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What is the typical presentation of an auricular endochondral pseudocyst?
Painless, fluctuant outpouching on the upper anterior surface of the auricle, often preceded by low-grade chronic trauma.
What are the two types of bony growths in the EAC?
Diffuse exostoses and osteomata.
Which is more common?
Exostoses.
Which is usually attached to the tympanosquamous suture line?
Osteomata.
Which has a male predilection?
Both.
Which is more likely to be bilateral?
Exostoses.
Which is more likely to be seen in surfers?
Exostoses.
What are the indications for removal of exostoses?
Less than 1mm aperature, recurrent otitis externa, water trapping.
What is the term for a keratin plug occluding the EAC?
Keratosis obturans.
How do patients with keratosis obturans usually present?
Conductive hearing loss, acute severe otalgia, usually bilaterally; otorrhea is rare.
What are the physical findings in a patient with keratosis obturans?
Thickened TM, widened EAC medially, hyperemic canal skin with granulation tissue.
How do patients with EAC cholesteatoma present?
Chronic dull pain, usually unilaterally, with otorrhea and normal hearing.
What are the physical findings in a patient with EAC cholesteatoma?
Localized erosion and periostitis of the posterior-inferior EAC associated with otorrhea.
What are the symptoms of patulous eustachian tube?
Aural fullness, autophony, tympanophonia that improve when the head is placed down between the legs; onset often occurs with weight loss or after irradiation to the nasopharynx.
What is tympanophonia?
Audition of one's own breath sounds.
What are some treatments for patulous eustachian tube?
Reassurance, weight gain, SSKI (10 gtt in juice po TID), Premarin nasal spray (25 mg in 30 cc NS, 3 gtt per nose TID), occlusion of the ET, and myringotomy and tympanostomy tube placement.
What signs and symptoms are specific for necrotizing otitis externa (NOE)?
Persistent otalgia for longer than 1 month.;Persistent, purulent otorrhea with granulation tissue for several weeks.;Diabetes mellitus, another immunocompromised state, or advanced age.;Cranial nerve involvement.
Why are diabetics more prone to NOE?
The pH of their cerumen is higher and more conducive to bacterial growth.
How does the infection spread from the external canal to the skull base?
Through the fissures of Santorini.
What is the most causative organism of NOE?
Pseudomonas aeruginosa.
Which cranial nerves are most commonly involved in NOE?
VII (75%), X (70%), XI (56%).
What imaging studies are used to diagnose NOE?
CT scan with contrast, technetium-99m bone scan.
What study is used to monitor the response to therapy?
Gallium-67 scan.
How is NOE treated?
6 weeks of 2 different IV antibiotics directed against the organism cultured; alternatively, ciprofloxacin and rifampin for several months; hyperbaric oxygen is recommended for advanced NOE.
Why is ciprofloxacin contraindicated in children?
It has been shown to cause arthropathy of the weight-bearing joints in immature animals.
What medication reduces the absorption of ciprofloxacin?
Antacids containing calcium or magnesium salts.
When is surgery indicated in the treatment of NOE?
Progression of pain despite aggressive medical therapy, persistence of granulations, and development of cranial nerve involvement.
Why is it difficult to treat infections involving the perichondrium or cartilage?
The metabolic demands of cartilage are low, and its blood supply is hence diminished.
How can one differentiate between relapsing polychondritis involving the ear and other causes of external otitis?
Relapsing polychondritis spares the lobule.
What is the incidence of congenital aural atresia?
1:10,000-20,000.
What % of these are bilateral?
33%.
What does stenosis of the external auditory canal predispose to?
Canal cholesteatoma.
Which portion of the ossicular chain is least likely to be malformed in patients with congenital aural atresia?
Stapes footplate.
What is the incidence of facial nerve displacement in congenital aural atresia?
25 - 30%.
Using the rating system developed by Jahrsdoefer, what score is associated with the best outcome after surgical treatment of aural atresia?
8 or greater (80% chance of obtaining an SRT 15-25 dB).
T/F: A patient with a score of 5 or less is considered a very poor operative candidate.
True.
What is the most important factor in assessing the possibility of surgery in a patient with congenital aural atresia?
Presence of the stapes.
Why is it particularly difficult to assess the auditory function in patients with bilateral atresia?
Masking dilemma.
What test should be used to assess auditory function in these patients?
ABR.
Which wave of the ABR is ear-specific?
Wave I.
In a patient with aural atresia and no evidence of SNHL, when should a CT scan of the temporal bones be obtained?
Age 4 or 5.
On CT imaging, which ear structures are best seen on axial views?
Body of the malleus and incus, incudostapedial joint, and the round window.
On CT imaging, which ear structures are best seen on coronal views?
Stapes, oval window and the vestibule.
Why should surgery be delayed until age 5?
To allow for completion of pneumatization of the temporal bone.
T/F: Surgery is contraindicated in children with unilateral atresia.
False; many will operate if the patient is likely to achieve a residual conductive deficit of 30 dB or less.
What factors are considered contraindications to correction of unilateral atresia?
Poor mastoid pneumatization, anterior displacement of the middle ear, and facial nerve anomalies.
What are the 2 basic approaches for repair of aural atresia?
Transmastoid and anterior approaches.
What are the 2 most important landmarks of the anterior approach?
The middle cranial fossa dura superiorly and the TMJ anteriorly.
What advantage does hugging the middle fossa dura have on protecting the facial nerve?
One will enter the middle ear first in the epitympanum; the facial nerve will always lie medial to the ossicular heads in the epitympanum.
What are the reasons for persistent conductive hearing loss after aural atresia repair?
Inadequate mobilization of the ossicular mass from the atretic bone, an unrecognized incudostapedial joint discontinuity, or a fixed stapes.
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