Complete ENT (Otorhinolaryngology) question bank — ear, nose, throat, larynx, airway & head-neck — in explanation-first exam-topper style, with 72 diagrams.
12chapters144questions77High-Yield
THE CONCEPT
Otitis externa is inflammation of the skin of the external auditory canal (and sometimes the pinna). Acute diffuse otitis externa ('swimmer's ear') is a diffuse bacterial infection of the canal skin, common in hot, humid climates and in swimmers. Because the canal skin is tightly bound to the underlying cartilage and bone, even slight swelling causes severe pain.
The auricle (pinna)
helix
antihelix
tragus
concha
ext. auditory canal
lobule
The auricle (pinna): the outer helix and inner antihelix ridges, the tragus guarding the entrance to the external auditory canal, the bowl-shaped concha, and the cartilage-free lobule. Only the outer third of the canal is cartilaginous and hair-bearing.
PREDISPOSING FACTORS & ORGANISMS
It is precipitated by moisture (swimming, humidity, sweating), trauma (cotton buds, scratching, hearing aids/earphones), loss of the protective wax, a narrow canal, skin conditions (eczema, psoriasis) and diabetes. The usual organisms are Pseudomonas aeruginosa (commonest) and Staphylococcus aureus (a fungal cause gives otomycosis).
Diffuse otitis externa
red, swollen, narrowed canal + debris · tragal tenderness · drum (right) may be normal
Diffuse otitis externa: the skin of the external canal is red, oedematous and narrowed, with debris; because the skin is tightly bound to the underlying cartilage/bone, the swelling makes the ear intensely tender — classically on moving the tragus.
CLINICAL FEATURES
Severe ear pain (otalgia), worse on moving the pinna/tragus (tragal tenderness) or chewing.
Itching (early); scanty, watery or purulent discharge.
A blocked ear/conductive hearing loss if the canal swells shut.
A red, oedematous, narrowed, tender canal with debris; the drum, if seen, is usually normal.
MANAGEMENT
The key steps are aural toilet (cleaning/suctioning the debris — essential so drops can work), topical antibiotic + steroid ear drops (a wick is inserted if the canal is very swollen), analgesia, keeping the ear dry, and avoiding scratching/cotton buds, with treatment of predisposing factors. Oral antibiotics are reserved for spreading cellulitis or systemic illness.
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CLINICAL PEARL: Acute diffuse otitis externa ('swimmer's ear') = a diffuse bacterial infection of the canal skin (Pseudomonas commonest) from moisture/trauma/loss of wax. It gives severe pain worse on moving the tragus/pinna, itching, scanty discharge and a red, swollen, narrowed canal. Treat with aural toilet (clean debris) + topical antibiotic-steroid drops (± a wick), analgesia and keeping the ear dry, and address predisposing factors.
WHY THE PAIN IS SO SEVERE
A striking feature of otitis externa is how disproportionately painful it is for what is, in effect, a skin infection, and understanding why explains much of the clinical picture. The skin lining the external auditory canal is unusually thin and is bound down tightly to the underlying cartilage and bone, with almost no subcutaneous cushion. When this skin becomes inflamed and swells, there is nowhere for the swelling to expand, so pressure builds rapidly and stretches the richly innervated lining, producing intense, throbbing pain. The same tight anatomy explains the marked tenderness on moving the pinna or pressing the tragus — movements that tug on the inflamed canal skin — and why the canal so readily swells shut, causing conductive deafness.
WHY AURAL TOILET IS SO IMPORTANT
A point that cannot be over-emphasised in treating otitis externa is that meticulous aural toilet — thoroughly cleaning and suctioning the debris from the canal — is often more important than the drops themselves. A canal packed with pus, desquamated skin and debris forms a barrier that prevents topical medication reaching the inflamed skin. By removing the debris under direct vision (and inserting a wick if the canal is so swollen that drops cannot penetrate), the clinician allows the antibiotic-steroid preparation to reach and act on the disease. This is why otitis externa that 'fails to respond to drops' so often improves once the ear is properly cleaned.
A NOTE ON PREVENTION
Because otitis externa is so often precipitated by moisture and self-inflicted trauma, prevention is a large part of managing recurrent cases. Patients are advised to keep the ears dry (using ear plugs when swimming, and drying the ears gently after washing), to stop using cotton buds and stop scratching the canal, and to treat any underlying skin condition such as eczema. In those with repeated attacks — particularly swimmers — acidifying/drying drops after water exposure can restore the protective acidic environment and prevent recurrence. Addressing these predisposing factors is often more valuable in the long run than treating each acute episode in isolation.
THE BOTTOM LINE
Acute diffuse otitis externa is a painful bacterial infection of the tightly-bound canal skin, treated above all by aural toilet plus antibiotic-steroid drops, with prevention aimed at moisture and trauma.
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KEY POINTS / NUMBERS (viva)
Acute diffuse otitis externa ('swimmer's ear') = diffuse bacterial infection of the canal skin; Pseudomonas aeruginosa (commonest), Staph. aureus.
Precipitants: moisture (swimming/humidity), trauma (cotton buds/hearing aids), loss of wax, narrow canal, eczema/psoriasis, diabetes. Pain worse on moving tragus/pinna, itching, discharge, red swollen narrowed canal.
Treat: aural toilet (clean/suction debris), topical antibiotic-steroid drops (± wick if very swollen), analgesia, keep ear dry, avoid cotton buds; oral antibiotics only for spreading cellulitis/systemic illness.
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KEY POINTS TO REMEMBER
Acute diffuse otitis externa ('swimmer's ear') = diffuse bacterial infection of the external canal skin (Pseudomonas commonest, also Staph).
Precipitated by moisture, trauma (cotton buds), loss of wax, narrow canal, eczema/psoriasis, diabetes.
