Ear Disorders Flashcards
What are the 3 parts of the ear?
Outer (external) ear
Middle ear
Inner ear
Describe the outer ear
Auricle (pinna) - directs sound waves into the ear
External auditory canal (EAC)
Describe the middle ear
Made up of the eardrum and 3 small bones called the ossicles (malleus aka the hammer, incus aka the anvil, and the stapes aka stirrup)
Vibrations of the eardrum are picked up by these bones and sent to the inner ear
The eustachian tube is a hollow tube which connects the middle ear with the nasopharynx
The eustachian tube functions as a pressure equalizing valve for the middle ear which is normally filled with air
Describe the inner ear
Houses the sensory and equilibrium system
Consists of the cochlea, vestibule and semicircular canals
Describe the ear of children younger than 3 years old
The EAC is shorter, straighter and flatter than in adults (instillation of eardrop with ear pulled downward and back)
The shape and direction of the eustachian tube is more horizontal than vertical (drainage is more difficult)
Easier entry of nasopharyngeal aspiration into the middle ear, leading to proliferation of bacteria
Helps explain why children suffer from more middle ear infections
Describe the ear of children over 3 years old and adults
The EAC is longer and forms an S shape (instillation of eardrop upward and back)
The eustachian tube lengthens downward as it enters the nasal cavity (design promotes drainage and inhibits aspiration of nasopharyngeal content into the middle ear)
Describe the external auditory canal
Only skin-lined cul-de-sac in the human body
Warm, dark and prone to becoming moist (excellent environment for bacterial/fungal growth)
Skin is very thin (lateral 1/3 overlies cartilage and the rest has a bone base; easily traumatized)
Exit of debris, secretions and foreign bodies is impeded by a curve at the junction of cartilage and bone
Presence of hair (especially thicker hair (older men) which further impedes the debris)
EAC has some special defenses
Failure of the defences or damage of epithelium of the ACH causes otitis externa
What are the defences of the EAC?
Cerumen
Epithelial migration
S shape of canal
Hair located in the canal
What are some outer ear disorders?
Otitis externa (OE)
Cerumen (ear wax) impaction
Water-clogged ears
What is otitis externa?
Inflammation or infection of the external auditory canal (EAC)
Acute diffuse OE is generally referred to as “swimmer’s ear”
Most often unilateral
Symptoms range from pruritus to severe pain and discharge
Pain is often worse with motion of the ear
What is cerumen impaction?
Develops when earwax accumulates in the inner part of the ear canal and blocks the eardrum
Often caused by misguided attempts to remove earwax
What is water-clogged ears?
Excessive moisture in the external auditory canal
What are some middle ear disorders?
Acute otitis media (AOM)
Secretor otitis media
Chronic suppurative otitis media
Otic barotrauma or aerotitis media
Describe acute otitis media
Inflammation or infection of the middle ear
Most often purely viral and self-limiting
Symptoms include acute ear pain, fever and reduced hearing
Ear pain is often unilateral, developing over a few hours
Tugging or pulling on the ears is often described
How is acute otitis media treated?
Topical agents are not used in AOM
Systemic antibiotics may be required
Acetaminophen or ibuprofen analgesia
Local heat application may be beneficial but should be used cautiously in young children
Describe secretor otitis media
Otitis media with effusion
Middle ear space becomes full with sticky effusion which is unable to escape
Describe chronic suppurative otitis media
Involves a perforation (hole) in the eardrum and active bacterial infection within the middle ear space
Describe otic barotrauma or aerotitis media
Also referred to as airplane ear
Pain resulting form increased air pressure
Due to a respiratory infection or mechanical pressure factors such as scuba diving or flying
What are some inner ear dirsorders?
Vertigo (and dizziness)
Ménière’s disease
Tinnitus
What is vertigo?
Vertigo is a feeling that you or your surroundings are moving when there is on actual movement
It is specific type of dizziness and is a major symptom of a balance disorder
Usually accompanied by nausea and vomiting
Often self-limiting
Can be accompanied to tinnitus, decreased hearing and ear pain
What are common causes of vertigo?
Common causes include viral infections, inner ear disturbances (Ménière’s disease), ototoxic drugs, trauma to the ear or head, vascular disorders
What is dizziness?
Dizziness refers to a variety of sensations including motion sickness, lightheadedness, fainting, spinning
Includes a number of causes unrelated to ear conditions
Can be drug-induced
What is Ménière’s disease?
Believed to be result from fluctuating pressure of the fluid within the inner ear
Increased pressure in the labyrinth (organ of balance)
Cause is not yet understood
Referral is necessary/often drug-induced
What are symptoms of Ménière’s disease?
