Clinicopathologic Correlations

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Infectious, inflammatory, traumatic, and neoplastic diseases are common in the organs of the ear and nose. Some of the more common ear infections are discussed in this section.

Acute otitis externa is a common inflammatory condition of the external ear canal, most often caused by Pseudomonas aeruginosa. The prominent symptom is severe ear pain (otalgia) accentuated by manipulation of the pinna and especially by pressure on the tragus. Edema of the external ear canal, erythema, and a yellowish-green discharge are prominent signs of this disease. Commonly, the canal is so tender and swollen that adequate visualization of the entire canal and tympanic membrane is impossible. ''Swimmer's ear'' is a form of otitis externa in which there is a loss of the protective cerumen, and chronic irritation and maceration by water and bacteria occur. Itching is a common precursor of otalgia. Figure 11-26 shows the external ear canal of a patient with acute otitis externa. Notice the follicular appearance of the canal, which resulted from epithelial swelling. As the condition progresses, the lumen may be occluded, producing conductive deafness.

Bullous myringitis is a localized form of external otitis, commonly associated with an acute viral upper respiratory infection. Severe otalgia is present, caused by bullous, often hemorrhagic, lesions on the skin in the deep external ear canal and on the tympanic membrane. A blood-tinged discharge may also occur. Fortunately, bullous myringitis is a self-limited condition. Figure 11-27 shows the tympanic membrane of a patient with bullous myringitis. Notice the blood-filled bullae on the membrane. Figure 11-28 shows the left ear of another patient with bullous myringitis. Notice the huge bulla filled with serosanguineous fluid arising from the floor of the bony external auditory canal. The bulla is so large that it obscures the tympanic membrane from view.

Acute otitis media is a bacterial infection of the middle ear, occurring most commonly in children. Up to 50% of all children experience an attack of acute otitis media before they reach 1 year of age, and 75% of children are affected before their second birthdays. After 5 years of age, the incidence declines rapidly. Affected patients suffer ear pain and have constitutional symptoms of fever and malaise, often associated with gastrointestinal problems and a conductive hearing loss. In contrast to external otitis, in which pulling on the auricle and tragus causes pain, no pain is elicited when these maneuvers are performed on a patient with acute otitis media. The tympanic membrane becomes injected, and the entire membrane is a fiery red. A mucopurulent exudate in the middle ear causes the membrane to bulge outward. In most cases, antibiotic therapy resolves the condition and restores normal hearing. Figure 11-29 shows the tympanic membrane of a young child with the classic features of acute otitis media. Notice the erythema, resulting from the acute inflammation, and the cloudiness and bulging of the tympanic membrane, resulting from the middle ear exudate.

Acute Otitis Externa

Figure 11-26 Acute otitis externa.

Zapalenie Ucha

Figure 11-27 Bullous myringitis.

Figure 11-26 Acute otitis externa.

Figure 11-27 Bullous myringitis.

Bullous Myringitis
Figure 11-28 Bullous myringitis. Figure 11-29 Acute otitis media.

Spontaneous rupture of the tympanic membrane may result from the increased pressure, with discharge of the mucopurulent exudate into the external ear canal. If this occurs, advanced acute otitis media is said to be present. Figure 11-30 illustrates perforation of a tympanic membrane as a result of otitis media.

Perforations may be central or marginal and may result from either otitis media or trauma. A central perforation does not involve the margin or annulus of the tympanic membrane; a marginal perforation involves the margin. Marginal perforations are more serious because they predispose the patient to the development of a cholesteatoma, which is a chronic condition of the middle ear. A marginal perforation allows squamous epithelium from the external canal to grow into the middle ear. As these cells invade, they desquamate, and debris accumulates in the middle ear, forming a cholesteatoma. Slow enlargement of the cholesteatoma leads to erosion of the ossicles and expansion into the mastoid antrum. Figure 11-31 illustrates a cholesteatoma.

A congenital cholesteatoma of the right anterior middle ear is pictured in Figure 11-32. It is smooth and white, medial to a normal tympanic membrane.

Figure 11-33 depicts chronic tympanic membrane perforation of the right ear. Notice the smooth epithelium-covered margin of chronic perforation, as well as patches of tympanosclerosis.

Serous otitis media occurs primarily in adults with viral upper respiratory infections or during sudden atmospheric pressure changes. In the presence of a blocked eustachian tube, air becomes trapped within. The tiny blood vessels in the middle ear absorb much of the air,

Perforation Tympanique Photo
Chorda tympani nerve

Round window niche

Incudostapedial joint

Round window niche

Right Tympanic Membrane Injection

Tip of malleus

Fibrous annulus

Medial wall of middle ear

Incudostapedial joint

Tip of malleus

Fibrous annulus

Medial wall of middle ear

Figure 11-30 Photograph (A) and labeled schematic (B) illustrating a central perforation of the right tympanic membrane.

Ear Effusion

Tip of malleus

Light reflex

Cholesteatoma of pars flaccida

Cholesteatoma behind drum

Tip of malleus

Light reflex

Cholesteatoma of pars flaccida

Tympanic Membrane Injection And Images

Cholesteatoma behind drum

Injection of external canal

Injection of external canal

Figure 11-31 Photograph (A) and labeled schematic (B) illustrating a cholesteatoma of the left ear that resulted from a marginal perforation of the tympanic membrane. Note the injection of the distal external canal.

Congenital cholesteatoma

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