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OTIC PRODUCTS (1) Anatomy & Physiology • Keywords: auricle (pinna), external auditory canal, cartilage, thin skin, highly vascularised, lobule, fatty tissue, tragus; • absence of subcutaneous layer makes auricular skin subject to frostbite despite rich supply of superficial blood vessels; • External auditory canal (24 mm in adults): transmission & protection • Skin in the farther portions of the canal, contains hair follicles, exocrine glands & apocrine glands Tympanic membrane • Normally: smooth, transluscent, pearl-gray • Concave and oval with thickness of 0.074 mm • The contineous skin layer of the EAC forms the outer tympanic membrane layer • The middle layer is fibrous tissue • Internal layer is mucous membrane continous with the lining of the middle ear • Function: 1. transmits sound waves 2. protection to middle ear Protection of the ear: 1. Hair: trap foreign material in a waxy network 2. Cerumen (ear wax)= milky fatty fluid (apocrine glands) + oily secretions (of sebaceous. exocrine glands) ceruminous glands (1) lubricates skin (2) traps foreign bodies (3) Contains antimicrobials such as lysozymes - semisolid: expelled to the outside by jaw movement during talking & chewing 3. Skin of normal healthy ext auditory canal: waxy water-resistant with pH 5-7.2 that prevents pathologic bacterial and fungal growth Ear Disorders • Disorders of the ear are very common and usually cause discomfort • Patients often complain of earache, impacted ear, running ear, cold in the ear or itching in the ear or combination of the symptoms What causes ear disorder/discomfort? Causes of Ear Disorders 1. Disease of the auricle (the most external portion of the ear) 2. Disease of the external auditory canal 3. Disease of the middle ear 4. Disease of the other area of the head & neck (tongue, mandibles, oropharynx, tonsils or paranasal sinuses) referred pain to the ear. In this case, self-treatment is not suitable refer to doctor Causes of ear conditions • • 1. 2. Hairs, size of ear canal, its isthmus & cerumen provide barrier protection against foreign bodies Acidic pH & integrity of skin layer are defense mechanisms against infection Any predisposing factor that breaks down these mechanisms (e.g. warm & humid climate, water, sweating) cause tissue maceration breaks down protective barrier and changes pH expose skin to infection Trauma: e.g. improper cleaning of the ear or improper fitting of ear plugs or hearing aids, involuntary scratching or rubbing of the ear may cause fissures in the epidermis of ear canal which creates culture area for bacteria & fungi Disorders of the External Ear Otitis Externa • One of the most common diseases of the ear • A v painful & annoying inflammation of the skin lining ext auditory canal, often due to infection • The ext auditory canal is a blind cul-de-sac lined with skin: dark and very well suited to collect moisture • Prolonged exposure to moisture will disrupt the integrity of epithelial cells & raise pH above 5-7 range more prone to bacterial & fungal infections Otitis Externa • Causative organisms: pseudomonas, staphylococcus, protues & bacillus. Fungi can be causative in some cases (otomycosis) • Complications: inflammation may lead to inflammation & destruction of the tympanic membrane may progress & perforate the membrane spread infection to middle ear intense pain and discomfort • Inflammation that causes edema provokes severe pain that is disproportionate to any visible swelling • Pain increases during chewing 1. Otitis Externa Types of Otitis Externa: 1. 2. 3. 4. 5. Swimmer’s ear Acute otitis externa Chronic ~ Allergic ~ Malignant ~ Swimmer’s Ear • Bacterial infection caused by tissue maceration: 1. Accumulation of water in the tympanic recess may contribute to tissue maceration 2. Also, the cerumen accumulated in the ext auditory canal absorbs water & expands and the trapped water provides a medium for bacterial growth Swimmer’s Ear Normal Abnormal What are the symptoms of swimmer’s ear? Swimmer’s Ear Symptoms: • • • • Pain around the ear Itching Plugged ear Movement of the ear is painful (especially the tragus) • Discharge of yellowish-greenish thick liquid from the affected ear • Redness and tenderness around the ear and the surrounding tissue • Wisdom teeth may be painful Swimmer’s Ear • With the spread of infection to the surrounding bone, brain and the middle ear, a severe infection called Malignant Otitis Externa (MOE) can occur and contain the following: – Fever if the infection is severe – Neurological symptoms (i.e., confusion, headaches, balance problems, weakness or paralysis on one side) that spread to the inside of the brain and skull. Allergic Otitis Externa Allergic Otitis Externa = dermatitis of the external auditory canal • Caused by: nickel in earrings, poison ivy, chemicals used to process the rubber or plastic in the hearing aid molds or earphones or type of soap • Symptoms: itching, burning or stinging of the lesions • Often complaints >>> than visible signs (maculopapular rash, formation of vesicles, erythema) 2. Impacted Cerumen • Accumulation of the ear wax in the external auditory canal Causes: 1. Overactive ceruminous glands 2. Small abnormal narrowing of the canal 3. Secretion of abnormal cerumen (drier, as in elderly) 4. Hearing aids or ear plugs prevent migration of cerumen 3. Foreign Object in the Ear • Children often insert: small items, candy, pencil erasers, peas, beads etc • Symptoms: may