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Michael Hawke Peter Kwok A Mini-Atlas of -drum Pathology SUMMARY RESUME The authors provide a number of ear-drum Cet article presente plusieurs images du tympan et identifie et discute les differentes pathologies pictures and identify and discuss diseases affectant le conduit auditif externe, la membrane affecting the external , the tympanic tympanique et l'oreille moyenne. Les auteurs membrane and . They also deal poursuivent la discussion sur l'extraction de corps with the removal of foreign bodies from the etrangers du conduit auditif exteme, la perforation external canal, perforation of the tympanic de la membrane tympanique et l'usage d'un tube de membrane, and the use of an artificial ventilation artificielle. ventilation tube. (Can Fam Physician 1987; Key words: ear-drum pathology, 33:1501-1507.) management of ear problems

A N ACCURATE EXAMINATION of the external audi- tory canal and the tympanic membrane is the first step in the management of any patient with symptoms sugges- tive of ear disease. The majority of diseases affecting the ex- ternal ear canal, and many of those affecting the tympanic membrane and middle ear, can be diagnosed primarily on the basis of their otoscopic appearance. These deeply recessed structures are best visualized if the examiner uses one of the modern which have a quartz halogen light source that is evenly distributed through a ring of glass fibres. Figure 1 External Canal Foreign Body Foreign bodies should be removed as safely and expedi- tiously as possible, while avoiding damage to the delicate skin of the external canal, tympanic membrane and ossi- cles. The method of removal depends on the type of foreign body present and the level of patient co-operation. Many small foreign bodies can be flushed out with an ear syringe, whereas others may require special forceps. When a foreign body is tightly impacted, or when the patient is unable to tolerate manipulation, removal under general anesthetic is usually safer.

Figure 2 External Canal Exostoses Exostoses are areas of bony hypertrophy which develop as the result of repeated stimulation (or irritation) by cold water of the periosteum lining the tympanic bone. Such ac- tivities as swimming, surfing, and diving may cause the condition. Exostoses appear as hard, round or oval excre- sences which are usually multiple and bilateral. Since most exostoses are asymptomatic, they usually require no treat- ment. In some patients, however, huge exostoses may nar- row the external canal to such an extent that debris from the skin lining the canal accumulates and produces a conduc-

-V~2~22.V-22 2 4 1501 CAN. FAM. PHYSICIAN Vol. 33: JUNE 1987 tive . This severe form of exostoses has been called 'surfers' ear'. In these patients, a trans-canal removal may be necessary. Because exostoses are caused by cold water, they may be prevented by the wearing of ear plugs. Figure 3 Extemal Canal Furuncle A furuncle is a small Staphylococcal abscess which arises from the base of a hair follide. These extremely painful lo- calized swellings only occur in the outer cartilaginous canal, as the skin of the deep canal is hairless. If the furun- cle is obviously pointing, it can be lanced with a 16-gauge sterile hypodermic needle, bringing relief from pain. If the patient is seen at an earlier stage, analgesics and a full course of an effective antistaphylococcal systemic antibiotic (e.g., cloxacillin or amoxicillin and clavulinic acid) are indi- cated.

Figure 4 Acute Externa Acute otitis extema (Swimmer's ear), is an acute and dif- fuse bacterial infection of the skin of the extemal ear canal. A gram-negative bacteria (Pseudomonas aeruginosa) is the causative organism in most cases of acute . Local trauma (e.g., from fingemails or bobby pins) and ex- posure of the skin to water (e.g., in swimmning, sweating or showering) are the main predisposing factors in the devel- opment of this disease. The skin of the outer canal is dif- fusely swollen, extremely tender, and shiny in appearance. In some cases the ear is so inflamed that even the gentlest movement of the pinna causes severe pain. Acute otitis externa is treated primarily by local or topical medications. For this type of treatment to be effective, the canal must be thoroughly cleaned. If the swelling of the skin lining the canal is severe enough to occdude the lumen, a cotton wick should be gently inserted in the lumen to carry the medication into the canal. The frequent instilla- tion of an acid aluminum acetate solution (e.g., Burosol otic drops) is usually all that is needed. If the ear is extremely painful, systemic analgesics may be needed for one or two days.

