External ear (comprising the auricle and the external auditory canal)

Middle ear

Inner ear

Nervous supply

Darwin’s tubercle (Fig. 5-2): Benign and congenital nodule near the auricular apex (on the helix, at the junction of upper and middle thirds). Nontender and rarely bilateral, it was first described by the British sculptor Thomas Woolner, a founding member of the Pre-Raphaelite Brotherhood and a spare-time anatomist. Woolner depicted it in his statue of “Puck,” and Charles Darwin was so impressed that he named it the Woolnerian tip. It is an atavistic feature (i.e., a trait typical of our mammalian ancestors—more specifically, monkeys).

Keloids (Fig. 5-3): Smooth and flesh-colored papule(s) on one or both sides of the earlobe. They indicate an exuberant and fibrotic response to injury.

Tophi: One or more nontender nodules on the auricular edges. They are named after the Latin tufa (a calcareous and volcanic deposit) and may indeed be mildly hard. They can occur on both helix and antihelix, and usually indicate hyperuricemia and gout.

Chondrodermatitis nodularis chronica helicis (CNH): This is a common, benign, and painful condition of the most prominent projection of the ear, usually the apex of the helix, but it also may affect the antihelix. It is typical of the right ear of middle-aged to older men, usually fair-skinned individuals with cutaneous sun-damage. In 10–35% of cases, it may also affect women. It is rather common (in a series, the most frequent external ear condition seen in an ear-nose-throat clinic) and is probably due to prolonged and excessive pressure, leading to inflammation, edema, and ischemic necrosis. This eventually degenerates into secondary perichondritis due to the vascular characteristics of the ear. Onset may be precipitated by pressure, trauma, or cold. Sleeping on the affected side is also common. The nodule appears spontaneously and painfully, rapidly enlarging to a maximum size of 4–8   mm, after which it remains stable. It is firm, tender, skin-colored, sharply demarcated, and round to oval in shape. The edge is usually raised, with a central ulcer or crust. It is not associated with systemic disorders.

A bloody discharge suggests trauma or cancer.

A clear and serous discharge suggests leakage of cerebrospinal fluid—often posttraumatic.

A purulent discharge suggests either infection of the middle ear with perforation of the drum (otitis interna) or infection of the external ear (otitis externa).

Trauma: This also may result in auricular ecchymoses and even hematomas (see question 22).

Port wine stain: Usually congenital and of only cosmetic importance. One of the most famous port wine stains in history was on the forehead of Soviet President Michail Gorbachev.

Sturge-Weber disease: Port wine nevus on the upper part of the scalp, associated with intracranial vascular abnormalities that may cause cerebellar calcifications and seizures.

Trauma: Easily identifiably by a history of recent altercation, especially if supported by other evidence of trauma, like a broken nose or a black eye. In fact, a “cauliflower” ear auricle is a time-honored occupational hazard of boxers, first portrayed in a beautiful Hellenistic statue of a resting fighter (Fig. 5-4). Unless evacuated, auricular hematomas heal with fibrosis and deformity and may even result in hearing loss. For instance, it has been suggested that Edison’s deafness was the result of having been picked up by the ears as a child. Still, there is no evidence that he had a cauliflower ear. President Johnson, on the other hand, contributed to our advance in veterinary medicine by demonstrating that cauliflower ears do not occur in dogs, especially beagles. In fact, he used to pick up his pooch by the ears and then toss him around in front of the press corps. LBJ, however, had no ear problems we know of, with the possible exception of selective deafness to war protesters in nearby Lafayette Park.

Relapsing polychondritis: May affect all facial cartilages, including the alar of the nose and the auricular of the ear(s).

Otitis externa maligna (see question 12).