Ear Conditions

• Ear Conditions


  • Presentation: Earache and wax, causing either discomfort or reduced hearing
  • Inflammation/pain of outer ear
• Causes


  • Excess/impacted cerumen (ear wax)
  • Otitis externa
  • Eustachian tube catarrh trauma
• Ear Symptoms and Ear Structures

  • Symptom
  • External Ear
  • Middle Ear
  • Inner Ear
  • Itch
  • Pain
  • Discharge
  • Deafness
  • Dizziness
  • Tinnitus
• Ear Wax (Cerumen)


  Protects the tympanic membrane by trapping foreign particles and traps dirt; it also repels water and contributes to a slightly acidic medium, which has been reported to exert protection against bacterial and fungal infections
• Types of Cerumen


  • Wet or sticky type (common in children and those of white and African American ethnicity)
  • Dry (common in Asian populations)
• Cerumen Formation


  1. Secretions of sebaceous and apocrine glands

  2. 50% exfoliating cells from stratum corneum and foreign particles

  3. Expelled due to migration of epithelial cells to ear canal entrance

  4. Facilitated by normal mouth movement, e.g. chewing, talking etc.
• Exact prevalence of impacted earwax not clear but 3 to 6% of the population suffer from it
• Patients more prone to earwax build up/excess

  • Patients with congenital anomalies (narrow ear canal)
  • Patients with learning difficulties
  • Those fitted with a hearing aid
  • Older patients (decrease in cerulean-producing glands, resulting in drier and harder earwax)
• Auditory canal


  The bodyʼs only 'dead endʼ and abrasion of the stratum corneum canʼt occur
• Ear wax migration


  1. Skin moves outwards away from the ear drum and out along the ear canal

  2. Ears are largely self-cleaning because the ear canal naturally sheds wax from the ear

  3. This function can be interrupted due to erroneous attempt to clean ear
• Causes of excess ear wax

  • Physical structure of external auditory canal
  • Excess production of cerumen
  • Abnormal secretion (softer or drier)
  • Impaction
• Symptoms of excess ear wax

  • Gradual hearing loss/difficulty hearing
  • Ear discomfort (to variable degrees)
  • Ear is blocked
  • Itching, tinnitus and dizziness occur infrequently
• Otoscopic examination should reveal excessive wax
• Recent attempts to clean ears
• Questions to Ask


  • Course of symptoms
  • Associated symptoms
  • History of trauma
  • Use of medicines
• When To Refer


  • Pain (middle ear issue)
  • Mucinous discharge (middle ear infection)
  • Fever and general malaise in children — middle ear infection?
  • Trauma-related deafness/redness/swelling — requires further investigation by a doc
  • Failure of OTC treatment
  • Dizziness/tinnitus (inner ear problem that requires further investigation)
  • Foreign body
  • Caution: children and elderly
• Cerumenolytics


  • Check for allergies before recommending
  • Donʼt interact with any medicines
  • Can be used in children
  • Have very few side effects, which if experienced, would appear to be limited to local irritation when first administered. They might, for a short while, increase deafness and patient should be warned about this
  • Can be given to all patient groups
  • Donʼt interact with any medicines
• Analgesics


  Shouldnʼt be needed; pain requires referral
• Oil based products, e.g. almond, olive oil drops, peanut oil


  It softens as cerumen is hydrophobic and therefore is soluble in oil. Simplest and cheapest method of treatment, which normally is as effective as more expensive preparations and less irritant
• Allergy risk


  • Peanut oil (no longer in Cerumol) and arachis, peanut and camphor Earex
• For olive oil drops

  Two to three drops should be instilled twice a day for up to 7 days for adults and children; a cotton wool plug should be gently placed in the ear to retain the liquid
• For cerumol ear drops

  The standard dose for adults and children is five drops into the affected ear twice a day, repeated for up to 3 days. In between administration, a plug of cotton wool, moistened with Cerumol or smeared with petroleum jelly, should then be applied to retain the liquid
• Water-based cerumenolytics


  Increase water penetration and therefore softens e.g. docusate sodium
• Water-based cerumenolytics


  Instilled two to three times a day for up to 3 days
• Peroxide-based products


  H₂O₂ or NaHCO₃ effervesce in contact with trapped water within wax, liberating O₂ and causing a popping sensation, which is mechanical removal. Urea and glycerol Otex, Exterol), which increases hydration of cerumen
• Otex


  For adults and children, up to five drops should be instilled once or twice daily for at least 3 to 4 days. Unlike other products, the patient should be advised not to plug the ear but retain the drops in the ear for several minutes by keeping the head tilted and then wipe away any surplus. Patients might experience mild temporary effervescence in the ear as the urea – hydrogen peroxide complex liberates oxygen
• Donʼt try to remove ear wax yourself with cotton buds, fingernails etc.
• If wax reoccurs frequently, could try using olive/almond drops regularly (anything from once daily to once a fortnight)
• Otitis Externa


  Itʼs the generalised inflammation of external ear, which is caused by bacterial infection. Initial irritation leads to scratching which leads to pain/trauma. Itʼs present in seborrhoeic dermatitis and psoriasis. Itʼs also known as 'swimmerʼs earʼ. Repeated contact with water flushes out wax. The excess water is a moist environment for bacteria. Itʼs more common in hot and humid climates.
• Lifetime prevalence of otitis externa is 10%
• Otitis externa is most common in those aged

  • 7 to 12 years
• Otitis externa is more common in humid and hot climates and in the west, the number of episodes increases in the summer months
• People who swim are 5 times more likely than non-swimmers to develop otitis externa
• Otitis externa is slightly more common in women
• Causes of otitis externa


  • Primary infection
  • Contact sensitivity
  • Combination of both
• Changes to microflora


  Result from excessive moisture leading to skin maceration and skin cerumen breakdown that changes the microflora of the ear canal
• Pathogens implicated with acute otitis externa

  • Pseudomonas aeruginosa
  • Staphylococcus spp.
  • Streptococcus pyogenes
• Fungal overgrowth with Aspergillus spp. is also seen, especially after prolonged antibiotic treatment
• Factors that can precipitate otitis externa

  • Local causes: Trauma or discharge from the middle ear
  • General causes: Seborrhoeic dermatitis, psoriasis and skin infections
• Symptoms of otitis externa

  • Itching and irritation, which, depending on the severity, can become intense
  • Scratching, which may result in trauma and pain
  • Otorrhoea (ear discharge), if present, isnʼt mucopurulent (discharge containing both mucus and pus)
  • Skin on EAM can become oedematous, leading to conductive hearing loss
  • Shouldnʼt present with any systemic symptoms