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55 Cards in this Set
- Front
- Back
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what is the rate of migration of skin in the EAC?
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0.07 mm/day, occurs at the basal layer
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the EAC is straight in early childhood. at what age does it become S shaped
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9 yrs/ 1/3 cartilage, 2/3 osseous
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cerumen is good because....
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protects canal from maceration, antibacterial properties, and acidic pH.
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innervation of the external ear?
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Great Auric - inf and post pinna
Arnolds (X) - innervates the EAC from TM to cymba concha (has a small IX contribution) Facial N - posterior EAC Auriculotemporal branch of V3 - anterior pinna |
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external ear lymphatic drainage patterns?
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anterior/superior EAC and tragus - drain to preauricular LN's
inferior EAC and helix - drain to the infraauricular nodes concha and antihelix - to the mastoid |
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blood supply? 2 main branches of carotid and 1 deep supplier.
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postauricular a. and superficial temporal a.
deep EAC is supplied by the deep auricular branch of the maxillary a. |
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grades of microtia
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1 small ear or slightly malformed - low-set ears, lop ears, cupped ears, and mildly constricted ears
2 small ear missing some elements 3 ranges from peanut to anotia, lobule is usually present and anteriorly displaced |
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whats a lop ear?
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poorly developed antihelix with auricular cartilage inferiorly angled with a deep conchal bowl
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what the general goals of each stage of microtia repair
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Stage I: obtaining similar ear positioning, involves harvest and implantation of rib cartilage
3 months later Stage II: moved the lobule into place with the previously placed rib cartilage. 3 months later Stage III: where the ear is elevated and the postauricular sulcus is created, a skin graft is usually needed Stage IV: tragal reconstruction and soft tissue debulking. .... vs prosthesis that can be glued or anchored to the bone. |
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what defines a protruding ear?
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greater than 15-20 mm from mastoid to auricle, or greater than 45 degree conchomastoid angle (30 is normal)
treated via Otoplasty: placement of 2-4 Mustarde sutures to recreate the antihelical fold, then placement of concha -to- mastoid sutures pearls: overcorrection of the middle third results in telephone ear. hematoma is the most common post op complication(3%) prepare patients/parents for up to 40% loss of the correction |
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what are the reasons to get a CT scan in canal atresia?
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assess Jarsdoerfer score. Evaluate for canal cholesteatoma. should wait to get scan. pt will not undergo surgery until age 5 ish and a cholesteatoma will not have formed yet in the neonate.
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where is the fluid collected in an auricular hematoma?
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subperichondrial space, acts as a barrier for the diffusion of metabolic byproducts, tissue necroses
need to drain, use some kind of abx irrigation, place, pressure dressing, abx. |
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most common otitis externa bugs
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staph a. and pseudomonas in swimmers.
also- proteus (gram neg bacillus), e coli (gram neg), staph e. and diphtheroids (gram +) loss of acidity in the EAC is proportional to the severity of infeciton |
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for OE, which is better? antibiotic, acidifying, or antiseptic gtts
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all equally effective in uncomplicated OE
antiseptic preparations include acetic and boric acids, ichthammol, phenol, aluminum acetate, gentian violet, thymol, thimerosal (eg, Merthiolate), cresylate, and alcohol antibiotic preparations include ofloxacin, ciprofloxacin, colistin, polymyxin B, neomycin, chloramphenicol, gentamicin, and tobramycin For Staph: Polymyxin B and Neomycin For broad spectrum: cipro and ofloxacin |
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what is the most common fungus isolated from otomycosis swabs?
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aspergillus is 80%. candida comes in second.
otomycosis makes up 9% of OE tx by acidifying the canal, then applying antifungal agent. non specific: thimerosal (mercury base) or gentian violet (methylated dye - long history of use as abx, antifungal and antihelminth tx) antifungal: clotrimazole, nystatin, ketoconazole |
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what's in CSF powder?
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chloramphenicol, sulfamethoximazole, fungizone-(amphotericin B)
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what does granulation tissue at the osseous-cartilaginous junction indicate in OE?
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skull base osteomyelitis. need to bx to r/o SCC.
the w/u with CT or Tc99 scan to eval, then or gallium scan to follow course of dz. ( consider MRI with gad) gallium is just a radiotracer (like Tc99) that builds up in sites of infection and certain tumors. it's used for bone imaging too. the disease likes to follow the vascular and neural passages in the bone. Check cranial nerves!! |
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what's the treatment for malignant (necrotizing) OE?
