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Home loans by DHFL, a leading housing finance company. dhfl offers house loans, NRI Home Loans, Mortgage loans, SME loans, with higher eligibility and lower EMIs at attractive interest rates across India. DHFL also offers Deposits with higher interest rates
. Mortgage Inc, Astoria Company, Atlantic Financial Inc, Atlantic Home Capital, Atlantic Home Loans, Atlantic Mortgage & Finance, Atlantic Mortgage & Funding .
OnePlus 7T Pro will likely have a 5G variant and the launch will take place before the end of 2019, according to the.
Anil Ambani-led Reliance Capital and Reliance Home Finance Wednesday said Price Waterhouse & Co Chartered Accountants (PWC) has resigned as statutory auditor of both the companies. PWC put in its.
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Usaa Pre Qualify Home Loan As of this afternoon, 10 of the 12 Federal home loan banks have been cut. northwestern mutual, TIAA and USAA. Five industrial revenue bonds were also cut today. At the same time, the ratings agency.
JCF Lending Group offers Manufactured & Mobile Home Financing Programs for New & Used homes located in mobile home parks, manufactured home communities and on private land where the land and the home will not be financed together The homes that we finance must be titled and will be your primary residence or vacation home.
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text: > On Mar 16, 2018, at 12:39 PM, Jean-Claude DE SOZA <jeanclaudedesoza at orange.fr> wrote: > > Bonjour à tous, > > I've just updated my TeX installation with the MacTeX 2018 package. No problem except with TLU.app weird behaviour. > After two crashes, and critical updates done, I can typeset my very complex French-Vietnamese recipes book without any error. > TeXLive 2018 seems also to be very fast. > > Jean-Claude DE SOZA > jeanclaudedesoza at orange.fr Howdy, There seems to be a bit pf a glitch with that first infrastructure update. If, after you go through that and quit TeX Live Utility, you restart it all is well. I assume this will not occur once TeXLive 2018 is released and the final setup of the repositories are complete; i.e., this is just growing pains. What OS version are you using? I now have it installed on High Sierra and El Capitan and both are working fine. Good Luck, Herb Schulz (herbs at wideopenwest dot com)

subset: commoncrawl


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Paul Coleman Obituary. Family and friends are welcome to leave their condolences on this memorial page and share them with the family. Born in wolverhampton uk, his early years were spent in tenby and bracknell before moving to the united states when he was
He was employed by pepsi co. Bob coleman january 13, 2021 paul r. To send flowers or plant a tree in memory of paul coleman, visit the tribute store.
Coleman, Lost His Long Battle With Parkinson's On Wednesday, December 9, 2020, Peacefully Surrounded By Family, Longtime.
Edit search new search jump to filters. He was 54 years old. We know that paul coleman had been residing in saint albans, kanawha county, west virginia 25177.
Coleman Obituary Remember Paul C.
Paul came into this world as a bouncing bundle of joy and never stopped. Coleman, 60, of livingston, n.j., passed away peacefully at home on wednesday, july 11, 2018. Visit www.schoedinger.com for complete obituary.
He Was Born To The Late Vivian And Coleman Mitchell In Greensboro, Nc.
Bob was born and raised in syracuse and lived the majority of his life in auburn after marriage in 1956. You can send your sympathy in the guestbook provided and share it with the family. Williams memorial chapel with rev.
We Are Sad To Announce That On December 15, 2021 We Had To Say Goodbye To Paul Coleman (Milwaukee, Wisconsin).
Share a memory send flowers. Paul kerry coleman, age 34, passed away peacefully surrounded by his family on april 26, 2018 after a long and valiant battle with cancer. Please accept echovita's sincere condolences.
Obituary For Paul Coleman Mitchell.
You may also light a candle in honor of paul. Here is paul coleman's obituary. The cause was cardiac arrest.


text:
Russia's invasion of Ukraine in late February serves as a stark reminder of the importance of good intelligence in risk management. Indeed, the breakout of Europe's largest conventional war for 75 years should not have come entirely by surprise given prevailing realities at both the strategic and tactical levels, but for many it did.
In this article we examine the current conflict in Ukraine, and its wider implications, to explore the role of good intelligence in managing organisational risk.
The red flags
At the broader strategic level, for more than 15 years, Russian President Vladimir Putin has been working to undermine the liberal international order, building an increasingly personalistic autocracy at home, while waging wars and subverting democracy and the rule of law internationally.
In the months before the invasion, all the signs of imminent military action began to emerge at the more tactical level: Russia amassed more than 100,000 troops near the Ukrainian border; US intelligence services released numerous reports predicting an invasion; fighting in the Donbass region escalated; Russia intensified its misinformation campaigns to justify an invasion; and Putin made a grand show of recognising the Donetsk and Luhansk republics. All this culminated in the release of a televised statement presenting a revisionist history of Russo-Ukrainian relations to justify military intervention.
Yet despite all these flags, the reality of Russia's invasion in the early hours of 24 February was largely met with incredulity: the possibility of an inter-state war in Europe was simply too outlandish to take seriously and while many took comfort in the fact that a full-scale invasion was improbable, it was in fact never impossible.
Preparing for a range of outcomes
Intelligence is often about much more than reading the tea leaves. Like the global Covid-19 pandemic, Russia's recent belligerence has lain bare just how disruptive extreme events can be. These seemingly unlikely but yet highly disruptive crises teach us that good preparation is not necessarily about forecasting and responding to what we perceive as the most likely future. Rather, it is about preparing for a range of outcomes informed by their consequence, often despite their probabilities.
To function well, organisations need to be prepared for a range of external disruptors, ranging from the routine, such as changes to the inflation rate, to the radical, such as a global pandemic or, indeed, an inter-state war. In this respect, the Russian invasion has underlined the importance of preparing for a wide spectrum of scenarios.
By considering both the routine and the radical, organisations can put in place the necessary processes, structures and failsafe mechanisms to prepare for, respond to, and recover from potentially disruptive events. More and more organisations understand this, reflected perhaps in projections that the size of the global risk management market is set to grow from USD 7.39 billion in 2019 to USD 28.87 billion by 2027.1
Taking the strategic view
While the world's attention is rightly focused on the war in Ukraine and Putin's intentions in the country, it would be wise to remain cognisant of Russia's longer-term foreign policy objectives elsewhere.
Nowhere are these more apparent than in Africa. The newly consolidated Mali junta's alignment with Russia is perhaps the most overt recent example of increased ties with Russia, but it is not the only one. Of the 35 countries that abstained in the UN vote to condemn Russia's invasion of Ukraine, 17 were from Africa. In fact, Russia has been aggressively pursuing its strategic objectives in Africa, and elsewhere, for decades.
In contrast to another key player on the continent, China, who has prioritised large (infrastructure) investments resulting in state-level influence, Russia has sought to leverage personal ties across asymmetrical engagements. These have included covert security support, 'weapons-for-resource' deals, and perhaps even election interference, to gain favour and increased influence by prioritising relationships with Africa's elites, and indeed elites elsewhere, propping up embattled incumbents or seeking to support new military stakeholders amid post-coup transitions. These relations will not only be destabilising for citizens, resulting in the continuation of illegitimate governments, but bring with them associated corruption and reputational risks for commercial players. And, depending on the trajectory of the Ukraine conflict, being on the wrong side of history could have additional implications around sanctions and associated commercial disruptions in African countries and, by corollary, those operating there.
Evidence of Russia's foreign policy manoeuvrings is on display elsewhere, too. Security and trade deals, including over oil supplies, have made it challenging for players such as Saudi Arabia and the United Arab Emirates to openly condemn Russia's actions.
Meanwhile, Algeria, Tunisia, Libya, Lebanon and Egypt, all set to be severely impacted by raising wheat prices, could too be more favourable towards Russian offers of food security lifelines. Russia is indeed embedded in Syria, but the country will also need to lean more on ties with Iran and Turkey to combat economic isolation; the latter will prove to be an increasingly important stakeholder given Turkey's influence over the Black Sea. These more subtle relationships could prove increasingly important to understanding the global implications of the Ukraine war, beyond the frequently touted 'will they / won't they' question concerning Russia / China alliances.
Beyond the headlines
Just as important as understanding significant developments and their direct impacts on business operations geographically, organisations would be well served to delve beyond the first order consequences of these types of events.
The war in Ukraine and the West's response to Russia, including wide ranging sanctions and measures aimed at Russia's international isolation, will have long stretching and long-lasting consequences for markets across the globe. Here, much of the global debate has centred on the impact on energy markets, but with Russia being a major exporter of cereals, metals, wood and fertilisers, the second and third tier impacts are much wider.
Russia accounts for almost 30% of the word's exports of wheat and barley, a large part destined for Turkey and Egypt, and while some importers had already moved away from their reliance on Russian grain, countries such as Lebanon sourcing Ukrainian supply are also facing severe disruption. For countries like Egypt already confronting the unpopular challenge of reducing bread subsidies, higher wheat prices will force their hand and could prompt widespread protests.
The consequence on the price of food staples will be felt in African and Asian markets, including countries such as Sudan, Nigeria, Tanzania, Algeria, Kenya, South Africa and Indonesia, themselves vulnerable to outbreaks of unrest driven by socio-economic challenges.
Global networks and local impact
The very nature of the interdependence of global economies, and companies' extended exposure that results, means that one has to take a strategic view of key developments. As Russia's invasion of Ukraine has unfolded we have seen a wide range of knock-on effects for Russia, Ukraine, Europe and the rest of the world. From the closing of European and North American airspace, to the estimated 3 million refugees fleeing the conflict, the increasing isolation of Russia from the world economy, and the rises in food and fuel prices, it is clear that war has a price beyond the battlefield. Maintaining an ongoing understanding these implications will be a key business asset.
The Ukraine / Russia conflict serves as a useful reminder of the drivers of risk in the geopolitical space. For commercial operators everywhere, insulation from developments occurring on the other side of the globe is no longer a guarantee and there is an inherent need to understand and respond appropriately to emerging geopolitical risk(s). Now more than ever, commercial stakeholders need to pay attention to points of tension and the potential implications for business that extend beyond pure geopolitical posturing.
1 "Global Risk Management Market: Opportunities and Forecast, 2020-2027", Allied Market Research, March 2021.