Severe pain worse on moving the tragus/pinna, itching, scanty discharge, red swollen narrowed canal; drum usually normal.
Oral antibiotics only for spreading cellulitis or systemic illness; treat predisposing factors.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat; Scott-Brown's Otorhinolaryngology.
THE CONCEPT
Malignant (necrotizing) otitis externa is a severe, invasive, potentially fatal infection of the external ear that spreads to cause osteomyelitis of the temporal bone and skull base. It is not a cancer — 'malignant' describes its aggressive behaviour — and it classically affects elderly diabetics or the immunocompromised, caused by Pseudomonas aeruginosa.
Malignant (necrotizing) otitis externa
VII (facial n.)
granulation tissueat bony-cartilaginous junction
skull-base osteomyelitis
Elderly diabetic / immunocompromised · Pseudomonas · deep pain worse at night · cranial-nerve palsies
Malignant (necrotizing) otitis externa: Pseudomonas infection spreads from the canal (granulation tissue appears at the bony-cartilaginous junction) into the temporal bone, causing skull-base osteomyelitis and cranial-nerve palsies (the facial nerve first) — typically in an elderly diabetic.
PATHOGENESIS
The predisposing factors are diabetes mellitus (especially elderly, poorly controlled) and immunocompromise (HIV, chemotherapy). The Pseudomonas infection spreads from the canal through the fissures of Santorini and the bony-cartilaginous junction to the skull base, causing osteomyelitis, which in turn produces cranial-nerve palsies — the facial nerve first (at the stylomastoid foramen), then IX, X and XI (at the jugular foramen).
CLINICAL FEATURES
WHY THE NAME 'MALIGNANT' AND WHY IT IS SO DANGEROUS
The alarming name is worth explaining. It is not a cancer — 'malignant' conveys its aggressive, relentless, potentially fatal behaviour, quite unlike ordinary otitis externa. In a susceptible host — typically an elderly, poorly-controlled diabetic or an immunocompromised patient — the Pseudomonas infection invades through the soft tissues and cartilage into the temporal bone, setting up a skull-base osteomyelitis that can march along the bone to involve one cranial nerve after another and, ultimately, the meninges and brain. It is this capacity to progress from a 'simple ear infection' to a life-threatening skull-base osteomyelitis that makes early recognition essential.
THE KEY WARNING SIGNS TO RECOGNISE
Because it begins looking like ordinary otitis externa, recognising the warning signs is the crucial skill: an elderly diabetic/immunocompromised patient; severe, deep, unrelenting pain out of proportion to the findings and worse at night; an otitis externa that fails to settle with usual treatment; granulation tissue at the bony-cartilaginous junction (the classic sign); and, most ominously, any cranial-nerve palsy, especially a facial palsy. Any of these should prompt urgent investigation and prolonged systemic anti-pseudomonal therapy rather than continued treatment as simple otitis externa.
A NOTE ON THE PROLONGED, MONITORED TREATMENT
A defining feature of managing malignant otitis externa is that it requires prolonged, closely-monitored antibiotic therapy rather than a short course. Because the infection is a bone infection (osteomyelitis) with a poor local blood supply, it clears slowly and relapses easily, so systemic anti-pseudomonal antibiotics are usually continued for six to eight weeks or more, guided by the clinical response, the inflammatory markers (ESR/CRP) and repeat imaging or gallium scans. Alongside this, strict control of the underlying diabetes or immunosuppression is essential, since the host defect is what allowed the infection to become invasive in the first place. This combination of prolonged targeted antibiotics, source control and correction of the underlying condition is what gives the best chance of cure.
THE BOTTOM LINE
Malignant otitis externa is an invasive Pseudomonas skull-base osteomyelitis in elderly diabetics that must be recognised early by its unrelenting pain, granulations and cranial-nerve palsies and treated with prolonged antibiotics and glycaemic control.
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DANGER / REMEMBER: There is severe, persistent, deep ear pain (out of proportion, worse at night) that does not respond to ordinary otitis-externa treatment, persistent purulent otorrhoea, and — the hallmark — granulation tissue at the floor of the canal at the bony-cartilaginous junction. Cranial-nerve palsies (a facial palsy is ominous) appear in advanced disease; the patient is often afebrile.
INVESTIGATION & MANAGEMENT
Investigation shows a raised ESR/CRP, with CT (bone erosion), MRI (soft tissue/skull base) and a technetium/gallium bone scan (osteomyelitis and monitoring), plus biopsy of the granulation tissue to exclude carcinoma and culture. Management is prolonged (6–8 weeks) systemic anti-pseudomonal antibiotics (e.g. ciprofloxacin, often IV), strict glycaemic control, aural toilet with topical drops, and surgical debridement if needed, monitored with inflammatory markers/scans.
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CLINICAL PEARL: Malignant (necrotizing) otitis externa = an aggressive Pseudomonas infection causing skull-base osteomyelitis, in elderly diabetics/immunocompromised (not a cancer). It gives severe deep persistent pain (worse at night, unresponsive), otorrhoea, granulation at the bony-cartilaginous junction and cranial-nerve palsies (facial). Diagnose with a raised ESR, CT/MRI, gallium/technetium scan and biopsy (exclude carcinoma). Treat with prolonged systemic anti-pseudomonal antibiotics (6–8 weeks) + glycaemic control + debridement.
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KEY POINTS / NUMBERS (viva)
Malignant (necrotizing) otitis externa = invasive Pseudomonas infection → temporal-bone/skull-base osteomyelitis; elderly diabetics/immunocompromised; NOT a cancer.
Spreads via fissures of Santorini / bony-cartilaginous junction → skull base → cranial-nerve palsies (VII first at stylomastoid foramen, then IX/X/XI). Severe deep pain (worse at night, unresponsive), otorrhoea, granulation at bony-cartilaginous junction.