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long term culture directed IV abx (unless early presentation with close follow up, then orals can be used)
control blood sugar and immunosuppression surgical debridement if necrotic tissue is present add HBO in refractory cases |
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what is a boney sequestrum in the EAC?
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it is a region of denuded, yellowing necrotic bone which may have granulation around the edges. the bone is necrotic, seen in malignant otitis externa
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what does atopic dermatitis look like on the external ear? what cells and cytokines are there.
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pruritic or erythematous patches, +/- weeping.
usually has h/o atopy. also rash seen in flex/extensor surfaces and the face patches have higher Th2 cells with IL 4,5,-10. Type IV hypersensitivity (??) tx with steroid creams, consider oral antihistamines for itching |
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psoriasis look like?
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salmon pink patches with silvery scales. :)
about 20 % of cases will have ear lesions they bleed in pinpoint areas when scratched - Auspitz sign. treat with steroids, anthralin topical, ...UVA phototherapy |
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First Branchial cleft anomalies....where?
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anterior border of SCM, at angle of the mandible.
an associated finding is a membranous band from the floor of the medial EAC to the manubrium on the TM |
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what is the Work Classification
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It describes first branchial cleft cysts.
1 - duplicate of the membranous EAC. superficial to the facial nerve. lined with squamous epithelium |
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how do you treat frost bite of the ear?
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warm to 40-42 degrees C.
pain meds and abx apply aloe vera (antithromboxane properties) and ibuprofen to re-establish circulation debride bullae and necrotic tissue |
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describe burns by thickness
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superficial - erythema and pain. tx with moisturizing creams
partial thickness - pain and blisters, blanch with pressure. tx with debridement and abx ointment full thickness and subdermal - no pain, black eschar, ulcer. treat with silver based ointment, systemic abx (avoid suppurative chondritis) and debridement/skin grafting. |
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The AJCC classification system is for external or canal ear carcinomas? which is the Pittsburgh system
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AJCC is for external. Pittsburgh is for canal
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What are the T stages for the Pittsburgh classification system?
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T1 - limited to EAC with out soft tissue involvement or invasion
T2 - limited (not full thickness bony erosion or < 0.5 cm soft tissue involvement T3 - full thickness bony erosion, involvement of mastoid or ME, facial nerve paralysis, still with limited soft tissue involvement T4 - tumor extending to the medial wall of the middle ear or having inner ear involvement, tumor extending to petrous apex or dura, or with > 0.5 cm soft tissue involvement |
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What is the AJCC staging system for auricular cancer?
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T1 - </= 2 cm with less than 2 high risk feature
T2 - Any size tumor with more than 2 high risk features or, > 2 cm with 1 high risk feature (just think of size being a high risk feature) T3 - involvement of T bone, maxilla, mandible, orbit T4 - involvement of the axial or appendicular skeleton, perineural invasion of the skull base. |
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When do you perform a lateral temporal bone resection for cancers of the ear canal?
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when the primary cancer is T2 or greater
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when do you perform a parotidectomy?
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advanced disease (T3/4) and palpable LN's
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Survival from EAC carcinoma is correlated best with what?
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T stage at presentation
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whats the most common cancer of the external ear? what part of the ear? what is the risk of mets?
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basal cell. 45%
posterior aurical or postauricular areas. .003- 0.1% staging is AJCC |
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what are the risk factors for basal cell?
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UVB sunlight. h/o of other skin cancers. age.
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What are the indications for the below basal cell treatments?
XRT/ 5 FU Electrocurretage Cryosurgery Local excision *Mohs |
Radiation therapy / 5 FU - unresectable or poor surgical candidate
Curretage - nodular lesions. electrodessicates the base Cryosurgery - sub CM lesions with well defined borders Local excision - basal cells < 2 cm in size. take 4 mm margin. (95% of basal cells will be successfully treated this way) - need 1 cm margin for aggressive subtypes - ok for primary repair *Mohs - for recurrent BCC, aggressive subtype, > 2 cm. cure rate should be 97% |
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what are the high risk and low risk histologic patterns of basal cell?
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Low risk - nodular, superficial, infundibulocystic, and fibroepitheliomatus of Pinkus.
High risk - sclerosing, morpheaform, micronodular, and mixed infiltrative |
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What makes a basal cell high risk for recurrence per NCCN guidelines?
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Region of the face :
Area H (mask area) - > 6mm Area M (cheeks, forehead, scalp, neck, pretibia) - 10 mm Area L (trunk/extremities) - > 20 mm Borders: poorly defined (as opposed to well defined) Recurrent (vs primary) Immunosuppression located at a site of prior radiotherapy Aggressive subtype + perineural invasion |
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Squamous Cell cancer of the ear is second most common cancer. What percentage does it make up? who gets it? what part of the ear?