Gabrielle Reid, Associate Director of Strategic Intelligence
Gabrielle is the Associate Director for S-RM's Strategic Intelligence practice. With over 10 years in the industry, Gabrielle has supported an array of clients with their bespoke intelligence needs, helping them navigate complex operating environments. She works closely with our clients to develop tailored solutions that map their precise requirements for intelligence and analysis based on their locations, exposure and objectives, analysing changing (geo)political, security and regulatory landscapes to better inform decision-making.
Prior to joining S-RM, she worked for a travel risk advisory firm, and assisted in the planning and coordination of several non-medical evacuations. Gabrielle holds a Bachelor of Social Sciences in Politics and Psychology, a Bachelor of Social Sciences in Justice and Transformation, and a Master's Degree in International Relations.
Markus Korhonen, Senior Associate for Strategic Intelligence.
Markus is a Senior Associate for S-RM's Strategic Intelligence practice. He has over a decade's experience in political analysis and risk consulting. He joined S-RM in 2018, and since then he has led on a range of projects globally. Within the Strategic Intelligence practice, Markus works with clients to develop tailored intelligence outputs, as well as overseeing S-RM's Global Security Insight threat intelligence platform.
Before joining S-RM, he worked as a lecturer at the Universities of Cape Town and Stellenbosch, and at Webster University's campus in Accra, teaching a variety of political science courses including International Political Economy and Comparative Politics. He also worked as a writer for Africa Check, the continent's first fact-checking organisation. Markus holds an MSc by Research in African Studies from the University of Edinburgh, and an MA in Politics and International Relations from the University of Aberdeen.


text: Yhomit coll. Part 1 WorksheetFor your final project, you will need to collectÿa minimum of 4 Scholarly Sources. Theseÿ4 Scholarly Sourcesÿmust:Relate to the research questions you posed in your Week 2 concept map or outline.Make connections between your scholarly resources and your research topic?(Please note: you are building toward your project with each assignment in this course).When you have logged at least 4 Scholarly Sources, fill out the Source Organizational Worksheet and include:The bibliographical information asÿGivenÿin the worksheet,ÿANDSummarize the source in your own words with proper grammar and spellingThen attach the document to the assignment submission.Part 2 Paragraph SubmissionIn the textbox space, draft a 4-5 sentence paragraph with proper grammar and spelling, describing:Your source search processÿAndHow these sources might be useful in creating your final presentation about a career interest.SEE ATTACHMENT FOR CONCEPT MAPÿand fill out ÿworksheet for sources (attached)


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|Greg A. Woods
|Re: Do we have an alternative to tag, to record status of cvs repo
|Tue, 22 Apr 2003 14:24:41 -0400 (EDT)
[ On Tuesday, April 22, 2003 at 20:18:26 (+0530), Satya Prasad DV wrote: ] > Subject: Do we have an alternative to tag, to record status of cvs repo > > In our orgn, we need to keep track of the code base status after each > engineer's check in is done. We were using tagging to keep track of this. > But the huge number of tags getting created over a long time have made the > CVS repository bloated with tags. This is also making the sync. of > repository with our branch located elsewhere too long. I think what you really should do is convert to using a versioning tool that is based on the idea of maintaining a working baseline. I would suggest Aegis: <URL:http://www.canb.auug.org.au/~millerp/aegis.html> It's either that or you'll have to use branches in CVS a lot more extensively. -- Greg A. Woods +1 416 218-0098; <address@hidden>; <address@hidden> Planix, Inc. <address@hidden>; VE3TCP; Secrets of the Weird <address@hidden>
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America Recycles Day 2019: Deals From Staples, Apple Store, Best Buy and More
Today is America Recycles Day (November 15), a day that encourages people across the country to produce less waste and recycle or reuse items they might normally discard.
America Recycles Day (ARD) is a Keep America Beautiful national initiative. According to its website, it is the only nationally recognized day dedicated to promoting and celebrating recycling in the U.S. Each year, on the day and in the weeks leading up to it, thousands of communities participate by promoting environmental citizenship and taking action to increase and improve recycling.
The Environmental Protection Agency (EPA) found that for every 10,000 tons of recycled materials, 16 jobs and $760,000 in wages are created.
Office supplies retailer Staples is offering rewards to customers on America Recycles Day through incentives. People can get double rewards on ink and toner cartridge recycling, can make the most of free shredding and get money off purchases when recycling old items.
- Reward Members get $10 off the next purchase of $30 or more when recycling electronics in store until November 16, 2019
- Get up to five pounds of shredding for free
- Earn up to an extra $50 when trading in an old printer
For customers wanting to make the most of these offers, this is what Staples recycles:
PCs & Printers
- All–in–ones
- Desktops
- Laptops
- Monitors
- Copiers
- Fax machines
- Printers
- Scanners
- Multifunction printers and copiers
Tablets & Mobile Tech
- Camcorders
- Digital cameras
- eReaders
- External hard drives
- Gaming systems
- GPS devices
- iPod/MP3 players
- Mobile phones
- Tablets
Other Electronics
- Cable/satellite receivers
- Calculators
- CD/DVD/Blu-ray players
- Coffee Brewers (less than 40 lb.)
- Computer speakers
- Cordless phones
- Digital projectors
- Email servers
- Keyboards and mice
- Modems and routers
- Shredders
- Stereo receivers
- UPS/battery backups
- Video streaming devices
Staples are unable to accept the following things for recycling:
- Floor speakers
- Floor model copiers & printers
- Kitchen electronics
- Lamps and bulbs
- Large servers
- TVs and appliances
Apple Store: Donate your Apple-branded item to any store and receive a gift card for the item's fair market value.
Best Buy: The store offers different trade-in deals for technology, allowing customers to get a gift card.
Kiehl's: Bring full-size empty bottles back to receive a stamp toward a free travel-size product worth $11. Each customer can redeem one reward per month, which equates to 10 empty full-sized containers
Cotton Incorporated: The company is urging its social followers to "snap their stack" through its denim recycling program, Blue Jeans Go Green. Participants can "stack up" their old denim shirts, jackets, pants and shorts, by taking a photo and sharing it on Instagram with the tag and hashtag @DiscoverCotton and #DenimStackChallenge. They are then encouraged to tag three friends in the post and invite them to join the challenge, the company told Newsweek. Some Blue Jeans Go Green participating retailers offer a discount on new denim for customers who drop off an old pair of jeans at their locations, so it's well worth taking part.
MAC Cosmetics: The makeup brand is giving away a free lipstick of the customer's choice if they return six primary packaging containers.
The North Face: Drop off clothing or footwear at any North Face Retail and Outlets stores to receive a $10 reward toward a future purchase of $100 or more.
Office Depot/Max: Get $2 back in rewards per recycled ink cartridge when you make a $10 qualifying purchase during the same month.
Lush: The company is famous for its Black Pot Program; customers can take back five empty Lush pots to get a free fresh face mask worth between $10 to $14.
Worldkind: The eco-friendly apparel brand is giving customers 10 percent off for America Recycles Day on its website.
Find further information on where to recycle products here, including recycling centers and local community initiatives. The below graphic, provided by Statista, gives an insight into exactly what materials Americans recycle the most.


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ANNAPOLIS — The fight over establishing liability for injuries and deaths related to dog bites moved one step closer to the House of Delegates Wednesday after the state Senate voted to amend a compromise proposal.
Preliminary approval of Senate Bill 247 came after more than 90 minutes of intense debate that ended with legislators moving to reconsider, and ultimately approve, an amendment that was previously rejected.
"The Senate has moved considerably and tried to meet the House in the middle," said Sen. Jamin B. "Jamie" Raskin, D-Montgomery. "Now it's their turn to meet us in the middle."
Raskin initially voted against an amendment proposed by Sen. Robert A. "Bobby" Zirkin, D-Baltimore County, which imposed a higher standard of liability for attacks by a dog that is roaming or "running at large." But after the vote, Raskin said he had second thoughts and invoked a procedural move to reconsider that amendment.
Raskin and two other senators changed their votes and the amendment passed 25-22.
Under the revised measure, the owner of a roaming dog is liable for attacks, subject to a limited set of exceptions. The exceptions include victims who were trespassing or committing other criminal acts, or who teased, tormented, abused or otherwise provoked the animal.
The original compromise bill, as proposed by Sen. Brian E. Frosh, D-Montgomery, establishes that an injury or death caused by a dog bite creates a rebuttable presumption that the owner knew or should have known that the dog had dangerous or vicious propensities.
The legislation comes in response to a 2012 Court of Appeals ruling in which the court said that pit bulls were inherently dangerous and that owners of those dogs — and landlords who rent to owners of pit bulls — are strictly liable.
Frosh fought hard to hold together enough votes to preserve his bill in an unaltered form, saying the House would not consider legislation that included any strict liability standard.
"We've had two train wrecks on this subject," Frosh said, speaking of previous efforts to resolve the Court of Appeals decision. Zirkin, he said "is inviting you to a third one."
Efforts to resolve the issue last year fell apart amid accusations from Del. Luiz R.S. Simmons, D-Montgomery, a vocal opponent of strict liability, that Frosh went back on a deal. The resulting conference committee compromise, which contained a liability with limited defenses, was supported in the Senate. That bill failed in the House.
Zirkin pleaded with the Senate to adopt his amendment that would have made Frosh's bill identical to the conference committee agreement last year. Even Frosh said he would prefer the bill from last year, but acknowledged his belief that it would not pass muster in the House.
But members of his own party, including Senate President Thomas V. Mike Miller Jr., were deeply divided on the issue.
"We should not have a shotgun held to our heads," said Sen. Nathaniel J. McFadden, D-Baltimore. "In the Senate we're going to do it and do it right. If the House does the wrong thing, that's on them."
Miller voted with Zirkin on his roaming-dog amendment, but that measure failed 23-24.
In a later interview, Simmons, D-Montgomery, praised Frosh for his work on the bill.
"We'll take a good hard look at what the Senate did," he said. Frosh, he said, "produced a compromise bill that was largely intact. I know he fought hard for it.
"I regret he could not fight off (the roaming dog amendment) but Senator Miller imposed that by fiat," Simmons said.