SOURCES: Dhingra — Diseases of Ear, Nose and Throat; Scott-Brown's Otorhinolaryngology.
THE CONCEPT
Otomycosis is a fungal infection of the external auditory canal. It is common in hot, humid climates and is favoured by the use of topical antibiotic drops (which alter the canal flora), swimming, immunocompromise and diabetes.
ORGANISMS
The usual organisms are Aspergillus (A. niger — the commonest, appearing black; also A. fumigatus/flavus) and Candida albicans.
CLINICAL FEATURES
Intense itching (pruritus) — characteristic, with aural fullness, discomfort/pain, hearing loss (if the canal is blocked) and discharge.
Otoscopy shows fungal debris with a 'wet blotting paper' appearance; Aspergillus niger gives black-headed filaments/spores (a 'salt-and-pepper' look) and Candida a white/creamy growth.
MANAGEMENT
The mainstay is repeated, thorough aural toilet (cleaning/suctioning the fungal debris), together with topical antifungals (clotrimazole, nystatin), acidifying agents (dilute acetic acid — fungi dislike an acidic pH) or gentian violet, keeping the ear dry and stopping any unnecessary antibiotic drops, and treating predisposing factors. Recurrence is common.
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CLINICAL PEARL: Otomycosis = a fungal external-ear infection (Aspergillus niger — black, 'salt-and-pepper'/'wet blotting paper', or Candida — white), favoured by heat/humidity, antibiotic-drop use and swimming. It causes intense itching, discharge and fullness. Treat with thorough repeated aural toilet (the mainstay) + topical antifungals (clotrimazole) + acidifying agents (acetic acid), keeping the ear dry and stopping antibiotic drops.
WHY ANTIBIOTIC DROPS CAN CAUSE IT
A clinically important, slightly paradoxical point is that otomycosis is frequently precipitated by the very treatment used for bacterial otitis externa — topical antibiotic drops. The normal canal has a balanced flora and an acidic, wax-protected environment that keeps fungi in check. When broad-spectrum antibiotic (and steroid) drops suppress the bacterial flora, they remove the natural competition and allow opportunistic fungi such as Aspergillus and Candida to flourish. This is why a patient treated for bacterial otitis externa may return with worsening itching and fungal debris, and why part of the treatment is to stop the antibiotic drops and use antifungals and acidification instead.
THE CENTRAL ROLE OF CLEANING AND ACIDIFICATION
Management rests on thorough repeated cleaning and restoring an acidic, dry environment. The mass of fungal hyphae, spores and debris is hard for drops to penetrate, so repeated meticulous aural toilet to remove the fungal load is the mainstay, often over several visits. Because fungi thrive in a warm, moist, alkaline canal, treatment aims to reverse those conditions — keeping the ear dry and using acidifying agents (dilute acetic acid) with topical antifungals. This combination of physical removal and environmental change, rather than antifungal drops alone, clears the infection and reduces its tendency to recur.
A NOTE ON THE ROLE OF DIABETES AND IMMUNOSUPPRESSION
Although otomycosis is usually a nuisance rather than a danger, it is worth remembering that persistent or severe fungal ear infection can be a marker of an immunocompromised host. In diabetics and the immunosuppressed, fungal infections are commoner, more stubborn and occasionally invasive, so a fungal otitis externa that is unusually severe, recurrent or unresponsive should prompt attention to the patient's general health and glycaemic control. In the rare invasive fungal infection (for example Aspergillus in a severely immunocompromised patient), the situation parallels malignant otitis externa and demands systemic antifungal treatment — a reminder that even a 'trivial' fungal ear can occasionally signal a more serious underlying problem.
THE BOTTOM LINE
Otomycosis is a fungal canal infection, often triggered by antibiotic drops, whose management centres on repeated cleaning, antifungals and acidifying the ear rather than antifungal drops alone.
A NOTE ON RECURRENCE
A recognised frustration with otomycosis is its tendency to recur, and understanding why helps in counselling patients. Recurrence happens because the predisposing conditions — heat, humidity, a moist canal, altered flora and any underlying immunocompromise — usually persist after treatment, allowing the fungus to re-establish itself. This is why successful long-term management depends not only on clearing the current infection but on changing these conditions: keeping the ear meticulously dry, avoiding unnecessary antibiotic or steroid drops, maintaining an acidic canal environment, and controlling any diabetes. Patients are warned that a single course rarely 'cures' the tendency, and that recurrent episodes may need repeated cleaning and attention to these underlying factors rather than simply another course of antifungal drops.
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KEY POINTS / NUMBERS (viva)
Otomycosis = fungal infection of the external canal; Aspergillus niger (commonest, black) / A. fumigatus/flavus, Candida albicans.
Favoured by hot/humid climate, topical antibiotic-drop use (alters flora), swimming, immunocompromise, diabetes. Intense itching (characteristic), fullness, discharge, hearing loss.
SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Furunculosis is a boil (furuncle) in the outer part of the external auditory canal — an acute staphylococcal infection of a hair follicle/sebaceous gland. Because only the outer, cartilaginous third of the canal carries hair follicles, furuncles occur only there (never in the bony inner canal).
Furuncle (localised otitis externa)
boil in hair follicle
outer (cartilaginous, hair-bearing) 1/3
inner (bony) canal — no hair, no boils
A furuncle (boil) is a staphylococcal infection of a hair follicle, so it occurs only in the outer, cartilaginous, hair-bearing third of the canal — not in the bony inner canal, which has no hair follicles.
ORGANISM & PREDISPOSING FACTORS
The organism is Staphylococcus aureus. It is predisposed to by trauma (scratching, cotton buds), diabetes (recurrent boils — always check the blood sugar) and poor hygiene.