be absent (accidentally) or may cause hearing deficiency, pain during chewing, exudates may form because of secondary bacterial infection • Dried peas or beans may swell during bathing or swimming and become wedged in the bony portion of the canal causing severe pain The "Gripper" Foreign Object Extractor 4. Otomycosis • It is an external fungal infection of the ear • It is more common in: warmer, tropical or semitropical climates • Most common causative agents: Asperigillus & Candida • Predisposing factors: antibiotics ( normal flora), immunosuppression (disease or drug) & DM • Primary complaint of patients with otomycosis is intense itching 4. Otomycosis • Color may vary. Skin lining & canal maybe beefy red and scaly, a musty smelling discharge. Skin maybe eroded or ulcerated with fungal filaments • Asperigellus niger: forms black growth in the canal • If the infection is superficial: patient will experience pruritis, feeling of fullness & pressure in the ear • Fungus leads to the accumulation of debris, exudates and cerumen. In acute cases, fungal infection/growth may block the canal and hearing may be impaired Disorders of the Middle Ear • Should not be treated with OTC otic products • Should be promptly evaluated and treated by a doctor • The usual treatment is systemic antibiotic therapy - Otitis Media - Chronic Otitis Media - Tympanic Membrane Perforation Otitis Media • Inflammation of the middle ear that occurs most commonly during childhood • Caused by any condition that interferes with the Eustachian tube function, e.g. URT infection, allergy, adenoid lymphadenopathy, cleft palate • Symptoms of Eustachian tube blockage: mild, intermittent pain, mild hearing loss & fullness in the ear. Otitis Media Recurrent Otitis Media: • In children: recurrent episodes of Eustachian tube blockage usually are caused by masses of adenoids that become edematous & block the Eustachian tube opening resulting in otitis media. Adenoidectomy usually prevents future occurrence • In adults: recurrent otitis media may be caused by nasopharyngeal tumors Otitis Media • Avoid: nose blowing & sneezing against occluded nostrils worsen condition Serous otitis media: • of viral origin • Symptoms: sensation of fullness in ear, hearing loss, voice resonance, a hollow sound or popping or cracking noise in the ear during swallowing or yawning • These symptoms are not present in otitis externa Otitis Media • • • • Purulent (Suppurative) otitis media: infection by bacteria purulent discharge Symptoms: pain, hearing loss and fever (>40°C) The acute pain is sharp, knifelike & steady (caused by high fluid production in a short period of time), the pressure of fluids in middle ear causes outward tension on the tympanic membrane causes pain. • Steady: pain usually doesn’t worsen with mastication, or with traction applied to auricle or tragus • Nose blowing may force additional purulent mucus into Eustachian tube worsen condition Chronic Otitis Media • It occurs most often in young children • Causes: inadequate treatment of previous otitis media or recurrent URT infections • It is also called “glue ear” as long-standing fluid may become more and more viscous. • The most common symptom is sudden onset of impaired hearing (without acute symptoms) • Diagnosis: visual inspection of tympanic membrane which appear to be yellow or orange & less flexible- not perforated but retracted Assessment of otitis media 1. The only conclusive means of diagnosing otitis media is via complete patient history & physical examination using a pneumatic otoscope 2. Most commonly in children 3. Patients may be asymptomatic or feel fullness, cracking or hollow sounds in the ear 4. Effect is usually bilateral 5. A bloody purulent foul-smelling discharge flows from infected ear only if tympanic membrane is perforated, after which patient experiences sudden relief from pain How to differentiate between otitis media & otitis externa? Acute Otitis Externa Acute otitis media Season Summer Winter Movement of tragus painful Ear canal Yes No Swollen Normal Eardrum Normal (or red) Perforated or bulging Discharge Yes Nodes Frequent Yes (but through a perforation) Less frequent Fever Yes Yes Hearing Normal or decreased Always decreased Tympanic Membrane Perforation 1. The most common cause: water sports e.g. diving, water skiing etc 2. Any corrosive agent introduced into the ear 3. Sudden explosion 4. Other causes: - Blows to head with cupped hand - foreign objects entering ear canal - forceful irrigation of ear canal Management of tympanic perforation • If the perforation is very small, otolaryngologists may choose to observe the perforation over time to see if it will close spontaneously. • They also might try to patch a cooperative patient's eardrum in the office. • Surgery (tympanoplasty): there are a variety of surgical techniques, but all basically place tissue across the perforation allowing healing. • Surgery is typically quite successful in closing the perforation permanently, and improving hearing. It is usually done on an outpatient basis. Tympanic Membrane Perforation Symptoms: • Pain: severe at moment of injury, decreases gradually with time • Hearing acuity diminishes quickly and if not treated, it may lead to otitis media • Other: Nausea, tinnitus, vertigo • Refer to doctor immediately if you suspect a perforated tympanic membrane Finally! • Patients with fever, malaise, lymphadenopathy associated with any ear condition should be thoroughly evaluated by a doctor