Simmons said he could live with the final version of the Senate bill but said it will open the door to delegates who will want to add their own amendments. He hinted that House amendments could again derail efforts to pass a bill.
"I won't speak to what will happen in the end," said Simmons.


text:
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Buona sera, dall'estratto conto risulta il pagamento di due abbonamenti, uno dei quali non ho la più pallida idea di che cosa sia, ma in fattura ne risulta soltanto uno. È possibile annullare quello che non mi interessa? E come?
This is a public forum, not Adobe support. Users, including the Community Experts, can't provide support for account, subscription, billing, download, or product activation issues. Support for those issues requires an Adobe employee.Adobe provides support through the Chat function on the contact page or through a phone call. There is no email support.CHAT: Click the following to contact Adobe customer support staff for help:https://helpx.adobe.com/contact/support.htmlYou must be signed in with your Adobe ID and allow cookies in your web browser for this to work. Disable any ad, pop-up, or script blockers.This is the link to the US website. If you are not in the US, the site should redirect to the page appropriate to the region associated with your ID.Click the chat icon at the bottom right of the page to open a chat session.If that doesn't work, try this link, which opens a chat window directly:https://helpx.adobe.com/contact.html?rghtup=autoOpenPHONE: You can also search this page for a regionally appropriate phone number for customer support.https://helpx.adobe.com/contact/phone.html


text:
Earrings - Daydreams
Earrings - Daydreams
Sale Sold out
Regular price Rs. 799.00
Regular priceUnit price per
Sale price
Rs. 799.00
Talk to us on WhatsApp
Just looking into the open, with nothing particular on your mind. Just lost in your own space and time.
For the longest time, we wanted to do something that's NOT apparel yet had to incorporate our art! And Voila, our earrings turned out to be so minimalistic yet impactful for all the outfits you pair them with!
Made in premium quality Brass.
Material: Made from a single brass wire. Seamless, lightweight and expressive.


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Research reveals possible lasting immunity after covid-19 infection
The length of time individuals retain immunity from covid-19 comes after a study by Australian scientists, published in the journal 'Science Immunology'.
One of the great unknowns about the novel coronavirus that has caused the current global pandemic is just how long people remain immune after contracting the disease. Over the past several months as the virus has spread around the globe, researchers have sought a reliable answer to this question. It may be key to the development and administration of the vaccine.
There have been some reported cases of reinfection but there remains doubt to whether these were reinfections or the disease "waking up" again.
"Immunity can last at least eight months"
Australian researchers have published a study in the journal 'Science Immunology' that determines the length of time a person retains immunity after contracting covid-19 is at least eight months.
The study reports that 25 patients who were infected with covid-19 had their blood samples analyzed from the fourth day of infection to day 242 after the infection. The 36 blood samples obtained from each patient revealed that they had retained durable B cell memory to SARS-CoV-2. B cells are memory cells which "remember" a virus infection by recognizing the nucleocapsid and spike proteins (two key components SARS-CoV-2) and then trigger a protective immune response if they are re-exposed.
This conclusion is great news, as there were some previous studies that revealed immunity could be lost quickly. "Nor does it seem that reinfection is common. And if there is, in these diseases it usually occurs with milder symptoms than the original infection," Jaime Jesús Pérez, director of the Spanish Association of Vaccination, commented to AS.
Very few cases of possible reinfected in the world
At least one case of reinfection in Spain is being investigated. There exists the possibility that it could be a false positive or that remains of the virus were still present in the body and 'woke up' after a period of time . In the world, among the more than 78 million confirmed cases, only around twenty possible cases of reinfection have been confirmed, which are also being studied.
In August a man from Hong Kong tested positive for a second time with covid-19 upon returning from a trip to Spain. He had contracted the disease for the first time in April and an initial analysis showed that his second infected was with a slightly different strain.
In October a woman from the Netherlands died after what was believed to be a reinfection. She was being treated for a rare cancer with a B-cell-depleting therapy when she contracted covid-19 the first time. 59 days after the start of that COVID-19 infection, she developed symptoms again. She had received chemotherapy two days prior to developing symptoms.
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SFW to MTV Converter
Convert your sfw files to mtv online & free
Convert to SFW
Seattle Film Works
Format for bitmap images that were created in the Seattle FilmWorks video editor, which is no longer being actively developed. It was also used to create slideshows. The format has a MGI PhotoSuite file structure that supports bitmap images. SFW files can be converted into JPG images.
MTV Converter
MTV Raytracing image format
This file format is used to transmit image data. It contains a set of images that can be linked to form an animation. It is used to store non-compressed bitmap images in 24-bit color created using MTV ray tracer.
How to convert SFW to MTV
Step 1
Upload sfw-file(s)
Select files from Computer, Google Drive, Dropbox, URL or by dragging it on the page.
Step 2
Choose "to mtv"
Choose mtv or any other format you need as a result (more than 200 formats supported)
Step 3
Download your mtv
Let the file convert and you can download your mtv file right afterwards


text:
Estero River (Florida) facts for kids
Quick facts for kidsEstero River
|United States
|Physical characteristics
|River mouth
|Estero Bay
|Basin features
|Basin size
|Estero Bay
The Estero River is a 6.4-mile-long (10.3 km) waterway in south Lee County, Florida, United States, near the census-designated place of Estero. It flows from east to west, emptying into Estero Bay, an inlet of the Gulf of Mexico.
Access to the river can be gained at 26°26′N 81°49′W / 26.43°N 81.81°W.
The river is bounded on the west by Estero Bay. The eastern boundary is three miles east of I-75. The northern and southern river banks are surrounded by developing housing communities towards the eastern part of the river, with greater biodiversity along the western banks.
The Estero River, in Southwest Florida, is 6.52 miles long. It flows west and spills into Estero Bay estuary. The Estero River has abundant wildlife and is an important habitat for endangered species such as the American alligator (Alligator mississippiensis), Key Largo woodrat (Neotoma floridana smalli), gray bat (Myotis grisescens), and the whooping crane (Grus americana) among others.
The mangroves on the banks of Estero River support a variety of wildlife and play a vital role in supporting the large biodiversity of the river. The majority of mangroves can be found at where the Estero River merges into Estero Bay.
The great blue heron (Ardea herodias) inhabits and breeds in both salt and fresh water habitats, making the Estero River perfect for this heron. It nests from "5 to 20 m above ground", and the trees surrounding the river make for a great nesting habitat. These herons feed mostly on aquatic and terrestrial insects that can be found along the river. The great egret (Ardea alba) does not directly compete with the great blue heron; instead it consumes small mammals, amphibians, and sometimes insects.
The tricolored heron (Egretta tricolor) is similar in diet and habitat to the great egret and can be spotted at the Estero River and estuary in the early morning. This heron nests closer to the ground and can coexist with the great blue heron. Its diet consists of insects and small amphibians. American alligators (Alligator mississippiensis) can be found along the Estero River, though the numbers are relatively small. This animal plays a crucial role in maintaining the biodiversity of the river by keeping the raccoon population in balance. Reported sightings happen along the western part of the river with isolated sightings in the eastern region. Their diet consists of small mammals, birds, and larger amphibians.
Raccoons (Procyon lotor) are one of the most common nocturnal mammals inhabiting the area. Their diet is omnivorous, consisting of berries, plants, smaller vertebrates, and invertebrates. It is not uncommon to see one during the day. This mammal has grown used to human presence.
The Estero River is a rich habitat for insects. An abundance of mosquito species can be found near the river, which is a perfect habitat for them. Females consume blood for the vital proteins required for egg development. Both males and females are pollinators and consume plant nectar for sustenance. The orb-weaver spider is found in abundance along the river banks. This spider is easily identified by the shape of its web. It eats small insects. Also bees can be found nesting on overhanging trees.
Human impact on the ecosystem
The water quality in the eastern part of the river is lower compared to the western part; this is attributed to the increasing human development in the Estero area and the subsequent waste.
The water quality increases dramatically with the distance from the drainage outlets and surrounding houses. Since the majority of development occurs on the banks of the eastern parts of the river the water quality decreases inland.
The first inhabitants known to occupy the Estero River were the Calusa Indians around 7000 years ago. They used the river for transportation and food; they were heavily dependent on fishing. Even though they lived on the Estero, much of their history is located around the Caloosahatchee River, where they first encountered European settlers. Artifacts are still being discovered in the area.
The Calusa's first contact with Europeans was with Spaniard, Juan Ponce de León around 1513. After that they began to diminish. Even though they used the Estero River they also stayed centrally around the Caloosahatchee River, which was a much more sophisticated and reliable river.
The river's recorded history started with Gustave Damkohler, who found the river in 1882 and lived alongside it in a small shack with his family. In 1894 traveled to his hometown in Chicago, Illinois where he met Cyrus Teed, the leader of Koreshanity (a new religious movement). Damkohler offered Teed 300 acres of the land in Estero, including access to the river. Cyrus and a small group of followers moved to Florida, arrived at Estero Bay, and made their way up the Estero River to what is now the Koreshan State Park. They gradually started to build a community and called more and more believers to come down from Chicago. The Koreshans had a major ecological impact on the river when they were living there. They traveled it every day, going in and out of the Estero bay. They hunted and gathered foods from Mound Key, an island just west of the Estero River inlet and used canoes, which were the fastest way of traveling at the time. They also fished the river. The Koreshans believed the earth was like a cell, and they were living on the inside looking at the center of the cell as the atmosphere of the earth. They lived in Estero alongside the river until 1961 when their land was given over to the state of Florida. The Koreshan cult, being believers in immortality and celibacy, had been in decline since 1908 when Cyrus Teed died. All that exists of the Koreshans is the state historic site where people may visit the land and observe the history of the Koreshan people. Canoeing, kayaking, boating, and fishing are still available at the local dock of the Estero River Outfitter store.