CLINICAL FEATURES
Severe, throbbing, localised ear pain, worse on moving the pinna/tragus and on chewing or pressure.
A tender, red swelling in the outer canal, which may point and discharge pus (bringing relief).
Regional (pre-/post-auricular) lymphadenopathy; the pinna may be pushed out if the swelling is large; hearing is usually normal unless the canal is blocked.
MANAGEMENT
Management is analgesia and local heat, a topical antibiotic or an ichthammol-glycerine wick (anti-inflammatory and hygroscopic), incision and drainage if it is pointing/fluctuant, and systemic anti-staphylococcal antibiotics if it is severe, spreading or in a diabetic. Recurrent boils warrant investigation for diabetes and treatment of any carrier state.
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CLINICAL PEARL: Furunculosis = a staphylococcal boil in the outer (cartilaginous, hair-bearing) ear canal only. It gives severe localised throbbing pain worse on moving the tragus/chewing, a tender red swelling ± pus. Recurrent boils → check for diabetes. Treat with analgesia, a topical antibiotic/ichthammol wick, incision and drainage if pointing, and systemic anti-staphylococcal antibiotics if severe.
WHY BOILS OCCUR ONLY IN THE OUTER CANAL
A neat anatomical point is why a furuncle can only occur in the outer canal. A furuncle is an infection of a hair follicle and its sebaceous gland, and the canal is only hair-bearing in its outer, cartilaginous third — the deep bony canal has no hair follicles. So boils are confined to the outer cartilaginous canal and never arise in the bony canal. This explains the localised swelling and the pain felt at the canal entrance, and neatly distinguishes localised otitis externa (furunculosis) from the diffuse form.
THE IMPORTANCE OF RECURRENT BOILS
An important lesson is that recurrent boils should prompt a search for an underlying cause, above all diabetes. A single furuncle usually just follows local trauma, but repeated staphylococcal boils suggest impaired host defence or a bacterial reservoir. The key treatable cause is diabetes, in which high tissue glucose and impaired neutrophil function predispose to recurrent skin infection, so the blood sugar should always be checked; staphylococcal carriage and habitual cotton-bud trauma are other factors. Recurrent furunculosis thus becomes an opportunity to detect undiagnosed diabetes.
A NOTE ON DIFFERENTIATING FROM DIFFUSE OTITIS EXTERNA
It is worth being able to distinguish furunculosis (localised otitis externa) from acute diffuse otitis externa, as the two are managed slightly differently. Furunculosis is a discrete, localised, pointing swelling in the outer canal, caused by Staphylococcus, that may need incision and drainage, whereas diffuse otitis externa is a generalised inflammation of the whole canal lining, usually caused by Pseudomonas, treated mainly by aural toilet and antibiotic-steroid drops. Both cause severe pain and tragal tenderness, but the localised, follicular nature of the furuncle — and its tendency to point and discharge — sets it apart, and it is the one that may require drainage of a discrete abscess rather than topical treatment alone.
THE BOTTOM LINE
Furunculosis is a staphylococcal boil confined to the outer hair-bearing canal, managed with analgesia, topical/systemic antibiotics and drainage if pointing — and recurrent cases should prompt a check for diabetes.
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KEY POINTS / NUMBERS (viva)
Furunculosis = staphylococcal boil (S. aureus) of a hair follicle in the OUTER cartilaginous (hair-bearing) canal only; bony inner canal has no hair follicles.
Predisposed by trauma (cotton buds/scratching), diabetes (recurrent boils — check blood sugar), poor hygiene. Severe localised throbbing pain worse on moving tragus/chewing, tender red swelling ± pus, regional lymphadenopathy.
Rx: analgesia + local heat, topical antibiotic / ichthammol-glycerine wick, incision & drainage if pointing/fluctuant, systemic anti-staph antibiotics if severe/spreading/diabetic; recurrent → investigate for diabetes.
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KEY POINTS TO REMEMBER
Furunculosis = staphylococcal boil in a hair follicle of the outer, cartilaginous (hair-bearing) canal only (not the bony canal).
Severe localised throbbing pain worse on moving the tragus/chewing; tender red swelling ± pus; regional lymphadenopathy; hearing usually normal.
Rx: analgesia + heat, topical antibiotic/ichthammol wick, incision & drainage if pointing, systemic anti-staph antibiotics if severe.
Recurrent furunculosis → investigate for diabetes.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Cerumen (ear wax) is a normal protective secretion of the ceruminous (modified apocrine) and sebaceous glands in the outer cartilaginous canal. It protects the canal, and problems arise only when it accumulates and impacts.
FUNCTIONS
Wax provides lubrication and waterproofing, has antibacterial/antifungal properties (lysozyme, an acidic pH) and traps dust and debris. The canal is normally self-cleaning — epithelial migration carries the wax outward.
WAX IMPACTION
Impaction results from overproduction, a narrow/hairy canal, cotton-bud use (which pushes wax inward — the commonest error), hearing aids, old age and failure of self-clearance. It causes a blocked ear, conductive hearing loss, fullness, tinnitus, itching, a reflex cough (via Arnold's nerve) and sometimes pain, and may precipitate otitis externa.
REMOVAL
WHY COTTON BUDS ARE THE ENEMY
A useful piece of patient education is why cotton buds do more harm than good. The canal is self-cleaning: the skin migrates outward, carrying wax to the entrance where it falls out. When a person pushes a cotton bud in to 'clean' the ear, they push most of the wax deeper, compacting it against the drum while removing little. Over time this causes the very impaction they were trying to prevent, and the trauma can cause otitis externa or perforate the drum. Advising patients to leave the canal alone is one of the simplest preventive measures in otology.
