Blocked or painful earsWax and otitis media

Mike SmithENT Consultant

Hereford County Hospitaland

Worcester Royal Hospital

UK

2009

Ear canal:2-3cm long

Cartilage Bone

Outer 1/3 Inner 2/3

Skin Thick Thin

Glands 1. Cerumen2. Sebum

None

Hair 1. Fine2. Thick

(older men)

None

What is wax?

CerumenIn hair follicles.Thin sweat like secretion. Long coiled tubes with muscle walls.

SebumIn hair follicles.Secrete Oily fluid.

Epithelial debris

HairsShed, and mat with secretions.

Dust, sand, f.b.’s etc

Functions of wax

Waterproofing layer Protective layer from

trauma Cleansing by migration

outward with dust, foreign material (e.g. sand, grommets)

Acid pH is antiseptic Contains antibacterial

agents

Canal Skin Migration

Squamous epitheliumand keratin / dead skinMoves from drum centre along canal to meet the secretions in outer canal

Keratosis ObturansFailure of migration. Epithelial build up and canal expansion. Rare.

Health education

Harmful :ScratchingCotton buds(‘Nothing smaller than elbow’)

False :‘Wax is dirty and must be removed’‘Wax often causes reduced hearing’

Ear ‘candling’ and other gadgets

Problems with wax?

Hearing lossNon-obstructive wax (no loss)

Apparent total obstruction (hearing loss 5dB)

Totally obstructed canal (conductive hearing loss 45dB)

Otitis ExternaDamp, itchy

Hearing aid

Treatment options

Solvent drops Manual Syringe Electric pulsed irrigation Aural speculum and loops/hooks Microscopic suction

Wax Solvent Drops

Effectiveness ?Exterol ++++Cerumol +++Oil ++Waxsol ++Bicarbonate +

Cost Irritation

Ear Syringing

Method Solvent beforehandStraighten canal

(Pull up and back)Water at 37-38 deg. CBrace nozzle with hand on headPoint syringe up and back

After syringing check canal/drum (Dr?)

Indications for syringing

Total occlusion Examination of obscured tympanic membrane Otitis Externa ( if other cleansing not available) Foreign body

Contra-indications to syringing

Normal 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 syringing

Complications 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 1995

Tested on 10-48 hr post mortem cadavers Large variations in pressure needed to

rupture, but well above that generated by syringing (if TM not atrophic)

Treatment of complications

Otitis externaprompt treatmentrefer if canal occluded by debris or oedema

Perforationspecialist referral(it usually heals)

Canal wall bleedingbicarbonate dropsfollow up to ensure clot clears

Acute sensori-neural hearing loss or vertigoUrgent referral

Refer early if in any doubt.

Do not blindly reassure the patient, check

Acute Otitis Media

Acute otitis media<3yrs-70% at least one episode

VarietiesAOM with dischargeAOM with complicationsResistant AOMRecurrent AOMAOM on ME EffusionChronic MEE/Glue ear

TreatmentAnalgesiaAntibiotics?Prophylaxis?GrommetsAdenoidectomyPrevention: parental smoking, pre-schoolRhinitisImmunity

Grommet With Discharge

Grommets/T-tubesCommonest operation~20% discharge

AcuteOrganisms same as AOM

ChronicOften Pseud. Or Staph.Biofilms?

TreatmentOral antibiotic?Drops?Water prevention?Tube removal?AdenoidsAllergyImmunityIV antibioticsSurgery

Ear drops and ototoxicity

OtotoxicityOtotoxicity 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-UKAlternatives (ciprofloxacin unlicensed as ear drop

in UK so far, but widely used)

Complications of AOM

Perforation and otorrhoea

Hearing loss Glue ear Mastoiditis Facial palsy Meningitis

Chronic Suppurative Otitis Media (CSOM)

CSOM

MucosalSafe?Active/InactiveDischarge character

TreatmentNoneMedicalSurgical

SquamousPockets/atelectasisCholesteatomaDischarge character

TreatmentStable pocketUnstable pocketEstablished cholesteatoma

Thankyou