Vertigo, nausea and vomiting, feeling of fullness/pressure in the ear, fluctuating hearing loss, tinnitus
What is tinnitus?
Continuous or intermittent alien noise in the ear
Can be perceived in one or both ears or in the head
Noise is described as buzzing, ringing, whistling, hissing, ticking or “whooshing”
Most people with tinnitus have hearing loss
Tinnitus often indicates an underlying abnormality rather than being a disease itself
Tinnitus over 24 hours requires a referral
What are the possible causes of tinnitus?
Loud noises for prolonged periods
Impacted cerumen
Airplane ear (pressure/barotrauma)
Chronic otitis media (middle ear infection)
Drug-induced causes (alcohol/NSAIDs)
Stimulants, caffeine, and nicotine may often worsen existing problem
What are ototoxic drugs?
Many ototoxic drugs can lead to both tinnitus and vertigo problems
Generally categorized as: high risk agents and low risk agents
What are some high risk ototoxic agents?
Aminoglycosides
Antineoplastics
IV diuretics
What are some low risk ototoxic agents?
NSAIDs
Antibiotics
What are otic conditions that must be referred?
Otitis externa (swimmer's ear) Otitis media Hearing loss (sudden) Ear pain (otalgia) Objects in the ear Ear drainage (otorrhea) Tinnitus, vertigo, dizziness over 24 hours Perforated eardrum
Cerumen impaction and water-clogged ear are both self-treatable outer ear conditions. Why?
Involves the EAC
These disorders are self-limiting and amendable to self-treatment.
Inflammation, infection, pain, discharges are not associated with above conditions (red flag otic conditions)
Maximum 4 days for self treatment. If problem persists or condition i treated inappropriately, then refer (more serious problems can arise)
What are some red flags?
Earache/pain (moderate to sever in adults and any kind in children)
Under 12 years of age
Discharge/drainage or bleeding
Signs of infection
Fever
Sudden hearing loss
Foreign body in the ear
Tinnitus or dizziness over 24 hours
Recent ear surgery (within 6 weeks) or possible tympanic membrane rupture
Tympanostomy tubes present
Recent or recurrent otitis media or externa
What is cerumen?
Mixture of secretion from ceremonies and sebaceous glands, combined with exfoliated squamous epithelium
Initially is colourless and somewhat fluid
Contact with air causes it to darken and become hard
Quantity and consistency varies with age (the elderly have drier wax)
What are the functions of the cerumen?
Cerumen is a protective component of the outer ear
Functions to lubricate and entrap foreign materials
Water repellant, preventing maceration of the EAC
Acid pH (5-7.2) which is bactericidal
How is wax removed?
It is removed naturally with chewing and talking
What are risk factors for cerumen impaction?
Abnormally narrow or misshaped EAC
Excessive hair growth in the canal
Overactive ceruminous glands
Physiological anormaly that disrupts the normal migration of the cerumen
Use of hearing aids, ear plugs and sound attenuators
Atrophy of ceruminous glands (elderly)
Previous impaction is also a risk factor
What are symptoms of cerumen impaction?
Feeling of pressure or fullness
Pruritis
Gradual hearing loss
General discomfort
What are the goals of treatment of cerumen impaction?
Soften and remove cerumen using a safe and effective method to relieve symptoms
Prevent future impaction
What complications could arise from cerumen impaction?
Attempts to remove cerumen by means of foreign objects can force the cerumen further into the EAC, thus becoming more hardened and compacted
Hearing loss can occur
Vertigo or pain (rare)
The skin lining the EAC can be scratched providing an entry point for water and pathogens
What are some OTC otic agents?
Cerumen softening agents (softening of the ear wax) Cerumenolytic agents (cerumen dissolving agents)
What are some cerumen softening agents?
Carbamide peroxide 6.5% in anhydrous glycerin (Murine Ear Wax Removal Drops)
Olive oil/vegetable oil
Light mineral oil
Glycerin
Propylene glycol
Hydrogen peroxide 3% diluted in water (1:1)
Sodium bicarbonate (10-15% solution)
How should carbamide peroxide 6.5% in anhydrous glycerin be used?
5-10 drops in affected ear(s) BID for 4 days
How should OTC otic agents be used (besides carbamide peroxide 6.5% in anhydrous glycerin)?
4-6 drops in affected ear(s) BID for 4 days
These agents are great and can be used 2-3 times weekly for prevention
What are some cerumenolytic agents?
Triethanolamine polypeptide oleast condensate 10% (Cerumenex)
Chlorbutol 5% oil of terebinth 10% (oil of turpentine), paradichlorobenzene 2%, peanut oil (inactive ingredient) (Cerumol)
How should triethanolamine polypeptide oleast condensate 10% (Cerumenex) be used?
