Download Blocked or Painful Ears. Wax and Otitis Media

Blocked or painful ears
Wax and otitis media
Mike Smith
ENT Consultant
Hereford County Hospital
and
Worcester Royal Hospital
UK
2009
Ear canal:
2-3cm long
Cartilage
Outer 1/3
Skin
Thick
Glands 1. Cerumen
2. Sebum
Hair
1. Fine
2. Thick
(older men)
Bone
Inner 2/3
Thin
None
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 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 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 education
 Harmful :
Scratching
Cotton 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 loss
Non-obstructive wax (no
loss)
Apparent total obstruction
(hearing loss 5dB)
Totally obstructed canal
(conductive hearing loss
45dB)
 Otitis Externa
Damp, 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 beforehand
Straighten canal
(Pull up and back)
Water at 37-38 deg. C
Brace nozzle with hand on head
Point 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 syringing
Study 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 externa
 Acute sensori-neural
prompt treatment
hearing loss or vertigo
refer if canal occluded by
Urgent referral
debris or oedema
 Refer early if in any doubt.
 Perforation
Do not blindly reassure the
specialist referral
patient, check
(it usually heals)
 Canal wall bleeding
bicarbonate drops
follow up to ensure clot clears
Acute Otitis Media
 Acute otitis media
 Treatment
<3yrs-70% at least one
Analgesia
episode
Antibiotics?
Prophylaxis?
Grommets
 Varieties
Adenoidectomy
AOM with discharge
Prevention: parental
AOM with
smoking, pre-school
complications
Rhinitis
Resistant AOM
Immunity
Recurrent AOM
AOM on ME Effusion
Chronic MEE/Glue ear
Grommet With
Discharge
 Treatment
Oral antibiotic?
Drops?
 Grommets/T-tubes
Water prevention?
Commonest operation
Tube removal?
~20% discharge
Adenoids
 Acute
Allergy
Organisms same as
Immunity
AOM
IV antibiotics
 Chronic
Surgery
Often Pseud. Or Staph.
Biofilms?
Ear drops and ototoxicity
 Ototoxicity
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 AOM
 Perforation and
otorrhoea
 Hearing loss
 Glue ear
 Mastoiditis
 Facial palsy
 Meningitis
 Chronic Suppurative
Otitis Media (CSOM)
CSOM
 Mucosal
Safe?
Active/Inactive
Discharge character
 Treatment
None
Medical
Surgical
Squamous
Pockets/atelectasis
Cholesteatoma
Discharge character
Treatment
Stable pocket
Unstable pocket
Established
cholesteatoma
Thankyou