Figure 5 of the External Canal Aspergillous niger and Candida albicans are two fungi which may infect the external canal. Otomycosis may pres- ent either as acute or as chronic otitis externa. Aspergillous niger can usually be diagnosed by otoscopy, whereas can- didal infections have no characteristic features and are usually diagnosed by culture. The finding in the canal of the white fluffy hyphae or the tiny brown or black conidio- phores (fruiting heads) of aspergillus niger are diagnostic. The underlying skin is often inflamed and granular because of the invasion of the skin by the fungal mycelia. The cor- nerstone of treatment is thorough deaning of the canal by suction, dry mopping or synnging (if the tympanic mem- brane is intact). Cotrimazole lotion (Canestin) is highly ef- fective in treating both aspergillus and candida.

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Figure 6 Bullous Myringitis Bullous myringitis is an unusual form of viral or mycoplas- mal infection of the epithelium lining the tympanic mem- brane and deep canal skin which is characterized by serous or hemorragic blebs. Patients with this disease frequently experience severe earache which may be followed, 12 to 20 hours later, by a sero-sanguinous otorrhea. The tympanic membrane is covered by relatively large blebs filled with a 41; yellow serous or serosanguinous fluid. In some cases it may be difficult to distinguish this condition from a severe acute . As this is a self-limiting condition, and as there is no specific treatment for the causative organisms, therapy is directed to providing adequate analgesia for one or two days and preventing the development of a secon- dary infection (bacterial otitis externa) by keeping the ear dry.

Figure 7 Normal Tympanic Membrane The normal tympanic membrane appears as a pale grey, ovoid, semi-transparent membrane which is obliquely set at the medial end of the bony external auditory canal. The posterior margin of the drum is closer (more lateral) than the anterior border. The handle of the malleus can be seen extending downwards and backwards ending at the umbo. The triangular reflected "cone of light" can be seen extend- ing antero-inferiorly from the umbo. Note the small white bony protuberance on the upper end of the malleus (the lat- eral process of the malleus). The long process of the incus and its articulation with the head of the stapes and the chorda tympani nerve passing between the handle of the malleus and the long process of the incus, may frequently be seen through the postero-superior quadrant of the pars tensa of a thin tympanic membrane.

Figure 8 Acute Otitis Media Acute otitis media (AOM) is an acute bacterial infection of the mucoperiosteal linirig of the middle-ear cleft (the eusta- chian tube, tympanic cavity, and mastoid air cells) that is primarily, but not exclusively, a disease of children. The common causative organisms include Staphyloccocus aureus, hemophilus influenzae, Pneumoccocus and Strep- tococcus. Clinically, AOM is characterized by pain in the in- volved ear associated with the constitutional signs of infec- tion (fever, malaise, and, in children, gastrointestinal symptoms). Otoscopically the manubrial and circumferential vessels supplying the tympanic membrane dilate, and the entire tympanic membrane eventually becomes uniformly fiery red in colour. The pressure of the creamy white mucopuru- lent exudate which accumulates within the middle ear causes the tympic membrane to bulge outwards.

1503 CAN. FAM. PHYSICIAN Vol. 33: JUNE 1987 ommmmmmmom

Figure 9 Advanced Acute Otitis Media If the infection progresses, the tympanic membrane may rupture, releasing the purulent middle-ear exudate into the external canal. As AOM is a bacterial infection, systemic antibiotics effec- tive against the causative organisms (amoxicillin or amoxi- cillin combined with clavulinic acid) are the mainstay of treatment.

