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Home , Ear drop, Otitis externa

WEEK 31 OSPAP Programme Ear Disorders

MPHM14 Kathryn Davison

Slide 1 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Learning Outcomes

• Identify the main ear disorders, their site & symptomatology

• Management of conditions

• When to refer / Red flag symptoms

Slide 2 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Cross section of the Ear

Slide 3 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Examining the ear

• Inspect - redness/ swelling/ discharge/ bleeding • Check pinna – , ulcer/blistering

• Mastoid area – apply pressure directly behind the ear and if tender possibly ( of the mastoid bone of the skull).

• Inspect • adult - hold top of ear and firmly pull up and back • child - gently firmly pull lobule down and back

Slide 4 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Outer Ear

• Cerumen - wax-like substance produced in external auditory canal by ceruminous glands. • - combination of cerumen, sebum, dead skin cells, sweat, hair, foreign matter (e.g. dust). • Normal and natural physiological substance that protects ear canal. Quantity produced varies.

Slide 5 of 35 MPHM14 OSPAP Ear Lecture

WEEK 31

Slide 6 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Earwax

• Colour and consistency will differ in various patient groups: • Asians- dry type (grey and flaky) • Caucasians & Africans – moist type (honey to dark brown) • This is genetically determined! • Soft cerumen - Children • Hard cerumen – Adults

Excessive or Impacted earwax • Lots of hair growing in ears • Narrow ear canals • Use of hearing aids/ear plugs • Age

Slide 7 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 The cleaning process

• “Conveyor belt" process • Cells formed in centre of tympanic membrane migrate outwards • Accelerate towards the entrance of the ear canal • Cerumen also carried outwards, taking with it dirt, dust etc Earwax only needs to be removed if symptomatic

Cotton buds not recommended!

Slide 8 of 35 MPHM14 OSPAP Ear Lecture

WEEK 31 Cerumenolytics

• Available as ear drops to soften hardened wax. Water-based • Urea + • Sodium Bicarbonate 5%+ glycerol • Docusate sodium

Oil-based Beware peanut !! • Almond oil • Olive oil • Arachis oil/paradichlorbenzene/chlorbutol (Cerumol) • Arachis oil/Almond oil/Camphor oil (Earex)

Slide 9 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Continued…

With added • Choline salicylate + glycerol (Audax;Earex Plus)

Antibacterial/ • 2% - available OTC as Earcalm®Spray for externa

• Cerumenolytics may take 7 days to achieve desired effect • Ear syringing no longer routinely recommended in GP practices • Syringing C/I – Hx of perforation of tympanic membrane, unilateral deafness, Hx of recurrent

Slide 10 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Evidence from clinical trials:

• Cochrane systematic review - trials of cerumenolytics found 8 clinical trials • All with small numbers of participants, • Most of poor methodological quality • Concluded that there is no evidence to guide selection • Supported by a more recent systematic review and economic evaluation of different methods of earwax removal, concluded that although softeners are effective, which specific softeners are most effective remains uncertain [Clegg et al, 2010]. • CKS – Recommends the use of either sodium bicarbonate 5%, sodium chloride 0.9%, olive oil, or almond oil.

Slide 11 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 How to Use Ear Drops….

• Warm the ear-drop bottle • Unscrew cap of the bottle, draw into dropper. • Either lie on your side or tilt your head over

• Gently pull your earlobe upwards, away from neck, • Squeeze correct no. of drops into ear. • Keep your head tilted for about 5 mins

• Straighten your head, wipe away any excess liquid • Replace the cap on bottle. • Complete the course. • Discard any drops left over at end of course.

Slide 12 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 When not to use drops…

• Perforation of Tympanic membrane present, previous, suspected, or grommets

• Previous or mastoid surgery

• Recurrent Otitis Externa or chronic middle ear disease

• Dizziness or

• People with nut allergies should not use arachis / almond oil. • With some drops earwax initially swells  temporary deafness

Slide 13 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Outer Ear Disorders • Dermatitis – dry, itchy irritation of pinna / ear canal • Tx – Emollients

• Contact dermatitis – sensitivity to earrings/ ear plugs/ aids • Tx – Topical HC – advise avoid nickel containing earrings

• – can affect ear in isolation or alongside scalp dandruff / eye brow scaling • Eczematous reaction – provoked by yeasts • Tx – Steroid drops/creams in extreme cases - Anti-fungal /creams should be tried first Eg. ketoconazole

Slide 14 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Otitis Externa

• “Swimmer’s ear”

• of the pinna skin/external ear canal • Localised/ diffuse • Acute/ chronic

Pre-disposing External Factors

• Ear trauma • Use of cotton buds • Syringing • Excessive moisture • Humid environment • Chemicals – /hair dye

Slide 15 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Otitis Externa - Types

• Infective exudate discharged

-Bacterial (E-coli, P.aeruginosa, S.aureus) -Viral -Fungal (C.albicans) -After prolonged topical c.steroid / ABx use

• Reactive form of dermatitis (atopic/contact)

• Furuncle (boil like) – s.aureus, severe pain, small red swelling, • Supportive Tx with if severe

Slide 16 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Acute Cases

Symptoms • • Itching • Impaired hearing • Fowl smelling discharge • Red ear • Swollen / scaly ear

POM Treatment • drops – for inflammation • Topical ABx drops – for infection • No more than 7 days Tx course

Slide 17 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 OTC Treatment

• Choline salicylate + glycerol (Audax; Earex Plus drops) • adults & age 1yr+ • fill the ear canal 3-4hrly – helps reduce pain and inflammation! • Acetic acid 2% Spray - 1st line for bact/fungal • adults & over 12yr olds • one spray tds - continued two days after symptoms resolved. • May cause burning or irritation on application as acidic warn of this, as it may otherwise affect compliance. • Less likely to cause super-infection than • Corticosteroids not to be used in infective cases! • Advice - Do not try to clean or clear ear canal with fingers, cotton buds, etc. They may scratch and irritate and push wax or dirt further in.

