blocked or painful ears wax and otitis media mike smith ent consultant hereford county hospital and...

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  • Blocked or painful earsWax and otitis mediaMike Smith ENT Consultant Hereford County Hospital and Worcester Royal HospitalUK2009

  • Ear canal:2-3cm long

    CartilageBoneOuter 1/3Inner 2/3SkinThickThinGlands1. Cerumen 2. SebumNoneHair1. Fine 2. Thick (older men)None

  • What is wax? Cerumen In hair follicles. Thin sweat like secretion. Long coiled tubes with muscle walls.Sebum In hair follicles. Secrete Oily fluid.

    Epithelial debris Hairs Shed, and mat with secretions.Dust, sand, f.b.s etc

  • Functions of waxWaterproofing layerProtective layer from traumaCleansing by migration outward with dust, foreign material (e.g. sand, grommets)Acid pH is antisepticContains antibacterial agents

  • Canal Skin MigrationSquamous epithelium and keratin / dead skin Moves from drum centre along canal to meet the secretions in outer canal Keratosis Obturans Failure of migration. Epithelial build up and canal expansion. Rare.

  • Health educationHarmful : Scratching Cotton buds (Nothing smaller than elbow)False : Wax is dirty and must be removed Wax often causes reduced hearingEar candling and other gadgets

  • Problems with wax?Hearing loss Non-obstructive wax (no loss) Apparent total obstruction (hearing loss 5dB) Totally obstructed canal (conductive hearing loss 45dB) Otitis Externa Damp, itchyHearing aid

  • Treatment optionsSolvent dropsManual SyringeElectric pulsed irrigationAural speculum and loops/hooksMicroscopic suction

  • Wax Solvent DropsEffectiveness ? Exterol++++ Cerumol+++ Oil++ Waxsol++ Bicarbonate+

    CostIrritation

  • Ear SyringingMethod Solvent beforehand Straighten canal (Pull up and back) Water at 37-38 deg. C Brace nozzle with hand on head Point syringe up and backAfter syringing check canal/drum (Dr?)

  • Indications for syringingTotal occlusionExamination of obscured tympanic membraneOtitis Externa ( if other cleansing not available)Foreign body

  • Contra-indications to syringingNormal wax (be more selective of patients)Past ear disease or surgery (thin drum) Perforation (may force debris into middle ear, dislocate ossicle, damage oval/round window, or infect middle ear)

    Only hearing ear (no risks)Recurrent Otitis Externa (keep dry)Anti-coagulant (care to avoid trauma)Vegetable f.b.s (swell)

  • Perfs and pockets

  • Risks of syringingComplications requiring specialist referral in 1:1000 e.g. pain, dizziness, bleeding, infection, perforation, tinnitus, hearing loss

  • Rupture of ear drum by syringingStudy by Sorenson et al 1995Tested on 10-48 hr post mortem cadaversLarge variations in pressure needed to rupture, but well above that generated by syringing (if TM not atrophic)

  • Treatment of complicationsOtitis externa prompt treatment refer if canal occluded by debris or oedemaPerforation specialist referral (it usually heals)Canal wall bleeding bicarbonate drops follow up to ensure clot clearsAcute sensori-neural hearing loss or vertigo Urgent referralRefer early if in any doubt. Do not blindly reassure the patient, check

  • Acute Otitis MediaAcute otitis media
  • Grommet With DischargeGrommets/T-tubes Commonest operation ~20% dischargeAcute Organisms same as AOMChronic Often Pseud. Or Staph. Biofilms?