The Estero River has an ongoing connection to the history of Florida. During modern times, new developments have been built by the river and it has become more of a landmark than it was in the past. The river is still accessible from about 6.4 miles inland to the outlet at the Estero Bay. Many boaters who live on the river visit the island of Mound Key and do a little exploring as the Calusa did. The river is now used for mainly sport fishing and sightseeing. Although the river was hit hard by hurricanes Wilma and Charley in the past couple of years it has been available to boating.
|Misty Copeland
|Raven Wilkinson
|Debra Austin
|Aesha Ash


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Reagan strike group trains with Japanese and Australian warships in Philippine Sea
July 22, 2020
YOKOSUKA NAVAL BASE, Japan — Fresh from two-carrier exercises in the same vicinity, the aircraft carrier USS Ronald Reagan and its strike group teamed up with naval forces from Japan and Australia for further maneuvers in the Philippine Sea, according to a Navy news release Tuesday.
The Reagan, with its embarked air wing and two accompanying warships, joined with five vessels of the Australian Defense Force and one from the Japan Maritime Self-Defense Force to train "in maritime operations" to strengthen allied relations and support "a free and open Indo-Pacific region," the statement said.
The demonstration of allied sea power occurred as Secretary of State Mike Pompeo, speaking in London at a meeting of British members of Parliament, said Australia should play a leading role in a new coalition to counter Chinese expansion in its regional neighborhood, according to a Wednesday report in the Sydney Morning Herald.
"We're going to need the one billion-plus people in India, we're going to need the Australians," the Morning Herald quoted Pompeo as saying. "It's going to take all of these democracies together.
Pompeo on July 13 put the U.S. on record as rejecting sweeping claims to territory in the South China Sea, as well as its claims to control access to the region. Such claims are "completely unlawful," he said.
The trilateral exercise that began this week is another in a series of naval demonstrations across the Indo-Pacific in the past two months involving U.S. forces alone or alongside its allies.
On Monday, the aircraft USS Nimitz Carrier Strike Group took part in exercises with ships of the Indian Eastern Fleet in the Indian Ocean.
Over the Fourth of July weekend, the Nimitz and Reagan groups rendezvoused in the South China Sea for a series of drills. The pair reunited in mid-July for more training in the same area and were joined Friday by a pair of Air Force B1-B Lancer bombers making overflights from Guam.
On Sunday, the Reagan and Carrier Air Wing 5, the guided-missile cruiser USS Antietam and the guided-missile destroyer USS Mustin joined up with the Japanese destroyer JS Teruzuki and the Australian navy's HMA Canberra, a helicopter landing dock, the frigates HMA Arunta and Stuart, fleet replenisher HMA Sirius and the guided-missile destroyer HMA Hobart.
"The United States is fortunate to routinely operate alongside its allies across the Indo-Pacific and coordinated operations like these reinforce our mutual commitments to international maritime norms and promoting regional stability," the Navy quoted Capt. Russ Caldwell, commander of USS Antietam, as saying.


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Paul Shoji "Yoshi" Yoshimura, 85, of Kaneohe, an electrical estimator at Atlas Electric and Aloha State Sales, died in Kaneohe. He was born in Honolulu. He is survived by wife Jean, son Wesley, daughters Paula and Cheryl, brother Ralph and four grandchildren. Private services. Condolences: hawaiian memorialparkmortuary.com.
Our deepest condolences to the family and friends of the deceased


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text: Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Diseases of the External Ear: Introduction Download Section PDF Listen +++ Anatomy +++ Morphology ++ The pinnae of the external ear are cartilaginous frames that aid in focusing and localizing sound. Each pinna is anchored to the cranium by skin, cartilage, auricular muscles, and extrinsic ligaments. The anatomy of the pinna is illustrated in Figure 47–1. ++Figure 47–1.Graphic Jump LocationView Full Size||Download Slide (.ppt)Anatomy of the pinna. ++ The external auditory canal (EAC) is typically 24 mm in length with a volume of 1–2 mL. The lateral third of the canal is made of fibrocartilage, whereas the medial two thirds are osseous. During early childhood, the canal is straight, but takes on an "S" shape by the age of 9. The EAC has an important relationship with the mastoid segment of the facial nerve, which lies posterior to the EAC as it descends toward the stylomastoid foramen. The temporomandibular joint is anterior to the EAC, and disease processes affecting this joint may lead to otalgia. +++ Skin ++ The EAC is lined by stratified squamous epithelium that is continuous with the skin of the pinna and the epithelial covering of the tympanic membrane. The subcutaneous layer of the cartilaginous portion of the canal contains hair follicles, sebaceous glands, and ceruminous glands, and is up to 1 mm thick. The skin of the osseous canal does not have subcutaneous elements and is only 0.2 mm thick (Figure 47–2). The epithelium of the EAC migrates laterally, allowing the canal to remain unobstructed by debris. The rate of epithelial migration is 0.07 mm/d and is thought to occur at the basal cell layer. ++Figure 47–2.Graphic Jump LocationView Full Size||Download Slide (.ppt)Coronal section of the ear canal. The skin of the cartilaginous and osseous canals are magnified. (Reproduced, with permission, from Lucente F, ed. The External Ear. Copyright Elsevier, 1995.) ++ The ceruminous glands are modified apocrine sweat glands surrounded by myoepithelial cells; they are organized into apopilosebaceous units (Figure 47–3). Cerumen prevents canal maceration, has antibacterial properties, and has a normally acidic pH, all of which contribute to an antibacterial effect of cerumen. ++Figure 47–3.Graphic Jump LocationView Full Size||Download Slide (.ppt)Skin of the cartilaginous portion of the external auditory canal depicting apopilosebaceous units. (Reproduced, with permission, from Main T, Lim D. The human external auditory canal: An ultrastructural study. Laryngoscope. 1976;86:1164. Copyright LWW.) +++ Innervation ++ The pinna is innervated laterally, inferiorly, and posteriorly by the great auricular nerve (cervical plexus). Arnold's nerve (a branch of the vagus nerve) innervates the inferior bony canal, the posterosuperior cartilaginous canal, and corresponding segments of the tympanic membrane and the cymba concha. The posterosuperior bony EAC is innervated by branches of the facial nerve. The auriculotemporal branch of V3 supplies the anterior portion of the pinna. The glossopharyngeal nerve contribution to the external ear is not well delineated. +++ Lymphatic Drainage ++ The anterior and superior wall of the EAC and tragus are drained by preauricular lymph nodes. The infraauricular lymph nodes drain the helix and the inferior wall of the EAC, whereas the concha and antihelix are drained by the mastoid nodes. +++ Vascular Supply ++ The posterior auricular artery and the superficial temporal artery arise from the external carotid artery and supply the auricle and lateral EAC. The deep auricular branch of the maxillary artery supplies more medial aspects of the canal and the external surface of the tympanic membrane. The posterior auricular and superficial temporal veins drain the external ear. +++ Physiology ++ The external ear aids in the efficient transmission of sound to the tympanic membrane by serving as a functional resonator and, in particular, boosts transmission in the speech frequencies. ++ The hairs in the lateral canal, as well as the depth and tortuosity of the EAC, protect the tympanic membrane and structures of the middle ear. +++ Embryology ++ The mammalian ear is divided into external, middle, and inner ear components, which differ in their embryologic origin (Figure 47–4). The external ear consists of the pinna, the EAC, and the tympanic membrane, and is embryologically derived from the first and second branchial arches, and includes both ectodermal and mesodermal components. The mesenchymal tissue of the arches is composed of paraxial mesoderm and neural crest cells. The pinna is formed by gradual change in shape and fusion of components of the six auricular hillocks, which are derived from the first and second branchial arches (Figure 47–5). The formation of the external auditory meatus results from an ingrowth of a solid epithelial plate of ectodermal cells, the meatal plug, which eventually resorbs with only the lining of the canal remaining. The canal is lined by epithelial cells of ectodermal origin. The tympanic membrane begins to develop during the 28th week of gestation and arises from the most medial aspect of the meatal plug, which eventually becomes the external layer of the tympanic membrane. ++Figure 47–4.Graphic Jump LocationView Full Size||Download Slide (.ppt)Development of the ear at 29 days' gestation. (Reproduced, with permission, from Larsen WJ, ed. Human Embryology, 3nd ed. Churchill Livingstone, 2001. Copyright Elsevier.) ++Figure 47–5.Graphic Jump LocationView Full Size||Download Slide (.ppt)Differentiation of the six auricular hillocks. (Reproduced, with permission, from Larsen WJ, ed. Human Embryology, 3nd ed. Churchill Livingstone, 2001. Copyright Elsevier.) + Congenital Anomalies of the External Ear Download Section PDF Listen +++ General Considerations ++ Congenital anomalies of the external ear include a spectrum of malformations of the pinna as well as varying degrees of atresia and stenosis of the EAC. The causes of these disorders may be genetic or secondary to environmental exposures. These disorders include variants of microtia, lop ear, cup ear, Stahl's ear, cryptotia, and prominent ear. Patient evaluation requires a thorough head and neck examination to exclude additional congenital anomalies. The list of associated syndromes is extensive and includes Goldenhar (hemifacial microsomia), branchio-oto-renal, Treacher Collins, and Robinow syndromes. +++ Pathogenesis ++ Multiple genes may have redundant roles in outer ear formation, which can account for phenotypically similar malformations. The sequence of such dysregulation is only beginning to be understood with the help of murine knock-out and knock-in models. The auricular hillocks that give rise to the pinna arise during the sixth week of embryogenesis, whereas the inner two thirds of the EAC are not formed until the 26th week. Untoward events throughout this period could give rise to structural anomalies of the external ear. +++ Microtia +++ Clinical Findings ++ Patients typically present at birth with obvious auricular malformations. Several classification systems are used to further subcategorize this entity, one of which is detailed below. +++ Grade I ++ The ear exhibits mild deformity, typically with a slightly dysmorphic helix and antihelix. This group includes low-set ears, lop ears, cupped ears, and mildly constricted ears. All major structures of the external ear are present to some degree. The lop ear is characterized by inferiorly angled positioning of the auricular cartilage and poor development of the