Figure 10 Mucoid Otitis Media Mucoid otitis media (MOM) is primarily a disease of chil- dren. It is characterized by the presence of thick mucoid non-purulent fluid in the middle-ear cleft. While the cause of MOM has not yet been clearly delineated, it currently ap- pears that the mucoid effusion arises from the mucoperios- teal lining of the middle-ear cleft in response to a viral upper respiratory infection as the result of an incompletely resolved episode of AOM. MOM is a relatively silent disease characterized clinically by a (because of the presence of the thick fluid in the middle ear). Otoscopically, the tympanic membrane may have a subtle discolouration (greyish, whi- teish or yellowish), and the radial blood vessels may have increased prominence. The turbidity of the effusion pre- vents the examiner from seeing the long process of the incus and the medial wall of the middle ear. The tympanic membrane is immobile to the pneumatic . As there is, unfortunately, no truly effective medical treatment for this condition, the physician should wait for an appropriate period of time (two to three months) to see if spontaneous resolution will occur (as it does in 90% of cases).

Figure 11 Serous Otitis Media Serous otitis media (soM), unlike MOM, is primarily a dis- ease of adults (with the exception of children who have a cleft palate deformity). Serous otitis media is characterized by the presence of a non-purulent clear, thin, watery, golden-yellow fluid in the middle-ear cleft. SOM is the re- sult of a blockage of the eustachian tube (most commonly from a viral URI, and in rare instances from a carcinoma of the nasopharynx). The presence of the thin serous effusion within the mid- dle ear generally gives the tympanic membrane a yellowish or orangish discolouration. The transparent nature of the fluid (unlike that of MOM) allows the examiner to look through the transudate and to see clearly the long process of the incus and the medial wall of the middle ear. If the eustachian tube obstruction is incomplete, air bubbles or an air-fluid level may be present. The tympanic membrane is frequently retracted (pulled medially) by negative pressure in the middle ear. As in MOM, "tincture of time" is the most effective treat- ment. The performance of Valsalva's manoeuvre (auto- inflation) by having the patient blow into the nose while holding the nostrils closed is often an effective method of

1504 CAN. FAM. PHYSICIAN Vol. 33: JUNE 1987 re-aerating the middle ear. If these measures are ineffec- tive, a myringotomy may be necessary. Because a non-re- solving or recurrent episode of serous otitis media in an adult may signify the presence of an underlying carcinoma of the nasopharynx, a thorough examination of the naso- pharynx with indirect mirror, nasopharyngoscope and, if necessary, directly under general anesthesia, is necessary in these patients.

Figure 12 Artificial Ventilation Tube The aim of treatment in non-resolving cases of mucoid or serous otitis media is to drain the fluid from the middle ear and restore normal ventilation. This can be accomplished by incising the tympanic membrane and aspirating the fluid (myringotomy). Myringotomy incisions usually close (heal) within seven days. In some patients it is desirable to keep the opening in the tympanic membrane patent. This can be accomplished by the insertion of an artificial ventilation tube into the myringotomy incision (myringotomy and tube insertion).

Figure 13 Adhesive Otitis Media Adhesive otitis media is a condition that develops in some patients (as the result of recurring episodes of middle-ear infection or inflammation that have been severe enough to damage the mucosal lining of the middle ear) in which the tympanic membrane has become pulled or "stuck" onto the medial wall of the middle ear by fibrous adhesions. This condition is not medically treatable. It usually produces a conductive hearing loss of varying severity. In this patient, the long process of the incus has been resorbed, and the tympanic membrane is lying directly on top of the head of the stapes. This is called a 'natural myringostapediopexy.'

Figure 14 Tympanic Membrane Perforation Tympanic membrane perforations may result from trauma (traumatic perforations) or as a complication of an acute at- tack of otitis media. Perforations of the drum are usually classified according to their location as either central or mar- ginal. Central perforations are often termed "safe", as they are not usually associated with , whereas by the same reasoning, marginal perforations are frequently termed "unsafe". Note how the medial wall of the middle ear can be seen through this large kidney-shaped perfora- tion.

CAN. FAM. PHYSICIAN Vol. 33: JUNE 1987 1505 Figure 15 Chronic Otitis Media Patients with perforated tympanic membranes may de- velop middle-ear infections during upper respiratory infec- tions or from contaminated water passing through the per- foration into the middle ear. Unlike acute otitis media, these infections are usually painless, and the prime symp- tom is the development of a foul-smelling otorrhea. The causative bacteria are usually of the gram-negative variety (pseudomonas, proteus or E. coli). The most effective treat- ment is the application of an appropriate topical antibiotic ear drop and the avoidance of water.