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20%
typically in old white males preauricular and on helix |
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What are the risk factors for SCC of the ear?
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UV exposure.
Exposure to chemicals (arsenic, coal, tar, petroleum, soot) Immunosuppression H/o burn advanced age non healing ulcer |
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what is the % of metastasis?
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6-18%
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Which treatment is appropriate for what kind of patient with SCC of the ear?
XRT |
XRT - for unresectable or unacceptable cosmetic result from resection, or poor surgical candidates
Local resection - for SCC < 2 cm, take 6mm margin and will get a 95% cure rate T1 ok for sleeve excision T2+ need temporal bone resection T4 lesions may need facial nerve resection with grafting |
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when do you do a neck dissection or parotidectomy for SCC of the ear?
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External ear : for palpable disease, or T3-4 lesions
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what are the cure rates for SCC of the external ear?
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72-95% depending on T stage, location, and histologic subtype
EAC: T1 83% and T4 25% over 5 years. - facial nerve involvement and nodes are poor prognostic indicators |
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what is the % on the ear and overall survival of auricular melanomas? Where are they usually seen on the ear?
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1% of melanomas. 10 year survival is 70%. Helix
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What kind of work up do you need for melanomas?
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CXR to look for mets. ** NCCN guidelines say no CXR. Get CT of Chest/Ab/Pelvis and then MRI. PET as indicated.
LFT's to look for liver involvement. CT and MRI help (should get MRI brain). Radio nucleotide bone scan for bone mets (gallium) LDH |
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What is the AJCC melanoma staging system?
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T's 1-4. all have a/b upgrade for ulceration (b).
T1 </= 1 mm T2 >1 to </= 2 mm T3 >2 to </= 3 mm T4 > 4 mm N's are divided to a/b for micro and macrometastasis respectively. N1 1 node N2 2-3 nodes N3 4 +, ganglionic, congomeration, in transit or satellites. M 1 ganglionic or distant, subq mets M 2 mets to lung M 3 mets to viscera or if ELEVATED LDH. http://scielo.isciii.es/img/revistas/maxi/v27n4/183table1.jpg **NCCN uses 0.75 as a cut off now. |
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How is the previous information used to generate stage?
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I a/b
II a/b/c III a/b/c IV http://scielo.isciii.es/img/revistas/maxi/v27n4/183table1.jpg |
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treatment of auricular melanomas? when do you perform a SLNBx? XRT?
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tx is surgical. NCCN guidelines suggest discussing/consider SLNBx for melanoma >/= 0.76 mm - 1 mm.
XRT should be used for nodal basin if multiple + nodes |
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what are the recommended resection margins for melanoma per NCCN?
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If insitu, perform 0.5 cm
If >/= 1mm, perform 1 cm If 1-2 mm, perform 1-2 cm If 2-3 or 4+ perform 2 cm margins |
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when do you use adjuvant therapy? local and regional indications.
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local: desmoplastic melanoma with narrow margins, recurrent disease, or extensive neurotropism
Regional: also for ECS, >/= 4 LN's or > 3 cm mass w/in a node, recurrence. |
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Glandular tumors of the EAC are rare. What are the 4 glandular tumors that can be seen in the EAC?
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Adenoid cystic ca (ACC), ceruminous adenoma, ceruminous adenocarcinoma, pleomorphic adenoma
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Adenoid Cystic Carcinoma - characteristis, histologic types, LN's and mets
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have a perineural (typically have otalgia), perivascular, and fatty predilection.
histologic subtypes - cribiform, solid, and tubular LN's/mets are rare - but will have long term mets show up typically in the lung. (get an annual CXR) |
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Ceruminous adenoma
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double layered cuboidal pattern, may have "snouts" of apical secretion.
typically painless masses that grow for long periods and present with CDHL or otitis externa |
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Ceruminous adenocarcinoma
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same as above, but with higher mitotic rate and more atypia.
LN's rare may invade surrounding structures |
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Pleomorphic Adenoma
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epithelial and mesenchymal (myxoid, hyaline, chondroid, osseous) elements
slow growing, does not invade. aka benign mixed tumor |
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osteoma vs exostosis?
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both are bony neoplasms
osteomas are pedunculated with a vascular core. exostosis are sessile, lamellar bone, reactive to cold water exposure (ear plugs to help) |