Triethanolamine is an alkaline agent and an emulsifying agent (SE: dermatitis/eczema)
Should not be left in the ear for more than 15 minutes (following by syringing or irrigation of the ear)
Should be done under the supervision or advice of a physician. Not for routine wax removal
What are some precautions of Cerumol?
When applied to intact skin, oil of turpentine acts as an irritant; paradichlorobenzene is a pesticide used in such things as wood preservatives and mothballs
Patients with peanut allergies should avoid this product
How effective is cerumol?
These agents have not been shown to be effective; they are not really warranted in practise
What is the duration of self-treatment?
Maximum 4 days for self-treatment
Up to 7 days if advised by a physician
When should cerumen impaction be referred?
Development of fever, pain, discharge, (or any other red flags appear)
If the condition worsens or there is no improvement after 4 days
How can cerumen impaction be prevented?
Patients should be counselled on appropriate ear hygiene
Patients should be reminded that earwax plays an important role in the ear’s health (improper or excessive attempts to remove cerumen should be addressed)
Removal of earwax with anything other than a washcloth-draped index finger should be discouraged
Should ear irrigation be used to treat cerumen impaction?
Generally not recommended without doctor’s supervision as the procedure can be dangerous and complications include trauma to the external ear canal, otitis externa, pain, nausea, vertigo, perforation of eardrum
If the patient insists they are purchasing the product to use, ensure the patient is physically and mentally capable. Ideally someone should assist. Ensure there are no red flags
Discourage the use of oral jet irrigators (Water-pik) as the high pressure can cause rupturing of the tympanic membrane with complete neurosensory hearing loss
How should ear irrigation be done?
Irrigation fluid should be at body temperature (to avoid pain, dizziness, nausea)
Recommended volume for ear irrigation is 240 ml (8 oz)
Use gentle pressure with irrigation bulb to introduce fluid
Ensure that fluid drains out of the ear canal
If pain or dizziness occurs during irrigation, discontinue process
What is ear candling?
Hollow cone or tube made from cotton or linen soaked in wax or paraffin
One end is placed in the patient’s ear and the other end is lit
The procedure claims to create a vacuum and pressure draws the wax from the ear
Candling is not only ineffective, it is also dangerous
This technique is not recommended
Describe water-clogged ears
Some patients are more prone to retaining water
Excessive moisture in the ears can result from hot, humid climates, swimming, bathing
Trapped moisture can compromise the EAC’s natural defences leading to inflammation in infection
It’s preventable
What are the symptoms of water-clogged ears?
Feeling of wetness/fullness in the ear
Gradual hearing loss can occur
Can lead to itching, pain, inflammation, or infection if condition progress
What are the goals of treatment of water-clogged ears?
Dry out ears using a safe/effective agent
Prevent recurrences in individuals prone to this condition
What is recommended for water-clogged ears?
An ear drying agent such as isopropyl alcohol 95% in 5% anhydrous glycerin (Auro-dri ear or Swim ear)
Alcohol is highly miscible with water and acts as a drying agent; also an effective as a skin disinfectant
Glycerin combined with alcohol reduces the moisture in the ear without over dying
How should ear drying agents be used?
For treatment: Instill 4-5 drops in each ear daily for 4 days
For prevention: Instill 4-5 drops in each ear after swimming, showering or bathing
Maximum: 10 drops/ear per day (i.e., 5 drops/ear twice daily)
What are contraindications for ear drying agent?
CI: in patients with tympanovstomy tubes
What is the duration of treatment for ear drying agents?
Maximum 4 days for self-treatment (WCE)
AOE - Rx for 7-10 days (up to 14 day may be needed)
When should someone with ear drying be referred?
Development of fever, pain, discharge (or any other red flags) Condition persists (or worsens) after 4 days of proper treatment
Are eye and ear products interchangeable?
Eye products can be used in the ear
Ear products should never be used in the eye
What is acute otitis externa?
It is an inflammation of the EAC often due to infection
Occurs most often during the summer, when humidity is higher
Generally occurs following prolonged exposure of the ear to water
More common with fresh water rather than pools or salt water areas
What causes acute otitis externa?
Excessive moisture or removal of protective ear wax makes the skin in the EAC more prone to infection
Any inflammation of the outer ear canal, such as infections, allergies or skin conditions can lead to swimmer’s ear
Ear plugs, hearing aids and other devices inserted into the ear canal may increase the risk of swimmer’s ear
What are symptoms of swimmer’s ear?
Symptoms include acute pain, itching, inflammation and a foul-smelling watery discharge
Some plugging and hearing loss can occur
AOE is not self-treatable
Treatment is usually with antibiotic +/- corticosteroid eardrops
It is preventable
What type of eardrops are used for swimmer’s ear?
