Diseases of Pinna
 

1. Haematoma auris

 Collection of blood under perichondrium of ear.

Etiology

 -- Blunt trauma to ear, mainly in athlets and boxers.

 -- Bleeding and clotting disorders.

Pathology

-- Blood collects in the space between the auricular cartilage and perichondrium.

Clinical features

-- Acute or delayed presentation.

-- Painful swelling of ear.

Complication.

-- Perichondritis due to infection

-- Fibrosis and new cartilage formation resulting in ear deformity which varies from mild cartilage thickening to severe deformity of the ear like cauliflower ear, wrestlers' ear, or boxers' ear.

Treatment

-- Evacuation

For smaller haematoma needle aspiration under local anaesthesia followed by pressure bandage.

For larger haematoma and recurrent haematoma, incision and drainage is the mode of treatment. Incision is made parallel to the helical margin (cosmetic) to prevent scar under aseptic technique. Expel the clots and remove the damaged cartilage if any. Suturing of wound is not needed. Apply pressure bandage. Followup to prevent recurrance. Antibiotics, anti inflammatory, and other supportive measures are also needed.

2. Perichondritis 

    The infection of the perichondrium and the cartilage of Pinna.

Etiology

-- Trauma 

   -- Iatrogenic -- Complication of surgery like (i) endaural approach in tympanoplasty, (ii) concho meatoplasty, (iii) evacuation of haematoma auris, (v) repeated aspiration or excision of pseudo cyst of Pinna, and (vi) surgery of auricular sinus. 

   -- Mechanical Trauma -- Accidents, injury by weapons

   -- Thermal trauma -- Burns and frost bite. Frost bite occurs in extreme cold which produce vasoconstriction, cellular exudation, and oedema. Cold blocks sensory nerve endings and the patient will be unaware of this injury. 

   -- Chemical Trauma -- Acid and Alkali burns. 

   -- Radiation to ear -- occurs as a side effect of radiation treatment in case of tumors of middle ear. 

Predisposing Factors

Diabetes mellitus, immuno compromised patients like AIDS, patients taking immuno suppresants, elderly and debilitated patients.

Pathology

Infection of perichondrium progresses to abscess formation. Since the cartilage depends only on perichondrium for vascularity, this leads to cartilage necrosis. 

Organisms

Most common organism is pseudomonas aeruginosa. 

Less common organisms are staphylococcus and streptococcus.

Clinical features 

Pain is the most common symptom which gets worste at night. 

Swelling and discoloration, deformity of Pinna, Pus discharging sinus.

Investigations


Ear swab for culture and sensitivity. Random blood sugar. 


Treatment

Early cases: out patient treatment with oral antibiotics. Ciprofloxacin is the drug of choice as it is most effective against pseudomonas and has got a better cartilage penetration. 

 

Anti inflammatory Drugs

 Cleaning and dressing with 1% Acetic acid. watch for  progression of disease.

If no improvement in two days, or if it is progressing, and in patients with severe infection, hospital admission and parentral antibiotics are recommended. If there is abscess formation, incision and drainage followed by pressure bandage. If the cartilage is necrosed surgical removal of the damaged cartilage and pressure bandage; follow up the patient regularly.

Complication

 Permanent ear deformity and cauliflower ear.

3. Other conditions of Pinna

Psueocyst of Pinna

Etiology

-- Unknown. Thought to be due to repeated microtrauma.

Clinical features

--Cystic swelling and minimal pain.

Treatment

--For small cyst, needle aspiration and pressure bandage. It has to be repeated several times if needed.

--In recurrent cases and for big cyst, incision and drainage followed by pressure bandage. Wedge excision is also recommended.

Erysepelas

Due to beta-haemolytic streptococci. It present as a bright red tender swelling which is  demarcated from normal skin.

Gout

Characterized by hyperurecimia due to the deficiency of hypo xanthine guanine phosphoribosyl transferase. In the ear, it affects the helix and presents as  painful salmon pink subcutaneous nodules. On application of pressure, Sodium biurate exudate will comeout. When examined in polarized light, these crystals appear as negatively birefrigerant.

Treatment

Analgesics, correction of underlying abnormality with colchicine or Allopurinol.

Sebacious cyst of Pinna

It occurs because of sebacious gland duct obstruction. It mainly affects the lobule and retro auricular area. Also affects the cartilageneous part of external auditory canal.

Treatment

Usually it is asymptomatic. Removal for cosmetic reasons.Infection needs antibiotic therapy. After the infection subsides, excision of the cyst with its capsule to prevent recurrence.

Keloid

It occurs as a result of trauma or surgery mainly in dark skinned people. It is a hypertrophied scar. Most common site is lobule of ear because of ear piercing.

Treatment

Medical: For small lesions, intralesional  injection of triamcinolone acetonide. It is of l imited use as the absorbtion is poor in the presence of hypertrophied tissue. So, repeated injection may be needed.

Surgical: Excision followed by intralesional corticosteriod injection at least three times postoperatively. But the success rate is only 50% percentage.

Low dose radiation can be given but not recommended in young adults because of the potential for malignancy.

Herpes Zoster Oticus

It is a painful condition  caused by the reactivation of varicella zoster virus(chickenpox virus) infection which  remained dormant in  some cranial and dorsal nerve roots.  Peculiarity of the lesions are that they are limited to a particular dermatome supplied by that specific cranial or dorsal nerve root.

Clinical feature:

Excruciating pain followed by skin lesion (vesicles as seen in chicken pox.)which appear in chonca and external auditory canal. It may burst and produce itching. Constitutional symptoms are  generalised tiredness,fever with chills.

Multiple cranial nerves may be affected as it present as  a poly neuropathy. So, hearing loss, vertigo, and dysphagia can occur.

Ramsay-Hunt syndrome is Herpes Zoster Oticus with facial nerve palsy.


Treatment

Analgesics for pain.

Antiviral drugs: Acyclovir 800 mg five times a day.

OR

Famciclovir 500 mg three times a day.

In Ramsay-Hunt syndrome, systemic steroids are given.

Relapsing Polychondritis

It is an autoimmune disease characterized by auto antibodies against Type-II collagen.

As the name suggests, it is a relapsing inflammation of articular and non-articular cartilage mainly seen in middle aged women. It can affect cartilage of ear, nose, and trachea.

Dignosis is clinical. Rheumatid factor will be positive. ESR will be elevated.

Treatment

Steroids.

Chondro dermatitis nodularis chronica helicis (Winkler's disease or chondro dermatitis helicis)

It  present as a discrete firm tender nodular lesion  mainly at the apex of the helix of the pinna. It affects middle aged and elderly males.

Etiology

(i) Solar damage to skin. (ii) Repeated minor trauma compromise the blood supply and cause degeneration of Pinna and cartilage.

Treatment

Steroids and removal of tumor.

Solar Keratisos

It is a premalignant condition. It is due to repeated sun exposure. It affects fair skinned people of third decade. Squamous carcinoma can develop from this lesion.

Ochronosis

It is seen in an autosomal recessive condition alkaptonuria. This condition is due to the deficiency of homogentisic acid oxidise.

Psoriasis

Psoriasis is  a multifactorial disease and is hetrogenitically inherited.It is linked with HLA.In ear it produce scaling of pinna and external auditory canal.The scales can block the external auditory canal resulting in hearing loss.Treatment is removal of scales and application of mineral oil to prevent further scaling.

Nevus

As in any part of body, nevus can affect Pinna also.

Leprosy

Leprosy of ear produce deformity of ear and ulceration.