WHY YOU MUST NEVER SYRINGE A PERFORATED EAR
A safety rule to be clear about: syringing is contraindicated in a perforated ear (or one with a grommet) and in an only-hearing ear. Syringing flushes wax out with a jet of water, which is safe with an intact drum; but with a perforation or grommet the water is driven into the middle ear, which can introduce infection, stimulate the labyrinth to cause severe vertigo, or damage middle-ear structures. In an only-hearing ear any complication is unacceptable. In these situations wax is instead removed by microsuction under direct vision — respecting these contraindications keeps a routine procedure safe.
A NOTE ON MICROSUCTION AS THE SAFEST METHOD
Increasingly, microsuction under direct vision is regarded as the safest and most versatile method of wax removal, and it is worth understanding why. Unlike syringing, which is done blind and drives water into the canal, microsuction is performed under the operating microscope with continuous direct vision, so the wax is removed precisely while the drum and canal are watched throughout. This makes it safe even when syringing is contraindicated — in a perforated or grommet ear, an only-hearing ear, or a canal with otitis externa — and avoids the mess and vertigo of water irrigation. Its main limitations are the need for equipment and training and the noise of the suction, but where available it has become the preferred technique for difficult or impacted wax and for any ear in which syringing would be unsafe.
THE BOTTOM LINE
Ear wax is a normal, protective, self-clearing secretion whose impaction is best avoided by leaving the canal alone, and removed by softening drops, syringing or — most safely — microsuction, never syringing a perforated ear.
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DANGER / REMEMBER: Removal options are cerumenolytics (softening drops — olive oil, sodium bicarbonate, hydrogen peroxide) as first line; ear syringing/irrigation with body-temperature water after softening; and manual removal under the microscope (suction, wax hook, forceps — the safest). Syringing is contraindicated with a perforation, grommet, an only-hearing ear, active otitis externa or previous ear surgery, and can itself cause pain, otitis externa, perforation or vertigo. Never syringe a perforated ear, and avoid cotton buds.
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CLINICAL PEARL: Cerumen (wax) is a protective secretion of the outer canal (lubricating, antibacterial, acidic, self-cleaning). Impaction (from cotton buds pushing it in, a narrow canal, old age, hearing aids) causes a blocked ear, conductive loss, fullness, tinnitus and a reflex cough (Arnold's nerve). Remove with cerumenolytics (olive oil) → syringing (warm water) or microsuction (safest). Do not syringe a perforated/grommet/only ear; avoid cotton buds.
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KEY POINTS / NUMBERS (viva)
Cerumen = protective secretion of the outer cartilaginous canal (ceruminous + sebaceous glands): lubricates, waterproofs, antibacterial/antifungal (lysozyme, acidic pH), traps debris; canal self-cleans by epithelial migration.
Cerumen (wax) = protective secretion of the outer canal (lubricates, antibacterial, acidic, traps debris); canal is self-cleaning by epithelial migration.
Impaction: cotton-bud use (pushes wax in — commonest error), narrow/hairy canal, elderly, hearing aids.
Removal: cerumenolytics (olive oil) first, then syringing (body-temperature water) or microsuction (safest).
Never syringe a perforated/grommet/only-hearing ear or one with otitis externa; avoid cotton buds.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Keratosis obturans is an accumulation of desquamated keratin (a plug of dead epithelial squames) impacted in the deep (bony) part of the external auditory canal, from abnormal epithelial migration, which causes widening and erosion of the bony canal.
FEATURES
It is usually bilateral and occurs in younger patients, and is associated with bronchiectasis and sinusitis. It presents with pain and conductive hearing loss, and a white/pearly keratin plug filling the deep canal, with a widened bony canal. It is distinct from ordinary wax (which sits in the outer canal) and from external-canal cholesteatoma (which causes a localised, unilateral bony erosion in older patients).
MANAGEMENT
Management is removal (microsuction/instrumentation, sometimes under general anaesthesia if impacted and painful), keeping the canal clean and treating the underlying condition.
A NOTE ON DISTINGUISHING IT FROM CANAL CHOLESTEATOMA
The main task is to distinguish it from external-canal cholesteatoma. Keratosis obturans occurs in younger patients, is bilateral, and causes diffuse circumferential widening of the bony canal, often with pain and a bronchiectasis/sinusitis association. Canal cholesteatoma occurs in older patients, is unilateral, and causes a localised area of bony erosion. This distinction guides management and follow-up and is a recognised examination point.
THE BOTTOM LINE
Keratosis obturans is an impacted keratin plug that widens the deep bony canal, typically bilateral in younger patients, and must be distinguished from the localised, unilateral erosion of canal cholesteatoma.
In practice, keratosis obturans is managed by careful removal of the impacted keratin, often under the microscope and occasionally under general anaesthesia when it is tightly wedged and painful, followed by regular follow-up to clear any re-accumulation and by treatment of any associated chest or sinus disease.
It is also worth noting that keratosis obturans is thought to arise from a disturbance of the normal outward epithelial migration of the deep canal, so that shed skin accumulates rather than being cleared — which is why it forms a firmly impacted plug and why simply removing it does not necessarily prevent it recurring, making follow-up part of care.
A further clue is that, because keratosis obturans widens the whole bony canal circumferentially rather than eroding it locally, the drum may become difficult to see behind the impacted plug, and the diagnosis is often made only once the plug is removed and the abnormally capacious, sometimes tender, bony canal is revealed.
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KEY POINTS TO REMEMBER
Keratosis obturans = plug of desquamated keratin impacted in the deep (bony) canal from abnormal epithelial migration; widens/erodes the bony canal.
Usually bilateral, younger patients; associated with bronchiectasis/sinusitis.
SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
A preauricular sinus is a common congenital anomaly — a small pit/sinus opening typically anterior to the ascending limb (crus) of the helix — arising from imperfect fusion of the auricular hillocks (of the first and second branchial arches) during development.
Preauricular sinus
pit (sinus opening)
a pit anterior to the ascending limb (crus) of the helix
(imperfect fusion of the auricular hillocks)
A preauricular sinus: a small pit lying just anterior to the ascending limb (crus) of the helix, resulting from imperfect fusion of the embryonic auricular hillocks. It is usually harmless but can become recurrently infected.
FEATURES
It is often bilateral and may be familial (autosomal dominant), and is usually asymptomatic. However, it may become infected or form an abscess (recurrent discharge, swelling and pain) or a retention cyst. It is lined by squamous epithelium and may have a branching tract.
MANAGEMENT
If asymptomatic, it is left alone. Recurrent infection is treated with antibiotics for the acute episode, followed by complete surgical excision of the tract when quiescent — incomplete excision leads to recurrence.
A NOTE ON WHEN AND HOW TO OPERATE
Surgery is reserved for recurrently infected sinuses and must be complete. An asymptomatic pit is left alone, but a repeatedly infected sinus keeps flaring unless the whole tract is removed. The tract often branches and runs deeper than expected, so incomplete excision leaves epithelium behind and causes recurrence; excision is therefore best done when quiescent, removing the entire tract — a lesson in why a trivial-looking congenital lesion still needs meticulous surgery.
THE BOTTOM LINE
A preauricular sinus is a common congenital pit near the helix, left alone unless recurrently infected, when the whole tract must be completely excised to avoid recurrence.
In practice, the diagnosis is usually obvious from the tiny pit anterior to the helix, and the main decision is simply whether it has caused enough trouble to warrant excision — a straightforward operation in experienced hands, but one that must remove the whole branching tract to succeed.
It is also worth being aware that a preauricular sinus can occasionally be associated with other branchial-arch or renal anomalies as part of a syndrome, so an unusual presentation or a family history of hearing or kidney problems may warrant looking beyond the ear itself.
Clinically, the pit is often so small that it is missed unless specifically looked for, and patients frequently present only when it becomes infected, with a tender swelling and discharge just in front of the ear — at which point the underlying congenital sinus should be recognised as the cause rather than treated as a simple skin abscess.
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KEY POINTS TO REMEMBER
Preauricular sinus = congenital pit anterior to the ascending limb of the helix, from imperfect fusion of the auricular hillocks (1st/2nd arches).
Often bilateral, may be familial (AD); usually asymptomatic; lined by squamous epithelium, may branch.
Can become infected/abscessed (recurrent discharge/swelling/pain) or form a retention cyst.
Asymptomatic → leave; recurrent infection → antibiotics for the acute episode then complete surgical excision (incomplete excision → recurrence).
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Perichondritis is infection/inflammation of the perichondrium of the auricular cartilage — important because the cartilage depends on the perichondrium for its blood supply, so the infection threatens the cartilage itself.
CAUSES & FEATURES
Causes include trauma (especially high cartilage ear-piercing, lacerations), surgery, burns, a haematoma and spread from otitis externa; the usual organism is Pseudomonas aeruginosa (also Staphylococcus). It presents with a painful, red, swollen, tender pinna that characteristically spares the lobule (which has no cartilage), and may progress to an abscess (pus between perichondrium and cartilage) → cartilage necrosis → deformity (cauliflower ear).
MANAGEMENT
A NOTE ON WHY IT IS AN EMERGENCY
Perichondritis needs prompt, aggressive treatment because the cartilage is at risk. The pinna cartilage is avascular and depends on the perichondrium for its blood supply, so perichondrial infection can deprive the cartilage of nutrition and, with abscess pus, cause it to necrose. Destroyed cartilage does not regenerate, giving a permanent cauliflower-ear deformity. This is why it is treated urgently with anti-pseudomonal antibiotics and drainage, and why the rise of high cartilage ear-piercing has made it increasingly important.
THE BOTTOM LINE
Perichondritis is an infection threatening the avascular auricular cartilage that needs prompt anti-pseudomonal antibiotics and drainage to prevent necrosis and a cauliflower ear.
In practice, any red, swollen, painful pinna that spares the lobule should be treated as perichondritis and covered against Pseudomonas without delay, with early drainage of any collection, because a few days' delay can mean the difference between full recovery and permanent deformity.
It is also worth remembering that the sparing of the lobule is a useful diagnostic clue: because the lobule contains no cartilage, its involvement points instead to a simple cellulitis or an infected earlobe piercing rather than true perichondritis, helping the clinician localise the problem and gauge the threat to the cartilage.
Clinically, the combination of a diffusely swollen, exquisitely tender pinna with a normal-looking lobule, often days after a cartilage piercing or an ear injury, is characteristic, and prompt recognition allied to early anti-pseudomonal cover offers the best chance of saving the cartilage from the disfiguring collapse that follows if treatment is delayed.
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DANGER / REMEMBER: Management is systemic anti-pseudomonal antibiotics (e.g. ciprofloxacin), incision and drainage of any abscess, and removal of necrotic cartilage; prevention lies in avoiding high-ear (cartilage) piercing. It is treated urgently because the cartilage is at risk.
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KEY POINTS TO REMEMBER
Perichondritis = infection of the perichondrium of the auricular cartilage; threatens the cartilage (its blood supply).
Painful, red, swollen, tender pinna SPARING the lobule (no cartilage); may abscess → cartilage necrosis → cauliflower ear.
Rx: systemic anti-pseudomonal antibiotics, incision & drainage of abscess, remove necrotic cartilage; prevent by avoiding high-ear piercing.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Haematoma auris is a collection of blood between the perichondrium and the auricular cartilage, usually from blunt trauma (boxing, wrestling, rugby). It matters because of what it does to the cartilage.