Gentamicin +/- betamethasone
Ciprofloxacin +/- dexamethasone
Polymixin B + gramicidin
How is water-clogged and swimmer’s ear prevented?
After swimming/bathing tilt affected ear down and gently manipulate auricle to help expel excessive water
Use a blow dryer on low setting around (not directly into) the ear
Use a bathing cap while swimming (ideal)
Use of ear plugs debatable (seal not water-tight, may push wax further into ear canal (caution), can cause abrasion to the ear canal)
Use of safe and effective “ear-drying” agent preventatively (recommended for use in adults and children over 12 years old)
Avoid overzealous wax removal (counsel on proper ear hygiene)
Avoid water sports for 7-10 days after AOE
Medical referral necessary if symptoms persist or signs of infection develop
Can benzocaine 1.4%, antipyrine 5.4% (Auralgan) be used for ear conditions?
Local anaesthestic/topical analgesic - inadequate concentration reached in middle ear to be effective
May cause local hypersensitvity reactions
Not recommended
Can aluminum acetate 0.5% benzethonium chloride 0.03% (Bur-sol Otic Solution) be used in ear conditions?
Astringent and antiseptic
Aluminum acetate has an anti-inflammatory effect and provides antibacterial activities as a function of its acidic pH
Promoted to prevent swimmer’s ear (in Canada only)
4-6 drops in each ear after swimming or bathing
Recommended use in children and adults over the age of 12 years
What is otic barotrauma?
Also referred to as airplane ear or aerotitis media
Injury to the middle ear caused by a rapid change in the air pressure
Can occur in one or both ears
Normally the eustacian tube equalizes the pressure on both sides of the eardrum and there is a rapid change in pressure (ear drum bulges out or retracts in; unequal pressure on your eardrum)
Blocked Eustachian tube (congestion) or narrower Eustachain tube (children) - no equalization of pressure between outside and inside and pressure changes may be severe enough to cause fluid buildup or bleeding in your middle ear
What are signs and symptoms of otic barotrauma?
Discomfort or pain in the ear
Feeling of fullness or stuffiness in the ear
Slight hearing loss
Tinnitus (ringing in the ears)
Bleeding from ear
Dizziness
Symptoms may last a few hours up to 2-3 days
How is a mild case of otic barotrauma treated?
Mild case is amendable to self treatment
- oral analgesics for pain
- oral or topical decongestants
How is a severe case of otic barotrauma treated?
Must refer
If not treated properly, complications may occur, such as ruptured ear drum, bleeding, infection and hearing loss
What are risk factors for otic barotrauma?
Any condition that blocks the eustachian tube or limits its function
A smaller eustachian tube, especially in infants and toddlers
Nasal congestion
Sinus infection
Hay fever (allergic rhinitis)
Middle ear infection (otitis media)
Sleeping on an airplane during ascent and descent
Scuba divers
Mountain climbers or driving through the mountains
Water skiers - falling/hitting water at high speed
Being slapped or hit on the ear
How is otic barotrauma prevented?
Avoid flying when you have a cold, sinus infection, nasal congestion, ear infection, or recent ear surgery
-if unavoidable, recommend either an oral decongestant 30 minutes prior to flight and before descent (this depends on the length of the flight) OR
-nasal decongestant applied 30 minutes before descent or ascent
-single entity products ideal
Patients with allergies should take their medication about an hour before flying
Yawning and swallowing during ascent and descent which activates the muscles that open your eustachian tubes
Suck on candy or chew gum to increase how often you need to swallow
Avoid sleeping during ascents and descents
Drink plenty of water to avoid dehydration (help ensure better function of the eustachian tubes)
Avoid alcohol and caffeine (can cause dehydration)
Try filtered ear plugs (the slowly equalize the pressure against your eardrum)
Have infants and young children drink fluids on take-off and landing and encourage frequent swallowing (pacifier also may help)
Give infants and young children acetaminophen 30 minutes before take-off to control any discomfort
Valsalva manoeuvre upon take-off and landing
What is the valsalva manoeuvre?
Pinch nostrils shut
Take a mouthful of air
Using your cheek/throat muscles, gently force the air into the back of your nose as if you were trying to blow your thumb and fingers off your nostrils (pop sound in your ear)
What are some key points for otic disorders?
Self-treatment should be restricted to minor disorders affecting the outer ear
Earache, discharges, bleeding, infection and fever are key symptoms for referral
All red flags must be referred
Clear instructions on how to use otic products including:
-instillation technique (age dependent)
-temp of the ear solution
Duration of therapy
With self-treatable symptoms to contact physician if symptoms worsen or do not improve after 4 days
Interim care for earache - oral analgesics
Advise patients about proper ear hygiene and the importance of cerumen to overall ear health