antihelical fold, whereas the cup ear protrudes with a deep conchal bowl. +++ Grade II ++ All pinna structures are present, but tissue deficiency and significant deformity exist. +++ Grade III ++ Also known as, classic microtia or peanut ear, type III microtia has few or no recognizable landmarks of the auricle. The ear lobule is usually present and anteriorly positioned. This subgroup includes anotia, which is complete absence of the external ear. +++ Treatment ++ Classically, microtia has been treated by a multistage auricular reconstruction. Patients undergo observation until the age of five to allow for growth of rib cartilage, which is harvested for reconstruction, and the development of the contralateral ear. This approach offers the benefit of reconstruction with autogenous material, which ultimately requires little or no maintenance. However, it is difficult to achieve a perfect cosmetic result. Typically, reconstruction occurs in four stages. +++ Stage I: Cartilage Implantation ++ Rib graft is typically harvested from the chondrosis of ribs 6, 7, and 8. The goals of this stage include symmetry in the position of the reconstructed cartilaginous ear framework with the normal ear. Postoperatively, the patient must be assessed for pneumothorax, which may arise with rib harvest. +++ Stage II: Lobule Transfer ++ This procedure should be performed 2–3 months after Stage-I reconstruction and aligns the lobule with the reconstructed cartilage framework. +++ Stage III: Postauricular Skin Grafting ++ A postauricular sulcus is created to allow the ear to project away from the mastoid. This step should be performed 3 months after Stage-II reconstruction. Skin for the creation of the sulcus may be harvested from the groin, lower abdomen, buttocks, contralateral postauricular sulcus, or back. +++ Stage IV: Tragal Reconstructtion and Soft Tissue Debulking ++ This should be performed several months after Stage-III reconstruction. +++ Other Treatment Options ++ Another option for reconstruction includes the placement of a prosthesis. This can be either glued on or anchored to bone. If the patient selects a bone-anchored prosthesis rather than auricular reconstruction, he/she must be aware that daily maintenance is required and that the anchor may compromise the vascularity of the surgical site, complicating future reconstructive surgery if the patient becomes dissatisfied with the prosthesis. A prosthesis does offer the advantage of a minor surgical procedure and allows for auricular replacement at an earlier age than surgical reconstruction. Complications of all types of auricular reconstructions include infection, hematoma formation, skin-flap necrosis, scar contracture, and poor contouring. +++ Protruding Ears +++ Clinical Findings ++ An increase in the distance from the helical rim to the mastoid is thought to be due to a lack of the antihelical fold and prominence of the conchal bowl. Ideal distance has been described as 15–20 mm with an ideal angle of 30°. Greater than 45° angulation is considered abnormal. This entity is most frequently bilateral. +++ Treatment ++ Otoplasty is the mainstay of treatment for protruding ears. Often used techniques include recreating the antihelical fold utilizing 2–4 horizontal mattress sutures through the cartilage and anterior perichondrium (Mustarde technique). Stiff cartilage may require additional contouring. Conchal excess may be treated by removal of soft tissue and skin from the postauricular sulcus followed by concha-to-mastoid sutures at the fossa triangularis, cavum concha, and cymba concha. +++ Complications ++ Excessive overcorrection of the middle third of the ear should be avoided to prevent development of the "telephone ear" deformity. Hematoma is the most common complication following otoplasty occurring in approximately 3% of cases. Lack of patient satisfaction, although not a true complication, is not an uncommon occurrence as loss of up to 40% of correction has been reported. +++ Atresia & Stenosis of the External Auditory Canal +++ Clinical Findings ++ Congenital anomalies of the EAC range from mild stenosis to complete atresia. These are often seen in association with malformations of the pinna and the structures of the middle ear. A canal cholesteatoma can develop in the face of severe EAC stenosis, and may also occur with epithelial rests left behind the atresia plate. ++ Audiologic evaluation via behavioral or electrophysiologic measures should be performed to confirm normal hearing in the contralateral ear in unilateral disease, and to assess for ipsilateral sensorineural hearing loss. The typical pattern of hearing loss in affected ears is a conductive hearing loss of 50–70 dB. Axial and coronal computed tomography (CT) scans are essential in the evaluation of patients with canal atresia or stenosis. CT scanning assesses for ossicular, facial nerve, and otic capsule abnormalities as well as for the degree of temporal bone pneumatization. In addition, CT scanning can be used to identify a cholesteatoma that would necessitate earlier surgical intervention. +++ Treatment ++ A discussion on reconstruction for aural atresia can be found in Chapter 48, Congenital Disorders of the Middle Ear. + External Ear Trauma Download Section PDF Listen ++ The external ear is subject to a wide variety of injuries. All trauma patients require appropriate stabilization and triage of associated injuries based on their severity. Adherence to basic surgical principles and wound care prevents complications and improves the likelihood of a successful outcome. +++ Auricular Hematoma +++ Essentials of Diagnosis ++ History of auricular traumaEdematous, fluctuant, and ecchymotic pinna with loss of normal cartilaginous landmarksEarly diagnosis and treatment necessary to minimize cosmetic deformity. +++ General Considerations ++ Auricular hematoma refers to the accumulation of blood in the subperichondrial space, usually secondary to blunt trauma. +++ Pathogenesis ++ Cartilage lacks its own blood supply and instead relies on the vascularity of the perichondrium via diffusion. Shearing forces secondary to blunt trauma to the pinna lead to an accumulation of blood in the subperichondrial space. This creates a barrier for diffusion between the cartilage and the perichondrial vascularity, leading to necrosis of the cartilage and predisposing it to infection and further injury. +++ Clinical Findings ++ A patient with an auricular hematoma usually presents with an edematous, fluctuant, and ecchymotic pinna, with loss of the normal cartilaginous landmarks. Failure to evacuate the hematoma may lead to infection and/or cartilage necrosis and permanent disfigurement known as "cauliflower ear." +++ Treatment ++ The evacuation of hematomas can be performed using a skin incision parallel with the natural auricular skin folds. The irrigation of evacuated hematomas with topical antibiotics reduces the likelihood of infection. Splinting after drainage prevents the reaccumulation of hematomas, and options include cotton bolsters, plaster molds, silicon putty, and water-resistant thermoplastic splints. Through-and-through whip-type absorbable mattress sutures without a bolster have also been described. +++ Auricular Lacerations ++ Sharp or severe blunt trauma may lead to laceration or avulsion of the auricle. The expeditious repair and prevention of infection are essential. Auricular lacerations should be cleansed and débrided prior to repair. Simple lacerations can be closed primarily, whereas extensive injuries with tissue loss may require undermining, flap reconstruction, or tissue grafts. In the case of a near-total ear avulsion still attached to the helical root, the ear can be successfully reattached as the supply of the upper auricular-helical artery seems to be sufficient for the entire ear. Leech therapy may be required to support venous outflow until neovascularization occurs. Repairs should be covered with pressure dressings to prevent edema and hematoma formation, and cartilage-penetrating antibiotics such as quinolones should be prescribed. Excellent cosmetic results can be achieved, even with extensive lacerations. ++Pham TV, Early SV, Park SS. Surgery of the auricle. Facial Plast Surg. 2003;19(1):53. [PubMed: 12739182] (A thorough review of external ear anatomy and embryology, as well as the surgical management of auricular deformities and trauma.) +++ Otitis Externa +++ Essentials of Diagnosis ++ Otalgia, otorrhea, pruritus, hearing loss, history of water exposureIn severe cases in which edema occludes ear canal, wick is critical to maintain EAC and permit antibiotic drops to reach infected tissuesCases in which erythema and tenderness extend outside of EAC require oral antibiotics with antipseudomonal activity. +++ General Considerations ++ Otitis externa is an inflammatory and infectious process of the EAC. Pseudomonas aeruginosa and Staphylococcus aureus are the most commonly isolated organisms. Less commonly isolated organisms include Proteus species, Staphylococcus epidermidis, diphtheroids, and Escherichiacoli. Fungal otitis externa is discussed in the next section. +++ Pathogenesis ++ In the preinflammatory stage, the ear is exposed to predisposing factors, including heat, humidity, maceration, the absence of cerumen, and an alkaline pH. Loss of acidity has been shown to be proportionate to the degree of infection. This can cause edema of the stratum corneum and occlusion of the apopilosebaceous units. In the inflammatory stage, bacterial overgrowth ensues, with progressive edema and intensified pain. Incomplete resolution or persistent inflammation for more than 3 months refers to the chronic inflammatory stage. +++ Clinical Findings ++ Symptoms of otitis externa may vary, depending on the stage and extent of disease. The clinical diagnosis is suggested by the presence of otalgia, otorrhea, aural fullness, pruritus, tenderness to palpation, and varying degrees of occlusion of the EAC. The patient may also present with hearing loss, which results from occlusion of the EAC by edema and debris. Signs of otitis externa include pain on distraction of the pinna, EAC erythema, edema, otorrhea, crusting, and, in more advanced disease, lymphadenopathy of the periauricular and anterior cervical lymph nodes. Skin changes of cellulitis may be present as well. In the chronic stage, the skin of the EAC may be thickened. A culture may be helpful for infections that are refractory to treatment. +++ Treatment ++ Treatment for otitis externa involves meticulous atraumatic debridement of the EAC with the help of a microscope. Analgesia can be achieved with nonsteroidal antiinflammatory drugs (NSAIDs), opioids, or topical steroid preparations. After cleansing is complete, otic drop preparations that are antiseptic, acidifying, or antibiotic (or any combination of these) should be used. These have been shown to be equally effective in the management of uncomplicated otitis externa in a recent Cochrane review. If the degree of stenosis of the canal is severe, a wick must be placed in an effort to stent open the EAC and permit delivery of drops to the medial portion of the canal. ++ Available antiseptic preparations include acetic and boric acids, ichthammol, phenol, aluminum acetate, gentian violet, thymol, thimerosal (eg, Merthiolate), cresylate, and alcohol. Available antibiotic preparations include ofloxacin, ciprofloxacin, colistin, polymyxin B, neomycin, chloramphenicol, gentamicin, and tobramycin. Polymyxin B