Download Para Otic Part1

OTIC PRODUCTS (1)
Before recommending any OTC product
to a person with an ear disorder, the
pharmacist should recognize the
symptoms of various disorders & their
corresponding pathophysiology for
accurate evaluation & treatment of the
case
OTC products use for the ear
• Home remedies and OTC products are usually
restricted to the self-limiting disorders that are
related ONLY to the external ear
• In such cases, OTC products may be used
effectively to aid the normal body defenses
and to improve the integrity of the skin that
lines the auricle and the external auditory
canal.
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
Student note :
*auricle is very thin layer of skin & no subcutaneous fat to dissipate
infection or inflammation & no fat to protect from shock.
*lobule it’s a fat tissue (external )
*any condition related to otalgia its very painful especially in chlidern as
strike on ear could be converted to hematoma & cartilage deformity in severe
conditin !
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
student note:
*The canal that’s reach to tympanic membrane 1\2 or 1\3 called
“cartiligenous “ part & remained 2\3 or 1\2 its called “Eustachian” part
presented inside the bone .
* The end of canal should be closed or lined Unless perforation its occur!
Protection of the ear:
1. Hair: trap foreign material in a waxy network (outer
half of the canal).
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 waterresistant with pH 5-7.2 that prevents pathologic
bacterial and fungal growth
Student note :
•
Hair :during aging the hair will be grow & become longer than adult
ear hair that’s whay some problem could appear especially with wax if
its hard , Nevertheless hair is protective mechanism.
• cerumen:
Sebum or ear wax its composed of [ milky fatty fluid &oily secretion
togather] and its presented normally on surface of ear skin .
*If use cotton buds only on surface of skin Never inside the ear .. Why ?
Because the infection of ear canal could occur :S
•
PH : must be acidic ph &moisture content isn`t too high because
cerumen has ability to absorb a little water content but not excessive
mosit !
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
st. Note :
Runninng ear increase infection !
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, selftreatment is not suitable refer to doctor
St. note:
*Disease of the external auditory canal due to inflammation or old infection
*Disease of middle ear = otitis media
•1st & 2nd point mention above (self treat ,by pharmacist counseling )
•3rd & 4th point mention above Need referal .
Causes of ear conditions
•
•
1.
2.
Hairs, size of ear canal, its 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
St. note :
Point 1 mention above , ex of Most commen infection (otitis externa) why its
happen ? Due to swimming , high humidity & frequent showring then high
maceration !!
Really problem when skin macerated open ear & for long prolong period of time
Then maceration of canal is too & loss of barier properities & infection occur !
Notes:
• The skin that covers the auricle is especially susceptible to
bleeding because: (1) lack of flexibility afforded by
subcutaneous layer of fat (2) large blood supply to the area
• The skin is highly innervated disproportionate otalgia when
inflammation is present
• Children suffer from more middle ear conditions that do adults
(why?)
St. note:
•Disproportionate otalgia its very painful & the pain greater than fact of infection !
•Childern suffer from more middle ear condition that do adult ??
Chlidern suffer from recurrent otitis media because when infant drink the milk
could back to the ear ! And when compare the canal in childern & adult we find
that
Child
Adult
short & straight canal
not straight & very long canal
Eustachian tube is very short
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
St. note:
The symptom to distinguish otitis externa from otitis media ,
Any movement of ear lead to svere painful :s
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 `
due to cerumen accumilation.
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.
St. note:
*recuernt otitis externa Need referal !
*Fver Must not related to swimmer ear Unless infection is Svere ..
Acute Otitis Externa
• Symptoms related to severity of pathologic conditions
• Symptoms: mild to moderate pain, that is more
prominent upon pulling upward the auricle or
pressing the tragus
Chronic Otitis Externa
• Caused by persistence of predisposing factors
• In people whose ears are exposed to persistent
excessive moisture
• Most common symptoms: itching which prompt
scratching break skin
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)
St. note :
In case of Allergy >>> systemic antihistamine
used
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
st. note :
•Otitis externa & recuernt otitis media is common in childern
•Impact cerumen occur in both child and adult but in childern more common
than adult , its liquid not thick due to hyperactivity of cerumen gland but not
made impact too .
•Small abnormal norrowing of canal specifically external part of ear its not
enough to expel cerumen outward so trapped inside !
2. Impacted Cerumen
Symptoms:
• the most common is sense of fullness or
pressure in the ear and
• gradual hearing loss
• Dull pain is sometimes associated with this
disorder
St. note :
Gradual hearing loss is very important sign for impact
cerumen so take care off !
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
Q: What should you do if
an insect enters in the
auditory canal?
A: Olive oil drops will suffocate the insect!
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
St. note :
*Otomycosis is very painful condition :S
*Asperigillus really its very bad prob. in which you find block dots on surface
due to itching ..
* Otomycosis its obvious than otitis externa to observed
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
Assessment of otitis externa
• The only means by which bacterial or fungal otitis
external can be confirmed is by microbiologic
culture which is not always practical or necessary
• Bacterial infections may be characterized by:
- increased pain with chewing or touching the
tragus or auricle;
- other characteristics: lymphadenopathy, feeling
of fullness, malaise
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
St. note :
*Tympanic membrane perforation
In case of perforation never give the patient OTC medication >> Need
referral .
*In minor perforation hearing still present 
But in severe perforation \rapture cause hearing loss  then returned
noramal with tratment .
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 inNose blowing
may force additional purulent mucus into Eustachian tube worsen
condition
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
St. note :
*fever is most important symptom .
*otoscope to differentiate between bacterial &viral infection .
* In infant the continual crying one of the most important sign of otitis media
because its only method for expression in the infant .
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
but
otitis media usually associated with fever & painful ! st.
note
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
Yes (but through a
perforation)
Fever
Yes
Yes
Hearing
Normal or decreased Always decreased
Tympanic Membrane
Perforation
1.
2.
3.
4.
The most common cause: water sports e.g. diving, water skiing etc
Any corrosive agent introduced into the ear
Sudden explosion
Other causes:
- Blows to head with cupped hand
- foreign objects entering ear canal
- forceful irrigation of ear canal
st. note :
*foreign objective its one of the most common cause ex
cotton buds.
*The otitis media patient suffer from allergy &ear congestion
especially when riding plane or go to very laying area! fot this
purpose give the patient 1- dose of antihistamine
2-decongestant
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