    Treatment Oral antibiotic? Drops? Water prevention? Tube removal? Adenoids Allergy Immunity IV antibiotics Surgery

  • Ear drops and ototoxicityOtotoxicity Ototoxicity of the infection itself. Inflammation acts as barrier to RW membrane. Vestibulo-toxicity also an issue. Familial trait / genetic susceptibility. Use endorsed for infected perfs by Am. Acad. of ORL, H & N and ENT-UK Alternatives (ciprofloxacin unlicensed as ear drop in UK so far, but widely used)

  • Complications of AOMPerforation and otorrhoeaHearing lossGlue earMastoiditisFacial palsyMeningitis

    Chronic Suppurative Otitis Media (CSOM)

  • CSOMMucosal Safe? Active/Inactive Discharge characterTreatment None Medical Surgical

    Squamous Pockets/atelectasis Cholesteatoma Discharge character

    Treatment Stable pocket Unstable pocket Established cholesteatoma

  • Thankyou

    **External Auditory Canal (EAC). Opening = External Auditory Meatus (EAM)Gentle S shape. Roof and posterior wall shorter than floor and anterior wall due to shape of canal and obliquity of tympanic membrane. Ceruminous glands are modified sweat glands (apocrine).Both cerumen and sebum glands open into hair follicles. Both male and female have very fine hairs in cartilaginous parts of ear canals.Thin skin of bony canal very delicate, can bleed if touched.

    *Skin of TM surface and bony canal does not flake like other skin, it migrates as a sheet slowly from drum centre, out and along canal. Takes several months. It is slowed at junction with cartilagenous canal and secretions there and may form a slightly wrinkled surface.. It the breaks up flaking and mixing with loose hairs, sebum and cerumen to form wax. There are racial differences. Asiatics such as Japanese have less secretion due to lack of apocrine sweat glands and so wax is powdery and flaking. Negroes have same or more secretion than white Europeans. Individuals also vary greatly in amount of wax produced.Sometimes dry material on drum surface will form a single large flake like a cast. This may stiffen the drum or mimic it. It may migrate out as a single flake in the canal.Canal injury with bleeding will leave a hard black clot. This is very slow to clear. If manipulated it may be painful and cause further bleeding.*******In children just pull pinna back, not up.Do not insertnozzle too far, it should not hurt.Desist if patient objects.Do not syringe if the notes or the patient describe advice against it.Grease piston of metal syringe well to give smooth action.Ensure syringe nozzle is firmly attached.It is sensible to sterilise the syringe after use.Tap water is adequate. A few drops of vinegar can be added as antiseptic agent if wished.If wax soft no need for solvent. If no opportunity for prior solvent can use Exterol or 3% hydrogen peroxide stat a little before attempting.Temperature must be correct to prevent a caloric effect I.e setting up a convection current in inner ear fluids due to temperature difference. This current will make perilymph in semicircular canal move and induce dizziness / vertigo and even nausea. This is especially likely if there is a mastoid cavity due to surgery or chronic ear disease.Stimulation of sensory branch of Vagus nerve in ear canal by syringing may cause freflek coughing, or occasionally bradycardia. Cardiac arrest has been reported!A survey showed many GPs do not examine the ear after syringing despite high incidence of problems or failure.*A survey in an A & E department found 60% of patients with ear f.bs were children. More than the patients underwent electric ear syringing. The f.b. was removed this way in 93% of adults and 88% of childrenDried vegetable type f.bs may swell if syringed and then be more difficult to remove.*Otitis externa is a skin condition like eczema of the ear canal skin. It mainly affects the outer canal skin. It is exacerbated by moistness, humidity, trauma. Many such patients chronically scratch and unnecessarily try to clean ear canals. Once infected, the canal must be cleaned and be treated with topical agents, usually antibacterial or antifungal drops with steroid additional content. Syringing once may aid this initial cleansing before starting medication.Very narrow ear canal may be occluded by the syringe nozzle allowing high pressure to build up. Particularly narrow canals may occur in congenital problems e.g. Downs syndrome.Bony lumps in the deep ear canal called exostoses can trap wax which is stubborn to remove. The skin over these bony lumps is thin and prone to damage, leading to otitis externa. Exostoses are commoner in keen swimmers.After ear surgery, if the drum is strong and well healed and this has been checked recently by a specialists there is no contra-indication to syringing.A past history of radiotherapy close to the ear is a C/I.A history of episodic severe vertigo may be a C/I.Tinnitus Occasionally develops or exacerbates after syringing. The reasons are unclear in the absence of obvious trauma. Perhaps incipient tinnitus was brought on early.****Medico-legal problems rarely arise, given the frequency of the procedure.If there is a problem deal with it promptly.Do not syringe when there are clear contra-indications******