Otorhinolaryngology (ENT)
Diseases of the External and Middle Ear
External and middle ear disease for MBBS ENT: otitis externa, acute and chronic otitis media, glue ear, cholesteatoma and otosclerosis, mapped to NMC codes EN3 and EN4.
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Diseases of the External and Middle Ear
External and middle ear disease for MBBS ENT: otitis externa, acute and chronic otitis media, glue ear, cholesteatoma and otosclerosis, mapped to NMC codes EN3 and EN4.
This chapter covers infections and structural diseases of the external and middle ear. It moves from otitis externa and its dangerous necrotising form through acute and chronic otitis media, glue ear, cholesteatoma and otosclerosis, and sets out the medical and surgical management and the complications that examiners emphasise.
High-yield: Diseases of the External and Middle Ear
- Otitis externa is inflammation of the ear canal, often from swimming or scratching, with pain worsened by moving the tragus or pinna.
- Malignant (necrotising) otitis externa is a severe Pseudomonas infection of elderly diabetics that can spread to the skull base.
- Acute otitis media presents with ear pain, fever and a bulging red tympanic membrane, and commonly follows an upper respiratory infection in children.
- Otitis media with effusion (glue ear) gives painless conductive hearing loss with a retracted or dull drum and a type B tympanogram.
- Chronic suppurative otitis media has two types: tubotympanic (safe, central perforation) and atticoantral (unsafe, associated with cholesteatoma).
- Cholesteatoma is keratinising squamous epithelium in the middle ear that erodes bone and can cause serious complications; scanty foul discharge is a warning sign.
- The unsafe (atticoantral) type of chronic ear disease requires surgery because of its risk of intracranial complications.
- Mastoiditis is a complication of acute otitis media with a tender, boggy postauricular swelling that pushes the pinna forward and down.
- A myringotomy with grommet insertion is the standard treatment for persistent glue ear causing hearing loss.
- Otosclerosis fixes the stapes footplate, causing progressive conductive deafness in young adults, often with a family history and improved hearing in noise (paracusis).
- Tympanoplasty repairs the eardrum and reconstructs the ossicles, while mastoidectomy removes disease from the mastoid.
- Complications of unsafe middle ear disease include facial palsy, labyrinthitis, meningitis and brain abscess.
- A furuncle in the outer canal is a localised staphylococcal infection of a hair follicle causing severe, tender swelling.
- Grommets (ventilation tubes) usually extrude on their own within several months as the drum heals.
Chronic suppurative otitis media: safe versus unsafe
- **Tubotympanic (safe):** Central perforation, mucoid non-foul discharge, no cholesteatoma. Low complication risk.
- **Atticoantral (unsafe):** Attic or marginal perforation, scanty foul discharge, cholesteatoma. High complication risk.
- **Cholesteatoma:** Keratinising squamous epithelium that erodes bone. Needs surgery.
- **Complications:** Facial palsy, labyrinthitis, mastoiditis, meningitis, brain abscess.
NMC competencies in this chapter
- **EN3.1:** Aetiology, features and management of diseases of the external ear
- **EN4.1:** Otitis externa: clinical features and management
- **EN4.2:** Malignant otitis externa and other external ear conditions
- **EN4.4:** Acute otitis media: features, complications and management
- **EN4.5:** Otitis media with effusion (glue ear)
- **EN4.7:** Chronic suppurative otitis media, safe and unsafe types
- **EN4.9:** Cholesteatoma and complications of middle ear disease
- **EN4.11:** Otosclerosis: features and management
Frequently Asked Questions
How do I tell safe from unsafe chronic ear disease?
Safe (tubotympanic) disease has a central perforation with mucoid non-foul discharge. Unsafe (atticoantral) disease has an attic or marginal perforation, scanty foul discharge and cholesteatoma, and needs surgery.
What is glue ear and how is it treated?
Glue ear is otitis media with effusion, giving painless conductive hearing loss and a flat type B tympanogram. Persistent cases are treated with myringotomy and grommet insertion.
Why is cholesteatoma dangerous?
It is keratinising squamous epithelium that steadily erodes surrounding bone, so it can cause facial palsy, labyrinthitis and intracranial infection, which is why it requires surgical removal.
What causes otosclerosis?
Abnormal bone remodelling fixes the stapes footplate, producing progressive conductive deafness in young adults, often familial, and classically with better hearing in noisy surroundings (paracusis willisii).
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