOMIA

STAPEDOTOMIA

Otosclerosis

STAPEDOTOMIA

Otalgia

neuralgias of the facial, glossopharyngeal nerve, the vagus nerve and the auricular branch

Pain arises deep in the head or neck irradiates to the ear

Pain is usually sudden and stabbing

Tympanoplasty surgery type I myrinogoplasty

Perforation of eardrum

Normal mobility of ossicular chain

Without cholesteatoma

Tympanoplasty type I

Tympanoplasty type II

Reconstruction of defective ossicular chain by bridging the defect with autologous bone or cartilage, homograf ossicle substitution

Tympanoplasty type II

Tympanoplasty type III

Direct transmission of the sound waves from the tympanic membrane to the stapes by the collumnella effect. A shallow tympanum is created

Tympanoplasty type III

Tympanoplasty type III

Tympanoplasty type IV

The ossicular chain is absent. The sound is transmitted directly to the oval window, and the sound protection is provided for the round window.

Tympanoplasty type V