Haematoma auris (cauliflower ear)
blood betweenperichondrium& cartilage
Drain promptly + pressure dressing → prevents cartilage necrosis
& the 'cauliflower ear' deformity
Haematoma auris: blunt trauma collects blood between the perichondrium and the auricular cartilage, stripping the cartilage of its blood supply. Prompt drainage and a pressure dressing prevent cartilage necrosis and the resulting 'cauliflower ear'.
PATHOGENESIS & FEATURES
The cartilage gets its blood supply from the overlying perichondrium; a haematoma strips the perichondrium off the cartilage, causing cartilage ischaemia/necrosis, and the subsequent organisation and new-cartilage formation produce a thickened, deformed 'cauliflower ear'. It presents as a boggy, tender, fluctuant swelling of the pinna that obscures its normal contours.
MANAGEMENT
A NOTE ON WHY DRAINAGE MUST BE PROMPT
The key message is that it must be drained promptly to prevent deformity. The cartilage has no blood supply of its own and relies on the perichondrium pressed against it. A haematoma lifts the perichondrium away, depriving the cartilage and providing a nidus that organises into fibrous tissue and new cartilage, producing the cauliflower ear. Prompt evacuation plus a pressure dressing/bolster that re-apposes perichondrium to cartilage restores the blood supply and prevents deformity — so a minor sports injury to the ear should not be ignored.
THE BOTTOM LINE
Haematoma auris strips the perichondrium from the cartilage and must be drained promptly with a pressure dressing to prevent the cauliflower-ear deformity.
In practice, a boggy swelling of the pinna after a blow or a contact-sport injury should be drained the same day rather than left to settle, and the pressure dressing kept in place and reviewed, since re-accumulation of the haematoma is common and equally damaging to the cartilage.
It is also worth noting that haematoma auris is essentially the acute, treatable stage of what, if neglected, becomes the permanent cauliflower ear seen in wrestlers and boxers — which is why sports-medicine practice emphasises immediate drainage and protective headgear to prevent the deformity developing in the first place.
Clinically, the swelling is smooth, tense and fluctuant, and obliterates the normal ridges and hollows of the pinna; recognising it as a drainable haematoma rather than simple bruising is what allows timely evacuation, and re-examination after a few days is important because a re-collection is easy to miss and just as harmful.
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DANGER / REMEMBER: Management is prompt evacuation of the haematoma (aspiration or incision and drainage) together with a pressure dressing/bolster (to prevent re-accumulation and re-appose the perichondrium to the cartilage), plus antibiotics. If untreated, it results in a cauliflower ear.
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KEY POINTS TO REMEMBER
Haematoma auris = blood between the perichondrium and auricular cartilage, usually from blunt trauma (contact sports).
Cartilage relies on perichondrium for blood supply → haematoma strips it off → cartilage necrosis + new cartilage → 'cauliflower ear'.
Boggy, tender, fluctuant pinna swelling obscuring the contours.
SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Exostoses and osteomas are benign bony overgrowths of the external auditory canal, differing in their nature and cause.
THE TWO LESIONS
Exostoses — multiple, bilateral, broad-based bony swellings of the deep bony canal, associated with repeated cold-water exposure ('surfer's/swimmer's ear').
Osteoma — a single, unilateral, pedunculated benign bone tumour (a true neoplasm), usually at a suture line (tympanosquamous/tympanomastoid).
FEATURES & MANAGEMENT
They are usually asymptomatic, but may obstruct the canal → trapping wax/debris, causing conductive hearing loss and recurrent otitis externa. Management is none if asymptomatic, and surgical removal (canalplasty/drilling) if they obstruct (causing hearing loss or recurrent infection).
A NOTE ON DISTINGUISHING THE TWO
The learning point is the distinction between exostoses and osteomas. Exostoses are multiple, bilateral, broad-based, an acquired reaction to cold-water exposure ('surfer's ear') — hyperplastic bone, not a tumour. An osteoma is a single, unilateral, pedunculated true benign neoplasm at a suture line. Both are usually incidental and only treated — by drilling in a canalplasty — when they obstruct the canal enough to trap debris and cause recurrent otitis externa or conductive loss. The 'multiple/bilateral/cold-water' versus 'single/unilateral/neoplasm' contrast is the key.
THE BOTTOM LINE
Exostoses (multiple, bilateral, cold-water-related) and osteomas (single, unilateral neoplasms) are benign canal bony growths treated only when they obstruct the canal.
In practice, both are usually noticed incidentally or when trapped debris causes a hearing loss or recurrent infection, and surgery is offered only for these functional problems, since drilling bone from the canal itself carries risks and is not warranted for an asymptomatic bony lump.
It is also worth appreciating that the strong link between exostoses and repeated cold-water exposure is the reason they are colloquially called 'surfer's ear', and that advising at-risk water-sports enthusiasts to wear ear protection can slow their formation — a rare instance where a bony canal condition is partly preventable.
Clinically, exostoses appear as smooth, skin-covered mounds narrowing the deep canal, sometimes with a small residual central lumen, and it is usually the trapping of water and wax behind them — leading to repeated otitis externa — rather than the bony swellings themselves that eventually brings the patient to seek treatment.
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KEY POINTS TO REMEMBER
Exostoses & osteomas = benign bony overgrowths of the external auditory canal.
Osteoma: single, unilateral, pedunculated benign bone tumour (true neoplasm), usually at a suture line.
Usually asymptomatic; may obstruct → wax trapping, conductive loss, recurrent OE; remove surgically (canalplasty) only if obstructing.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Ramsay Hunt syndrome (herpes zoster oticus) is reactivation of the varicella-zoster virus in the geniculate ganglion of the facial nerve.
