Blocked or painful ears Wax and otitis media
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Blocked or painful earsWax and otitis media
Mike SmithENT Consultant
Hereford County Hospitaland
Worcester Royal Hospital
UK
2009
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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
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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
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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
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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.
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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
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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
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Treatment options
Solvent drops Manual Syringe Electric pulsed irrigation Aural speculum and loops/hooks Microscopic suction
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Wax Solvent Drops
Effectiveness ?Exterol ++++Cerumol +++Oil ++Waxsol ++Bicarbonate +
Cost Irritation
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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?)
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Indications for syringing
Total occlusion Examination of obscured tympanic membrane Otitis Externa ( if other cleansing not available) Foreign body
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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)
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Perfs and pockets
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Risks of syringing
Complications requiring specialist referral in 1:1000
e.g. pain, dizziness, bleeding, infection, perforation, tinnitus, hearing loss
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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)
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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
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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
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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
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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)
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Complications of AOM
Perforation and otorrhoea
Hearing loss Glue ear Mastoiditis Facial palsy Meningitis
Chronic Suppurative Otitis Media (CSOM)
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CSOM
MucosalSafe?Active/InactiveDischarge character
TreatmentNoneMedicalSurgical
SquamousPockets/atelectasisCholesteatomaDischarge character
TreatmentStable pocketUnstable pocketEstablished cholesteatoma
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Thankyou