and neomycin preparations are often used in combination for the treatment of Saureus and P aeruginosa infections. Ofloxacin and ciprofloxacin are single-agent antibiotics with an excellent spectrum of coverage for pathogens encountered in otitis externa. Preparations with steroids help to reduce edema and otalgia. Systemic antibiotics are indicated for infections that spread beyond the EAC. For chronic otitis externa, a canalplasty may be indicated for thickened skin that has caused canal obstruction. Patients must be instructed to avoid EAC manipulation and water exposure if they have a history of recurrent otitis externa (Figure 47–6). ++Figure 47–6.Graphic Jump LocationView Full Size||Download Slide (.ppt)High-resolution coronal CT scan demonstrating soft tissue edema of the left external auditory canal consistent with otitis externa. +++ Otomycosis +++ Essentials of Diagnosis ++ Pruritus, otalgia, otorrhea, fullness, hearing loss, no response to topical antibioticsFungal elements on physical examinationPositive KOH preparation or fungal culture. +++ General Considerations ++ Otomycosis is an inflammatory process of the external ear canal due to infection with fungi and is responsible for more than 9% of the diagnoses of otitis externa. In 80% of cases, the etiologic agent is Aspergillus, whereas Candida is the next most frequently isolated fungus. Other more rare fungal pathogens include Phycomycetes, Rhizopus, Actinomyces, and Penicillium. +++ Pathogenesis ++ Otomycosis has similar predisposing factors to bacterial otitis externa. Patients with diabetes mellitus or an immunocompromised state are particularly susceptible to otomycosis. Patients with a mastoid bowl after a canal wall down procedure are predisposed to development of otomycosis as well. +++ Clinical Findings ++ Patients with otomycosis most frequently present with pruritus, aural fullness, and otorrhea, and may also complain of otalgia and hearing loss. The hearing loss associated with otomycosis usually results from the accumulation of mycotic debris. ++ Otoscopy often reveals mycelia, establishing the diagnosis. The EAC may be erythematous and fungal debris may appear white, gray, or black. Patients have typically been tried on topical antibacterial agents with no significant response. The diagnosis can be confirmed by identifying fungal elements on a KOH preparation or by a positive fungal culture. +++ Treatment ++ The treatment of otomycosis includes cleansing and debriding the EAC, acidifying the canal, and administering antifungal agents. Nonspecific antifungal agents include thimerosal (eg, Merthiolate) and gentian violet. Commonly used specific antifungals include clotrimazole, Nystatin (otic drops or powder), and ketoconazole. Topical ketoconazole, cresylate otic drops, and aluminum acetate otic drops were all relatively effective with >80% resolution rate on initial application. CSF powder (chloramphenicol, sulfamethoximazole, and fungizone) is also an excellent option. +++ Skull Base Osteomyelitis +++ Essentials of Diagnosis ++ Immunosuppressed patients with intense otalgia, otorrhea, hearing loss, fullness, and pruritusEdema and erythema of the EAC, granulation tissue at the bony–cartilaginous junction, cranial neuropathies in advanced stagesElevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP). Culture of EAC. CT and/or technetium scan diagnostic; gallium scan to follow resolution of diseaseBiopsy is necessary to rule out carcinoma. +++ General Considerations ++ Skull base osteomyelitis, also known as malignant otitis externa or necrotizing otitis externa (NOE), is a bacterial infection of the EAC and skull base. This disease process is most frequently seen in elderly diabetics and immunocompromised patients. It most commonly begins as an external otitis that progresses to involve the temporal bone, and may progress to fatal meningitis, sepsis, and death if unrecognized or untreated. +++ Pathogenesis ++ Skull base osteomyelitis commonly begins as an external otitis that progresses to cellulitis, chondritis, osteitis, and, ultimately, osteomyelitis. Unlike otitis media, which spreads through the pneumatized portion of the temporal bone, NOE disseminates through the haversian canals and vascularized spaces of the skull base. As this progresses along the base of the skull, the facial nerve (stylomastoid foramen), hypoglossal nerve (hypoglossal canal), the abducens and trigeminal nerves (petrous apex), the glossopharyngeal, vagus, and spinal accessory nerves (jugular foramen) may be involved. Cranial neuropathy has classically been considered to portend a poor prognosis, although recent data has not supported a difference in mortality. ++ The most frequently isolated causative organism is P aeruginosa, which may exhibit high levels of antibiotic resistance. Aspergillus may also be an etiologic organism and is thought to originate from the middle ear or mastoid. Elderly diabetics are thought to be particularly susceptible because of the microangiopathic changes that blunt an already attenuated immune response. The cerumen of diabetic patients has also been described to be more acidic in nature, further contributing to their susceptibility. +++ Clinical Findings +++ Symptoms and Signs ++ Patients may present with intense otalgia, otorrhea, aural fullness, pruritus, and hearing loss. As the disease advances to involve the temporal bone, granulation tissue is seen on the floor of the EAC at the osteocartilaginous junction. Bony sequestra can also be found in the EAC. Edema, periaural lymphadenopathy, and trismus may be present. Cranial neuropathies occur in more advanced presentations of disease, and the facial nerve is the most frequently affected cranial nerve. Further progression may lead to sigmoid sinus thrombosis, meningitis, sepsis, and death. +++ Diagnostic Tests ++ Inflammatory markers such as ESR and CRP may be elevated. Cultures and sensitivity should be obtained to help in selecting appropriate antibiotics. ++ CT and MRI are useful in the initial evaluation to determine the extent of disease. Bone scans are sensitive for assessing bony involvement but are not specific (Figures 47–7, 47–8, and 47–9). Gallium scans are used to track the resolution of the infection, since bone scans often remain positive long after the infection has resolved (Figure 47–10). ++Figure 47–7.Graphic Jump LocationView Full Size||Download Slide (.ppt)Axial high-resolution CT scan demonstrating skull base osteomyelitis with evidence of petroclival bone erosion. ++Figure 47–8.Graphic Jump LocationView Full Size||Download Slide (.ppt)Axial T1-weighted MRI depicting the replacement of bone marrow in the clivus with inflammatory tissue. ++Figure 47–9.Graphic Jump LocationView Full Size||Download Slide (.ppt)Axial T1-weighted MRI, with gadolinium enhancement, with evidence of petroclival bone erosion and enhancement of inflammatory tissue secondary to skull base osteomyelitis. ++Figure 47–10.Graphic Jump LocationView Full Size||Download Slide (.ppt)Sagittal image of a bone scan in a patient with skull base osteomyelitis revealing focal enhancement of the skull base. +++ Differential Diagnosis ++ Carcinomas of the EAC, chronic granulomatous disease, Paget disease, fibrous dysplasia, and nasopharyngeal carcinomas must be considered in the differential diagnosis. As carinoma of the EAC mimics many features of NOE, a biopsy is requisite to rule out carcinoma. +++ Treatment ++ Long-term parenteral antibiotics are the treatment of choice. Aminoglycosides (eg, tobramycin) and antipseudomonal β-lactam antibiotics, including piperacillin, ticarcillin, or ceftazidime, may be used. Some physicians recommend the use of outpatient fluoroquinolones such as ciprofloxacin or ofloxacin; however, this is appropriate only for patients with early presentations who can be followed up closely. Control of hyperglycemia and immunosuppression is necessary to maximize treatment. Surgical debridement may be necessary to remove necrotic tissue. Circumferential petrosectomy has been described as a method for surgical debridement with hearing and facial nerve function preservation. The use of hyperbaric oxygen has been described in cases refractory to antibiotics, with variable results. In an effort to prevent skull base osteomyelitis, all diabetic and immunocompromised patients must be followed up closely and treated aggressively if they present with symptoms suggestive of external otitis. ++Rubin Grandis J, Branstetter BF IV, Yu VL. The changing face of malignant (necrotizing) external otitis: Clinical, radiological, and anatomic correlations. Lancet Infect Dis. 2004;4(1):34. [PubMed: 14720566] (An overview of the diagnosis and management of skull base osteomyelitis.) + Dermatologic Diseases of the External Ear Download Section PDF Listen +++ Essentials of Diagnosis ++ Atopic dermatitis—pruritic erythematous patches or weeping plaquesPsoriasis—oval salmon-pink plaques with silvery scales on elbows, knees, scalp, and buttocksContact dermatitis—pruritic, indurated, and erythematous lesions after exposure to allergen or irritant. +++ Atopic Dermatitis +++ General Considerations ++ Atopic dermatitis is a chronic skin disease of immune-mediated origin. It may remit spontaneously or endure as a chronic condition. Lesions presenting on the ear may be pruritic and erythematous. Patients often have a personal or family history of atopy and allergy. ++ Atopic dermatitis often manifests in infancy on extensor surfaces and the face. Children may present with skin lesions on flexural areas and on the hands. +++ Pathogenesis ++ Though not completely understood, the clinical presentation of atopic dermatitis is thought to be secondary to immune dysfunction. Atopic skin lesions have been shown to have higher levels of Th2 T-lymphocytes, which produce inflammatory mediators such as interleukin 4, 5, and 10. +++ Clinical Findings ++ The diagnosis of atopic dermatitis is a clinical one. There is variability in skin lesions ranging from erythematous patches to weeping plaques. Lesions presenting on the ear are often pruritic and erythematous. Lesions typically persist for more than 1 month. Secondary infections with S aureus, herpes simplex virus, vaccinia, and molluscum contagiosum may occur. ++ Atopic dermatitis is characterized by the absence of specific laboratory and histologic markers. Elevated IgE and eosinophilia may be present yet are not specific for the diagnosis. +++ Differential Diagnosis ++ The differential diagnosis includes seborrheic dermatitis and psoriatic dermatitis. +++ Treatment ++ Topical corticosteroids are the mainstay of treatment. Antihistamines and lubricants may be used for the treatment of accompanying pruritus. Moisturizers and mild soaps are preferred to minimize exposure to potential allergens found in many cosmetic products. Food elimination and desensitization are not recommended. Though often self-limited, the disease may recur spontaneously and can become chronic. Bacterial superinfection may require topical and systemic antibiotics. +++ Psoriasis +++ General Considerations ++ Psoriasis is a chronic inflammatory disorder of the skin. Eighteen percent of patients with psoriasis have some involvement of the external ear, which may be secondary to extension from the scalp. Plaques may present on the concha and meatus of the EAC and are variably pruritic. ++ The incidence of psoriasis in the United States ranges from 2% to 5%. Males and females are equally affected, with the