Blocked or Painful Ears. Wax and Otitis Media
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Transcript 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