Figure 16 These chalky white patches seen on the tympanic mem- brane actually consist of plaques of hyalinized collagen which have been deposited beneath the mucosal lining on the medial surface of the drum. Current research suggests that these deposits are the result of an autoimmune reac- tion which has occurred during an episode of otitis media. These tympanosclerotic plaques are assymptomatic, have no prognostic significance (although they stand as evidence of a previous middle-ear infection), and can be safely ig- nored.

Figure 17 Cholesteatoma A cholesteatoma is a cystic collection of keratin debris which is enclosed by a sac of stratified squamous keratiniz- ing epithelium which has "invaded" the middle-ear cleft. The mouth of the sac is filled with a characteristic pearly debris (the keratin squames). Note how the sac can be seen as a white mass deep in the drum and descending behind the malleus. As the slowly enlarging sac of a cholesteatoma can erode not only the ossicle but also the bone of the mas- toid, surgical removal is usually necessary to prevent se- vere damage to the structure of the middle ear or even to the adjacent intracranial structures.

1506 CAN. FAM. PHYSICIAN Vol. 33: JUNE 1987 Figure 18 Glomus Jugulare Tumour This slowly enlarging and locally invasive vascular tumour arises from chemoreceptor tissue (the glomus bodies) within the middle ear. The usual symptom is that of a pul- satile in the affected ear. Note the red vascular tu- mour behind the tympanic membrane. Glomus tumours frequently have a visible arterial pulsation. Small to me- dium-sized glomus tumours can usually be surgically re- moved (after embolization to reduce their vascularity), while large tumours which have extended intracranially may be treated by local irradiation. Dr. Hawke, chief of Otolaryngology at St. Joseph's Health Centre, Toronto, has a special interest in diseases of the ear. Dr. Kwok practised otolaryngology in Hong Kong before becoming a research fellow at St. Joseph's Health Centre, Toronto. Requests for reprints to: Dr. Michael Hawke, Ste. 10, 1849 Yonge St., Toronto, Ont. M4S 1Y2 Colour printing sponsored by Beecham Laboratories Inc.

