Ear Disorders

Question 1

What are the 3 parts of the ear?

Answer 1

Outer (external) ear
Middle ear
Inner ear

Question 2

Describe the outer ear

Answer 2

Auricle (pinna) - directs sound waves into the ear

External auditory canal (EAC)

Question 3

Describe the middle ear

Answer 3

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

Question 4

Describe the inner ear

Answer 4

Houses the sensory and equilibrium system

Consists of the cochlea, vestibule and semicircular canals

Question 5

Describe the ear of children younger than 3 years old

Answer 5

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

Question 6

Describe the ear of children over 3 years old and adults

Answer 6

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)

Question 7

Describe the external auditory canal

Answer 7

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

Question 8

What are the defences of the EAC?

Answer 8

Cerumen
Epithelial migration
S shape of canal
Hair located in the canal

Question 9

What are some outer ear disorders?

Answer 9

Otitis externa (OE)
Cerumen (ear wax) impaction
Water-clogged ears

Question 10

What is otitis externa?

Answer 10

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

Question 11

What is cerumen impaction?

Answer 11

Develops when earwax accumulates in the inner part of the ear canal and blocks the eardrum
Often caused by misguided attempts to remove earwax

Question 12

What is water-clogged ears?

Answer 12

Excessive moisture in the external auditory canal

Question 13

What are some middle ear disorders?

Answer 13

Acute otitis media (AOM)
Secretor otitis media
Chronic suppurative otitis media
Otic barotrauma or aerotitis media

Question 14

Describe acute otitis media

Answer 14

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

Question 15

How is acute otitis media treated?

Answer 15

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

Question 16

Describe secretor otitis media

Answer 16

Otitis media with effusion

Middle ear space becomes full with sticky effusion which is unable to escape

Question 17

Describe chronic suppurative otitis media

Answer 17

Involves a perforation (hole) in the eardrum and active bacterial infection within the middle ear space

Question 18

Describe otic barotrauma or aerotitis media

Answer 18

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

Question 19

What are some inner ear dirsorders?

Answer 19

Vertigo (and dizziness)
Ménière’s disease
Tinnitus

Question 20

What is vertigo?

Answer 20

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

Question 21

What are common causes of vertigo?

Answer 21

Common causes include viral infections, inner ear disturbances (Ménière’s disease), ototoxic drugs, trauma to the ear or head, vascular disorders

Question 22

What is dizziness?

Answer 22

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

Question 23

What is Ménière’s disease?

Answer 23

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

Question 24

What are symptoms of Ménière’s disease?

Answer 24

Vertigo, nausea and vomiting, feeling of fullness/pressure in the ear, fluctuating hearing loss, tinnitus

Question 25

What is tinnitus?

Answer 25

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

Question 26

What are the possible causes of tinnitus?

Answer 26

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

Question 27

What are ototoxic drugs?

Answer 27

Many ototoxic drugs can lead to both tinnitus and vertigo problems Generally categorized as: high risk agents and low risk agents

Question 28

What are some high risk ototoxic agents?

Answer 28

Aminoglycosides Antineoplastics IV diuretics

Question 29

What are some low risk ototoxic agents?

Answer 29

NSAIDs | Antibiotics

Question 30

What are otic conditions that must be referred?

Answer 30

``` 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 ```

Question 31

Cerumen impaction and water-clogged ear are both self-treatable outer ear conditions. Why?

Answer 31

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)

Question 32

What are some red flags?

Answer 32

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

Question 33

What is cerumen?

Answer 33

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)

Question 34

What are the functions of the cerumen?

Answer 34

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

Question 35

How is wax removed?

Answer 35

It is removed naturally with chewing and talking

Question 36

What are risk factors for cerumen impaction?

Answer 36

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

Question 37

What are symptoms of cerumen impaction?

Answer 37

Feeling of pressure or fullness Pruritis Gradual hearing loss General discomfort

Question 38

What are the goals of treatment of cerumen impaction?

Answer 38

Soften and remove cerumen using a safe and effective method to relieve symptoms Prevent future impaction

Question 39

What complications could arise from cerumen impaction?

Answer 39

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

Question 40

What are some OTC otic agents?

Answer 40

``` Cerumen softening agents (softening of the ear wax) Cerumenolytic agents (cerumen dissolving agents) ```

Question 41

What are some cerumen softening agents?