THE TRIAD
A painful vesicular rash in the external ear/canal/concha (and sometimes the palate/tongue).
A lower-motor-neuron facial (VII) palsy.
Vestibulocochlear (VIII) involvement — sensorineural hearing loss, tinnitus and vertigo.
MANAGEMENT & PROGNOSIS
It causes a more severe facial palsy with a worse prognosis than Bell's palsy. Diagnosis is clinical. Management is antivirals (aciclovir/valaciclovir) plus corticosteroids started early, eye care (protecting the exposed cornea in facial palsy) and analgesia; early treatment gives better recovery, though facial-nerve recovery is still poorer than in Bell's palsy.
A NOTE ON WHY IT MATTERS VERSUS BELL'S PALSY
Ramsay Hunt is a more severe condition than Bell's palsy needing prompt specific treatment. Both cause an LMN facial palsy, but Ramsay Hunt — from zoster reactivation — also involves the eighth nerve (hearing loss, tinnitus, vertigo) and gives a painful vesicular rash, with a worse prognosis for facial recovery. So a facial palsy with ear pain, ear vesicles or vertigo should be identified as Ramsay Hunt and treated promptly with both antivirals and steroids, plus eye care — giving the best chance of recovery in an otherwise poorer-prognosis condition.
THE BOTTOM LINE
Ramsay Hunt syndrome — zoster of the geniculate ganglion with ear vesicles, facial palsy and eighth-nerve signs — is more severe than Bell's palsy and needs early antivirals plus steroids and eye care.
In practice, the combination of a facial palsy with ear pain and vesicles, or with dizziness and hearing loss, should trigger immediate antiviral and steroid treatment and referral, because the window for effective treatment is short and the facial-nerve outcome is worse the longer treatment is delayed.
It is also worth remembering that, as with any facial palsy, protecting the eye is a priority, because an incomplete blink leaves the cornea exposed and at risk of drying and ulceration; lubricants, taping the eye at night and follow-up are therefore an essential part of managing Ramsay Hunt alongside the antiviral and steroid treatment.
Clinically, the vesicles may be sparse or appear a little after the palsy, so the diagnosis is sometimes made on the combination of facial weakness with ear pain and eighth-nerve symptoms before the rash is obvious — a reason to examine the ear canal and concha carefully in any acute facial palsy.
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KEY POINTS TO REMEMBER
Ramsay Hunt syndrome = varicella-zoster reactivation in the geniculate ganglion (herpes zoster oticus).
Triad: painful vesicular rash in the ear/canal/concha (± palate/tongue) + LMN facial (VII) palsy + VIII involvement (SNHL, tinnitus, vertigo).
More severe facial palsy and worse prognosis than Bell's palsy; diagnosis clinical.
Rx: antivirals (aciclovir/valaciclovir) + corticosteroids early + eye care + analgesia; early treatment improves recovery.
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SOURCES: Dhingra — Diseases of Ear, Nose and Throat.
THE CONCEPT
Foreign bodies in the ear are common, especially in children (beads, seeds, paper) and adults (cotton-bud tips, insects).
TYPES & FEATURES
They are inanimate (beads, organic seeds, and button batteries — an emergency, as they cause liquefactive necrosis) or animate (a live insect). They may be asymptomatic or cause pain, discharge, hearing loss or bleeding; a live insect causes intense buzzing and distress.
MANAGEMENT
A NOTE ON THE DANGEROUS FOREIGN BODIES
Two categories are genuine emergencies or traps. A button (disc) battery is an emergency — it leaks alkali and generates a current causing rapid liquefactive necrosis, so it must be removed urgently. An organic/vegetable foreign body must not be syringed, because it absorbs water, swells and impacts. And a live insect should be killed first (oil/lignocaine) before removal, to relieve distress and ease extraction. Knowing these few rules prevents the common errors that turn a simple foreign body into a damaging one.
THE BOTTOM LINE
Ear foreign bodies are usually simple to remove, but button batteries are an emergency, organic objects must not be syringed, and live insects should be killed before removal.
In practice, the safest approach in a frightened or uncooperative child is not to make repeated blind attempts that push the object deeper and traumatise the canal, but to refer for removal under the microscope, with general anaesthesia if needed, reserving urgent same-day action for a button battery.
It is also worth noting that many ear foreign bodies in cooperative older children and adults can be removed easily in the clinic under direct vision, and that the decision to refer or use general anaesthesia is driven mainly by the child's cooperation, the object's position and type, and whether earlier attempts have caused swelling or trauma.
Clinically, a calm, well-illuminated, single attempt with the right instrument is far more likely to succeed than repeated hurried tries, and knowing when to stop and refer — before the object is pushed against the drum or the canal is bloodied and swollen — is as important a skill as the removal itself.
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DANGER / REMEMBER: Remove by the appropriate method: syringing (but NOT for a vegetable/organic foreign body — it swells — nor for a button battery or a perforation); instrumentation under direct vision (hook/forceps/microsuction); and, for a live insect, kill it first (instil oil/lignocaine) then remove. A button battery needs urgent removal (necrosis risk). An uncooperative child or an impacted/deep foreign body may need general anaesthesia. Avoid pushing it deeper, and refer difficult cases (risk of drum/ossicle injury).
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KEY POINTS TO REMEMBER
Ear foreign bodies: common in children (beads, seeds) and adults (cotton-bud tips, insects); inanimate (incl. button battery — emergency) vs animate (live insect).
May be asymptomatic or cause pain, discharge, hearing loss, bleeding; insect → intense buzzing/distress.
Remove: syringing (NOT for organic/vegetable FB — swells — or button battery/perforation), instrumentation under vision (hook/forceps/microsuction); kill a live insect first (oil/lignocaine) then remove.