onset of disease typically occurring in adolescence. +++ Pathogenesis ++ The cause of psoriasis is unknown, yet there is a strong genetic component. Attacks of psoriasis may be triggered by certain drugs such as NSAIDs, beta-blockers, lithium carbonate, and antimalarial agents, as well as by infection, trauma, and stress. +++ Clinical Findings ++ Psoriasis is characterized by erythematous papules that coalesce to form round or oval salmon-pink plaques with silvery white scales found on the elbows, knees, scalp, and buttocks. These lesions bleed in pinpoint areas when scratched (Auspitz sign). Opacification or "oil spots" of the nails, as well as pitting and subungual hyperkeratosis, are also suggestive of this disease. Psoriatic lesions may present over areas of trauma, an entity known as Koebner phenomenon. Psoriatic arthritis occurs in 5–10% of all psoriatic patients. +++ Treatment ++ Patients should avoid excessive drying of the skin. For ears and face, treatment includes low-dose topical nonfluorinated corticosteroids such as alclometasone, mometasone, desonide, clocortolone, hydrocortisone valerate, and butyrate creams and topical calcipotriene. Warm-water soaks, 1–5% coal tar treatment, and topical anthralin C may also be helpful. Oral psoralens and UVA phototherapy for patients with widespread disease may be necessary. Antihistamines are used to treat the associated pruritus. Methotrexate may be required for severe cases and for psoriatic arthritis. The response to treatment is variable, and the condition may become chronic. +++ Contact Dermatitis +++ General Considerations ++ Contact dermatitis can be an acute or chronic inflammatory disorder of the skin caused by contact with an allergen or irritant. This process may occur anywhere along the pinna or the EAC. Eruption may occur secondary to instrumentation, foreign objects—including jewelry, earplugs, and hearing aids—and other objects used to scratch pruritic lesions. In addition, cosmetics and hair products are frequent culprits. +++ Pathogenesis ++ Allergic contact dermatitis is a Type IV hypersensitivity reaction, and cutaneous manifestations are often delayed by 1–3 days. This is in contrast to irritant-mediated contact dermatitis, which usually manifests earlier. +++ Clinical Findings ++ Allergic contact dermatitis is characterized by an indurated, erythematous, pruritic, and poorly demarcated process. This is in contrast to irritant dermatitis, which often presents with well-defined areas of exposure. ++ Skin testing to identify contact allergens may be of use. +++ Treatment ++ The avoidance of exposure to irritants and allergens and high-dose topical glucocorticoids are the mainstays of therapy. +++ First Branchial Cleft Anomalies +++ Essentials of Diagnosis ++ Cyst or tract along anterior border of sternocleidomastoid muscle usually near angle of mandibleRecurrent neck or ear drainage and infectionCT scan may be helpful to identify tractWork classification system describes anomaly and relationship to facial nerve. +++ Pathogenesis ++ First branchial cleft anomalies occur as a result of anomalous fusion of the first and second branchial arches, with incomplete obliteration of the first branchial cleft. +++ Clinical Findings ++ Patients may present with a cyst or tract along the anterior border of the sternocleidomastoid muscle near the angle of the mandible. A membranous band between the medial aspect of the floor of the ear canal and the tympanic membrane at the manubrium of the malleus is also highly associated with first branchial cleft anomalies. The patient may have a history of recurrent infection and drainage from the ear or neck. ++ The Work classification system has been used to describe first branchial cleft cysts. A Work type 1 anomaly duplicates the membranous EAC only. It is lined with squamous epithelium and opens to the external skin. It is located superficial to the facial nerve. A Work type 2 anomaly duplicates both the membranous and cartilaginous EAC. It has a variable relationship with the facial nerve. +++ Treatment ++ The treatment for first branchial cleft anomalies is complete excision. Incomplete excision predisposes the patient to recurrence and reinfection. The tract may be intimately involved with the facial nerve, which is at risk during excision. This necessitates early identification of the facial nerve as it exits the stylomastoid foramen and tracing distally through the lesion. A superficial parotidectomy type approach may be required for complete excision. +++ Auricular Frostbite +++ Essentials of Diagnosis ++ Cold exposureAuricle initially numb, then subsequently painfulAuricle initially pale, cyanotic, and hypesthetic, then subsequently erythematous with bullae. +++ Pathogenesis ++ Freezing temperatures lead to both direct cellular injury as well as vascular compromise. Prolonged exposure to cold temperatures can lead to vasoconstriction, cold-mediated dehydration, endothelial injury, thrombosis, and ischemia of auricular tissue. In the early stage, this process may be reversible, but over time, it leads to tissue necrosis. +++ Clinical Findings ++ Temperatures below 10°C may lead to hypesthesia, and the person is frequently unaware of impending frostbite. The ear is initially pale and then cyanotic. Ultimately, as the ear thaws, pain, erythema, and subcutaneous bullae secondary to extravasated extracellular fluid or blood may develop. +++ Treatment ++ The initial treatment for auricular frostbite consists of rapid rewarming of the ear to 40–42°C. Nonhemorrhagic blisters may be débrided, and patients should be given pain medicine and antibiotics. Aloe vera has antithromboxane properties and, together with ibuprofen, may help in re-establishing circulation. More aggressive débridement should be delayed for several weeks until demarcation is complete. ++Petrone P, Kuncir EJ, Asensio JA. Surgical management and strategies in the treatment of hypothermia and cold injury. Emerg Med Clin North Am. 2003;21(4):1165. [PubMed: 14708823] (An overview of the current recommendations for the management of frostbite, including frostbite of the external ear.) +++ Auricular Burns +++ Essentials of Diagnosis ++ Superficial burn—erythema and painPartial-thickness burn—painful blistersFull-thickness and subdermal burns—painless, gray/black eschar. +++ General Considerations ++ Thermal injury can be classified by the degree of the burn. Superficial burns involve the superficial layer of the epidermis. Partial-thickness burns extend into, but not through, the dermis. Full-thickness burns extend through the full thickness of the dermis. Subdermal burns extend into the subcutaneous tissue, including fat, muscle, tendon, cartilage, and bone. +++ Clinical Findings ++ Superficial auricular burns present with erythema secondary to dermal capillary dilation and vessel congestion. These burns are red and moderately painful. Patients with partial-thickness burns usually present with blisters that blanch on direct pressure and are very painful. Deep partial-thickness burns are associated with less pain, and there may be an eschar. Full-thickness and subdermal burns are painless because dermal nerve endings have been destroyed. The wound surface is of varying color, but may be gray or black and charred. +++ Treatment ++ Superficial burns do not scar and may be treated with moisturizing creams. The blisters of partial-thickness burns should be débrided, and antibiotic ointment applied. When not deep, these burns heal without scarring as well. Full-thickness, subdermal, and deep partial-thickness burns of the auricle heal with scarring and contracture and may be complicated by suppurative chondritis. These burns should be treated with both topical (usually silver based) and systemic cartilage penetrating antibiotics. Early débridement and closure with skin grafts should be considered. Secondary reconstruction is usually performed at approximately 1 year after injury. ++DeSanti L. Pathophysiology and current management of burn injury. Adv Skin Wound Care. 2005;18(6):323. [PubMed: 16096398] (An overview of the current recommendations for the management of burns, including those of the external ear.) +++ Foreign Bodies of the External Ear +++ General Considerations ++ Foreign bodies within the external ear may present in both children and adults. Common objects include erasers, pills, batteries, and insects. +++ Clinical Findings ++ Patients may present with pain, pruritus, conductive hearing loss, and bleeding. A persistent foreign body may lead to infection and the formation of granulation tissue. Batteries lodged within the EAC, when in contact with moisture, may cause liquefaction necrosis, low-voltage injury, or pressure necrosis of the EAC skin or tympanic membrane. +++ Treatment ++ The removal of foreign objects should be done in an atraumatic manner. Injury to the EAC is minimized with direct visualization using the operating microscope and proper instrumentation (eg, right angle pick, curet, forceps, and suction) as well as minimizing patient movement. In children, general anesthesia is often required. Irrigation may help dislodge cerumen or smaller objects. Cerumen impaction may require prior softening with an otic preparation. Two percent lidocaine may be used for the removal of insects both to achieve topical anesthesia and also to kill the insect. Complete occlusion of the EAC with cyanoacrylate adhesives (ie, "superglue") may require surgical removal with a postauricular approach + Neoplasms of the External Ear and Ear Canal Download Section PDF Listen +++ Essentials of Diagnosis ++ The majority of external ear carcinomas can be reconstructed primarilyThe AJCC system may be used to classify external ear carcinoma, while the Pittsburgh staging system should be used for carcinoma of the ear canalLateral temporal bone resection is indicated for T2 or greater ear canal carcinomaParotidectomy and neck dissection should be reserved for advanced lesions and/or palpable diseaseSurvival with ear canal carcinoma is highly correlated with T stage at presentation. +++ Basal Cell Carcinoma of the Auricle +++ General Considerations ++ Basal cell carcinomas are the most common malignant neoplasm of the auricle, representing 45% of auricular carcinomas. +++ Pathogenesis ++ Chronic long-term sun exposure is the predominant cause of basal cell carcinoma. Specifically, UVB radiation has been identified as a major carcinogen. The incidence of cancer increases with age. Other risk factors include fair skin, outdoor occupations, and a history of skin carcinoma. +++ Clinical Findings ++ Patients may initially present with a skin lesion that is nodular, ulcerated, and/or bleeding. Basal cell carcinomas of the auricle typically occur on the posterior surface of the pinna and in the preauricular area. The diagnosis of any suspicious lesion should be confirmed with biopsy. CT scans and MRI may be used to evaluate advanced disease with tumor extension to the adjacent temporal bone and soft tissue structures of the head and neck. The overall rate of metastasis is 0.003–0.1%. +++ Staging ++ Basal cell carcinomas of the EAC can be staged using the American Joint Committee on Cancer (AJCC) general staging system for nonmelanoma cancer of the skin. This staging system is limited by the fact that it does not account for histologic subtypes or the anatomic variability of the skin of the external ear compared with other skin sites. +++ Differential Diagnosis ++ Given the