Answer 41

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)

Question 42

How should carbamide peroxide 6.5% in anhydrous glycerin be used?

Answer 42

5-10 drops in affected ear(s) BID for 4 days

Question 43

How should OTC otic agents be used (besides carbamide peroxide 6.5% in anhydrous glycerin)?

Answer 43

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

Question 44

What are some cerumenolytic agents?

Answer 44

Triethanolamine polypeptide oleast condensate 10% (Cerumenex) Chlorbutol 5% oil of terebinth 10% (oil of turpentine), paradichlorobenzene 2%, peanut oil (inactive ingredient) (Cerumol)

Question 45

How should triethanolamine polypeptide oleast condensate 10% (Cerumenex) be used?

Answer 45

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

Question 46

What are some precautions of Cerumol?

Answer 46

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

Question 47

How effective is cerumol?

Answer 47

These agents have not been shown to be effective; they are not really warranted in practise

Question 48

What is the duration of self-treatment?

Answer 48

Maximum 4 days for self-treatment | Up to 7 days if advised by a physician

Question 49

When should cerumen impaction be referred?

Answer 49

Development of fever, pain, discharge, (or any other red flags appear) If the condition worsens or there is no improvement after 4 days

Question 50

How can cerumen impaction be prevented?

Answer 50

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

Question 51

Should ear irrigation be used to treat cerumen impaction?

Answer 51

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

Question 52

How should ear irrigation be done?

Answer 52

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

Question 53

What is ear candling?

Answer 53

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

Question 54

Describe water-clogged ears

Answer 54

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

Question 55

What are the symptoms of water-clogged ears?

Answer 55

Feeling of wetness/fullness in the ear Gradual hearing loss can occur Can lead to itching, pain, inflammation, or infection if condition progress

Question 56

What are the goals of treatment of water-clogged ears?

Answer 56

Dry out ears using a safe/effective agent | Prevent recurrences in individuals prone to this condition

Question 57

What is recommended for water-clogged ears?

Answer 57

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

Question 58

How should ear drying agents be used?

Answer 58

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)

Question 59

What are contraindications for ear drying agent?

Answer 59

CI: in patients with tympanovstomy tubes

Question 60

What is the duration of treatment for ear drying agents?

Answer 60

Maximum 4 days for self-treatment (WCE) | AOE - Rx for 7-10 days (up to 14 day may be needed)

Question 61

When should someone with ear drying be referred?

Answer 61

``` Development of fever, pain, discharge (or any other red flags) Condition persists (or worsens) after 4 days of proper treatment ```

Question 62

Are eye and ear products interchangeable?

Answer 62

Eye products can be used in the ear | Ear products should never be used in the eye

Question 63

What is acute otitis externa?

Answer 63

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

Question 64

What causes acute otitis externa?

Answer 64

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

Question 65

What are symptoms of swimmer's ear?

Answer 65

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

Question 66

What type of eardrops are used for swimmer's ear?

Answer 66

Gentamicin +/- betamethasone Ciprofloxacin +/- dexamethasone Polymixin B + gramicidin

Question 67

How is water-clogged and swimmer's ear prevented?

Answer 67

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

Question 68

Can benzocaine 1.4%, antipyrine 5.4% (Auralgan) be used for ear conditions?

Answer 68

Local anaesthestic/topical analgesic - inadequate concentration reached in middle ear to be effective May cause local hypersensitvity reactions Not recommended

Question 69

Can aluminum acetate 0.5% benzethonium chloride 0.03% (Bur-sol Otic Solution) be used in ear conditions?

Answer 69

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

Question 70

What is otic barotrauma?

Answer 70

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

Question 71

What are signs and symptoms of otic barotrauma?

Answer 71

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

Question 72

How is a mild case of otic barotrauma treated?

Answer 72

Mild case is amendable to self treatment - oral analgesics for pain - oral or topical decongestants

Question 73

How is a severe case of otic barotrauma treated?

Answer 73

Must refer | If not treated properly, complications may occur, such as ruptured ear drum, bleeding, infection and hearing loss

Question 74

What are risk factors for otic barotrauma?

Answer 74

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

Question 75

How is otic barotrauma prevented?

Answer 75

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

Question 76

What is the valsalva manoeuvre?

Answer 76

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)

Question 77

What are some key points for otic disorders?

Answer 77

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