Anaphylactoid reactions (anaphylaxis, urticaria, angioneurotic oedema, bronchospasm) have been seen rarely following the parenteral and oral administration of Zantac. These reactions have occasionally occurred after a single dose. Decreases in white blood cell count and platelet count have occurred in a few patients. (ranitidine HCI) Other haematological and renal laboratory tests have not revealed any drug related abnormalities. No clinically significant interference with endocrine or gonadal function has been reported. Prescribing Information Symptoms and Treatment of Overdosage - No particular problems are expected following overdosage with Zantac. Symptomatic and supportive therapy should be given as Zantac Tablets (ranitidine hydrochloride) appropriate. If need be, the drug may be removed from the plasma by haemodialysis. Pharmacological Classification Histamine H2-receptor antagonist Dosage and Administration -Adults: Duodenal ulcer and benign gastric ulcer: 300 mg Indications and Clinical use-Zantac Tablets are indicated for the treatment of all once daily, at bedtime. It is not necessary to time the dose in relation to meals. In most cases conditions where a controlled reduction of gastric secretion is required for the rapid relief of of duodenal ulcer and benign gastric ulcer, healing will occur in four weeks. In the small pain and/or ulcer healing. These include duodenal ulcer, benign gastric ulcer and reflux number of patients whose ulcers may not have fully healed, these are likely to respond to a oesophagitis. further course of treatment. Contraindications-Zantac is contraindicated for patients known to have hypersensitivity to Patients who have responded to this short term therapy, particularly those with a history the drug. of recurrent ulcer, may usefully have extended maintenance treatment at a reduced dosage of Warnings-Gastric ulcer -Treatment with a histamine H2-antagonist may mask symp- one 150 mg tablet at bedtime. toms associated with carcinoma of the stomach and therefore may delay diagnosis of the To help in the management of reflux oesophagitis, the recommended course of condition. Accordingly, where gastric ulcer is suspected the possibility of malignancy should treatment is one 150 mg tablet twice daily for up to 8 weeks. be excluded before therapy with Zantac Tablets is instituted. Experience with Zantac in children is limited and it has not been fully evaluated in clinical Precautions- Use In pregnancy and nursing mothers -The safety of Zantac in the studies-see Precautions. treatment of conditions where a controlled reduction of gastric secretion is required during Availability-Zantac Tablets are available as white film-coated tablets engraved pregnancy has not been established. Reproduction studies performed in rats and rabbits have ZANTAC 150 on one face and GLAXO on the other, containing 150 mg ranitidine (as the revealed no evidence of impaired fertility or harm to the foetus due to Zantac. If the hydrochloride), in packs of 28 and 56 tablets. administration of Zantac is considered to be necessary, its use requires that the potential Zantac Tablets are also available as white, capsule shaped, film-coated tablets engraved benefits be weighed against possible hazards to the patient and to the foetus. Ranitidine is ZANTAC 300 on one face and GLAXO on the-other, containing 300 mg ranitidine (as the secreted in breast milk in lactating mothers but the clinical significance of this has not been hydrochloride) packed in cartons containing 28 tablets. fully evaluated. Zantac Injection is available as 2 mL ampoules each containing 50 mg ranitidine (as the Use In Impaired renal function - Ranitidine is excreted via the kidney and in the presence hydrochloride) in 2 mL solution for intravenous or intramuscular administration. Packages of of severe renal impairment, plasma levels of ranitidine are increased and prolonged. 10 ampoules. Accordingly, in the presence of severe renal impairment, clinicians may wish to reduce the References: dose to a half of the usual dose taken twice daily. Children - Experience with Zantac Tablets in children is limited and such use has not been 1. Gledhill T. et al: Single nocturnal dose of an H2-receptor antagonist for thetreatment of fully evaluated in clinical studies. It has however been used successfully in children aged 8-18 duodenal ulcer GUT 1983, 24:904-908. 2. Dragstedt L.R. & Owens, F.M.: Supradiaphrag- years in doses up to 150 mg twice daily without adverse effect. matic section of the vagus nerves in treatment of duodenal ulcer. Proc. Soc. Exp. Biol. (NY) Interactions with other drugs -Although ranitidine has been reported to bind weakly to 1943, 53:152-154. 3. Colin-Jones D.G.: Comparison of ranitidine, 150 mg twice daily, with cytochrome P450 in vitro, recommended doses of the drug do not inhibit the action of the ranitidine 300 mg in one evening dose, in the treatment of duodenal ulcer. In Misiewicz J.J. & cytochrome P450-linked oxygenase in the liver. There are conflicting reports in the literature Wood J.R. (eds) Ranitidine Therapeutic Advances, Excerpta Medica 1984, 140-153. * See about possible interactions between ranitidine and several drugs; the clinical significance of Appendix at end of chapter for physicians collaborating in this study. 4. Dammann H.G. et these reports has not been substantiated. Amongst the drugs studied were warfarin, al: Affects of histamine H,-receptor antagonists and other agents on Intragastric Acidity and diazepam, metoprolol and nifedipine. Acid Secretion. In Misiewicz J.J. & Wood J.R. (eds) Ranitidine Therapeutic Advances, Adverse Reactions-Headache, rash, dizziness, constipation, diarrhoea and nadsea have Excerpta Medica 1984,126-139. been reported in a very small proportion of drug-treated patients but these also occurred in patients receiving placebo. A few patients on re-challenge with Zantac have had a recurrence of skin rash, headache or dizziness. Some increases in serum transaminases and gamma-glu- tamyl transpeptidase have been reported which have returned to normal either on continued treatment or on stopping Zantac. In placebo controlled studies involving nearly 2,500 Glaxro patients, there was no difference between the incidence of elevations of SGOT and/or SGPT Glaxo Laboratories values in the Zantac-treated or placebo-treated groups. Rare cases of hepatitis have been A Glaxo Canada Limited Company PMB reported but have been transient and no causal relationship has been established. Toronto, Ontario Montreal, Quebec ICCPP

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