variability of subtypes, the differential diagnosis includes benign nevi, amelanotic melanomas, cutaneous squamous cell carcinomas, eczema, and scleroderma. +++ Treatment +++ Nonsurgical Measures +++ Topical 5-Fluorouracil. +++ Radiation Therapy ++ Indicated for poor surgical candidates or unresectable lesions. +++ Surgical Measures +++ Curettage with Electrodissection ++ Operator dependent and typically used to excise nodular lesions and desiccate the base. +++ Cryosurgery ++ Indicated for small basal cell carcinomas (<1 cm) with well-defined borders. +++ Local Excision ++ Ninety-five percent of basal cell carcinomas <2 cm in size can be successfully treated with local excision with a surgical margin of at least 4 mm. Auricular reconstruction may be required for large defects. +++ Mohs Surgical Technique ++ Refers to complete micrographic excision of the tumor using intraoperative histopathology to assess for positive margins. This technique is particularly useful for recurrent basal cell carcinomas, those larger than 2 cm, or those with an aggressive histology. Five-year cure rates using Mohs technique should approach 97.1%. +++ Cutaneous Squamous Cell Carcinoma +++ General Considerations ++ Squamous cell carcinomas account for 20% of all cutaneous malignant neoplasms and commonly occur in elderly males. +++ Pathogenesis ++ Risk factors for squamous cell carcinoma include immunosuppression, advanced age, a nonhealing ulcer, and exposure to chemicals such as arsenic, soot, coal, tar, paraffin, and petroleum oil. The most important risk factor is exposure to UV radiation. +++ Clinical Findings ++ The appearance of these tumors is variable and includes plaques, nodules, and ulcerations. They may be friable and prone to bleeding. Auricular lesions frequently occur on the helix or preauricular region, but may occur on any sun-exposed areas. ++ CT scanning and MRI may be used to evaluate advanced disease with tumor metastasis to the adjacent temporal bone and soft tissue structures of the head and neck. The proper diagnosis should be made with biopsy. The overall risk of metastasis for cutaneous squamous cell carcinoma of the external ear is approximately 6–18%. +++ Staging ++ The AJCC system may be utilized for carcinoma of the external ear. AJCC staging systems for nonmelanoma cancer of the ear canal may also be utilized, but the University of Pittsburgh system (Figure 47–11) is more frequently used for staging squamous cell carcinoma of the temporal bone, as the AJCC does not account for the unique nature of tumors arising in the ear canal. ++Figure 47–11.Graphic Jump LocationView Full Size||Download Slide (.ppt)University of Pittsburgh Staging System for Squamous Cell Carcinoma. +++ Differential Diagnosis ++ The differential diagnosis includes basal cell carcinoma, actinic keratosis, seborrheic keratosis, keratoacanthomas, scars, psoriatic lesions, melanomas, and sarcomas. +++ Treatment +++ Nonsurgical Measures ++ Radiation therapy may be indicated for unresectable lesions or those that may lead to significant cosmetic disfigurement with surgery. +++ Surgical Measures +++ Local Excision ++ Ninety-five percent of squamous cell carcinomas <2 cm limited to external ear can be successfully treated with local excision with a surgical margin of at least 6 mm. Auricular reconstruction may be required for large defects. T1 lesions of the EAC may be treated with sleeve excision with careful attention to deep margins. T2 lesions or greater necessitate lateral temporal bone resection. Subtotal temporal bone resection involves the piecemeal removal of structures medial to the tympanic membrane and may be necessary for T3 and T4 lesions. Facial nerve involvement may necessitate its resection and grafting with a nerve graft remote to the site of the tumor (ie, sural nerve). +++ Mohs Surgical Technique ++ This technique is particularly useful for recurrent lesions, those >2 cm, or those with an aggressive histology. +++ Neck Dissection and Parotidectomy ++ In all cases of palpable disease in the parotid and neck, and in the case of T3 and T4 squamous cell carcinomas, parotidectomy, neck dissection, and adjuvant radiation should be strongly considered. +++ Prognosis ++ In addition to the patient's age and overall immune status, the prognosis for squamous cell carcinoma is dependent on the histologic subtype, size, and location of the tumor. A better prognosis is associated with a well-differentiated histology. The 5-year cure rate for squamous cell carcinomas of the external ear range from 75% to 92%. ++ Squamous cell carcinoma of the EAC carries a much more dire prognosis with recent studies suggesting a range of 5-year survival of T1 tumors of 83% and T4 tumors of 25%. Facial nerve involvement and nodal disease are poor prognostic findings. +++ Melanoma of the External Ear +++ General Considerations ++ The incidence of melanoma in the United States is 11.1 cases per 100,000 individuals. Auricular melanoma accounts for 1% of all melanomas. Melanomas of the ear have a 10-year survival rate of 70%. +++ Clinical Findings ++ Most melanomas involving the ear present on the helix. Though initially painless, these lesions may change in size, ulcerate, and bleed. A thorough head and neck examination requires attention to enlarged lymph nodes that may occur with regional spread of disease. ++ The diagnosis of melanoma is dependent on the histologic evaluation of a biopsy. At a minimum, metastatic evaluation should include a chest x-ray to rule out lung metastases and liver function tests to rule out liver metastases. CT scanning and MRI have added sensitivity in detecting metastatic disease. Radio-nuclide bone scans can be used to diagnose bony metastases. +++ Staging ++ Melanomas may be staged using the staging system of the AJCC. This system incorporates the depth of invasion, measured in millimeters. Deeper lesions and lesions with ulceration are associated with higher stages and higher mortality rates. +++ Differential Diagnosis ++ The differential diagnosis is diverse and includes benign lesions as well as basal cell and squamous cell carcinomas. +++ Treatment +++ Nonsurgical Measures ++ Adjunctive radiation therapy may have a role in palliation. +++ Surgical Measures ++ The extent of excision, including surgical margins, is dependent on the histologic type and stage of disease. Management of the regional lymphatics is controversial and may include elective regional lymph node dissection and parotidectomy. Recently, sentinel lymph node biopsy has become a well-accepted approach in the management of the N0 neck for lesions more than 1 mm deep. +++ Prevention ++ The avoidance of and protection from sun exposure are important in preventing disease, as is early detection. Early detection is also extremely important in improving prognosis. +++ Glandular Tumors of the External Auditory Canal +++ Essentials of Diagnosis ++ Otorrhea, fullness, otalgia, and conductive hearing loss.Sensorineural hearing loss indicates inner ear extension.CT and MRI to define tumor and surrounding anatomy.Biopsy essential. +++ Classification ++ Glandular tumors of the EAC are rare and include four types: (1) adenoid cystic carcinomas, (2) ceruminous adenomas, (3) ceruminous adenocarcinomas, and (4) pleomorphic adenomas. +++ Adenoid Cystic Carcinoma ++ These are capsular tumors most often found in salivary gland tissue. They have a predilection for perineural, perivascular, and fatty infiltration. Patients with perineural invasion often present with otalgia. Histologically, these tumors may show cribriform, tubular, or solid patterns of cellular arrangement. Lymph node metastases are rare, but late distant metastasis in particular to the lung are not an uncommon feature of these tumors. +++ Ceruminous Adenoma ++ Ceruminous adenoma consists of benign painless masses that may grow undetected for prolonged periods of time. Patients may present with a conductive hearing loss or otitis externa. They are histologically characterized by double-layered cuboidal or columnar cells, and the epithelium may show apical "snouts" of apocrine secretion. +++ Ceruminous Adenocarcinoma ++ These tumors share histologic features with ceruminous adenomas, but they have higher rates of mitoses and cellular atypia. Invasion into adjacent structures may be present, and lymph node metastases are rare. +++ Pleomorphic Adenoma ++ These tumors vary histologically but are characterized by epithelial and mesenchymal elements. These benign tumors do not display features of invasion. +++ Clinical Findings ++ Patients with glandular tumors of the EAC may present with otorrhea, aural fullness, otalgia, and conductive hearing loss. Sensorineural hearing loss signifies tumor extension into the inner ear. CT imaging is helpful in determining the amount of bony erosion and the size of the tumor. Generous tissue samples are important for histologic diagnosis. +++ Treatment ++ Benign glandular tumors are treated with wide local excision. Malignant tumors are treated with a variant of temporal bone resection, and consideration should also be given to adjuvant radiation. In the case of adenoid cystic carcinoma, parotidectomy should be considered as it has been associated with increased survival. ++Devaney KO, Boschman CR, Willard SC, Ferlito A, Rinaldo A. Tumours of the external ear and temporal bone. Lancet Oncol. 2005;6(6):411. [PubMed: 15925819] (Overview of the diagnosis and management of malignancies that affect the external and middle ear.) +++ Osteomas & Exostoses of the External Auditory Canal +++ Essentials of Diagnosis ++ Usually asymptomatic; may present with cerumen impaction, otitis externa, or conductive hearing lossOsteoma—pedunculated bony EAC lesionExostoses—multiple EAC lesions. +++ General Considerations ++ Osteomas are benign osseous neoplasms. Exostoses are firm, bony, broad-based lesions composed of a lamellar bone (Figure 47–12). Exostoses are formed by reactive bone formation and have been associated with cold-water exposure. Both osteomas and exostoses arise from the bony portion of the EAC (Figure 47–13). ++Figure 47–12.Graphic Jump LocationView Full Size||Download Slide (.ppt)High-resolution axial CT scan revealing right anterior and posterior external auditory canal exostoses. ++Figure 47–13.Graphic Jump LocationView Full Size||Download Slide (.ppt)Coronal view of superior and inferior exostoses of the external auditory canal. (Reprinted with permission of Jackler RK.) +++ Clinical Findings ++ Osteomas are usually pedunculated and often have a vascular core (Figure 47–14). Exostoses commonly present as multiple lesions. Although most osteomas and exostoses are asymptomatic, occlusion of the EAC with an enlarged lesion may lead to cerumen impaction, external otitis, and a conductive hearing loss on audiogram. ++Figure 47–14.Graphic Jump LocationView Full Size||Download Slide (.ppt)High-resolution coronal CT scan demonstrating an inferiorly based osteoma of the right external auditory canal. +++ Treatment ++ Most exostoses and osteomas require no intervention. If surgery is necessary, a transcanal or postauricular approach can be used, depending on the size of the lesions. The preservation of skin flaps speeds healing. ++ When used for long, earplugs have been shown to be protective against exostoses in patients with frequent cold water exposure. ++ We would like to acknowledge Eli Grunstein, MD, and Felipe Santos, MD, for their contribution to this chapter in the previous editions of CDT.