• Try to stop soap or shampoo from getting in. A piece of cotton wool coated in Vaseline placed in the outer ear may help or ear plugs designed for swimming.

Slide 18 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 When to refer?

• Internal Ear pain- likely infection • Foreign body: suspect particularly in children. • : ear pain, if perforates, purulent smelly discharge. • : eroding epithelial tissue in mastoid, discharge • Mastoiditis: pt feels unwell, has marked , or mastoid tenderness/swelling • Neoplasm: if swelling in the ear canal that bleeds easily on contact and crusting lesions

• Referred pain: may originate sphenoidal sinus, teeth, neck, or throat.

• Barotrauma: Possible in divers or patients who have recently flown or had a blow to the ear.

• Skin conditions: seborrhoeic dermatitis, , dermatophytosis, ,

Slide 19 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Middle Ear Disorders

• Otitis Media • Usually a short-term inflammation characterised by earache that may be severe. • Often preceded by upper respiratory symptoms, including a cough and rhinorrhoea.

• Bacterial origin • although studies have shown that 25% of cases are not associated with a specific

• Viruses in 25% of people with AOM, and often precede or coexist with a bacterial infection

Slide 20 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Acute Otitis Media

• Common complaint seen in primary care • 1 in 4 children have 1 episode before age 10 • peak incidence: 3-6 years of age • causes pain and deafness. Signs • Pulling at the ear • Sleeplessness • Irritability • Fever • Perforation of ear drum gives relief & usually heals naturally

Slide 21 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Treatment

• are not necessarily useful for most children with acute otitis media

• Cochrane review found that antibiotics did not alter pain within the first day, (when most children were better) • only slightly reduced it in the few days following

• did not reduce the deafness (that can last several weeks).

• Antibiotics  unwanted effects such as diarrhoea, stomach pains and rash • ! Resistance!

Slide 22 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Treatment

• Antihistamines or decongestants not recommended.

• A Cochrane systematic review of 2569 cases found:

• no benefit in taking decongestants or antihistamines alone • an increase in adverse effects with these drugs.

• There was a small improvement in outcome in people taking combined antihistamines and decongestants after 2 weeks. However, benefit was small

• Unlikely to be clinically significant, and could have been due to the trial designs • should be the mainstay of treatment • Paracetamol preferred treatment - both adults & children. •

Slide 23 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Otitis media with effusion

• “Glue ear” inflammation of the middle ear accompanied by accumulation of fluid…blockage of the eustachian tube

• Without signs/symptoms of acute inflammation • Spontaneous resolution is common • 50% resolve within 3 months , 95% within a year

• If episodes frequent / persistent, speech/language development, behaviour may be adversely affected

• Often results in

Slide 24 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Glue ear Risk factors

• Gender - Males • Exposure to tobacco smoke • Young age (peak 2yrs old) • Formula feeding • Season (more prevalent in winter) • Sibling Hx of G.ear • Attendance at nursery/day care • Suggested link to gastric reflux – due to infants being supine majority of the time • ‘researchers looked at the effusion in 54 children and found that 83 per cent contained a high concentration of pepsin, a gastric protease not secreted in the ear. The levels were 1000 times greater than that in blood, the control fluid.’ Tasker et al. Reflux of gastric juice and glue ear in children. Lancet. 2002;359:493

Slide 25 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Inner Ear Disorders

• Tinnitus – sound in absence of stimuli • Buzzing, ringing, whistling, hissing • Varies between- intermittent, continuous, pulsatile

Associated with: • hearing impairment, impacted wax, head injury, toxicity, Meniere’s disease,

• Male more common ( 12 %) • Age • Oto-neurological not Psychological Slide 26 of 35 MPHM14 OSPAP Ear Lecture

WEEK 31 Tinnitus Treatment

• No cure • I.V. • Correct hearing loss • Counselling • Sound therapy • Support group

Slide 27 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Meniere’s disease • Progressive disorder of inner ear • Fluid build up • Age 20-50 • Attacks can last 20mins - hours • Attack frequent/once every few months

Symptoms • • Dizziness • Nausea • Vomiting • Dulled hearing, Tinnitus • pressure • Headache (migraine like aura)

Slide 28 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Vertigo – Spinning

Causes • Viral infection • Brain stem ischaemia • Eustachian tube dysfunction • Chronic Otitis media • Epilepsy/MS • Head injury • Travel sickness • Nasopharyngeal carcinoma

• Drugs – check list

Slide 29 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Meniere’s Management

• Cochrane review – little evidence for tinnitus/deafness Tx

• Acute attacks: Prochlorperazine 5mg tds 7/7 • Vertigo & nausea & vomiting • Buccally /rectally • Cinnarazine 30mg tds 7d

Prophylactic • Betahistine • BNF: 24-48mg od with food • RCT – statistically significant reduction in intensity & no. of attacks, treated with Betahistine 16mg BD for 3months

Slide 30 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Hearing impairment • Estimated 8.7 million deaf/partially hearing in UK • Causes in adults: ADR, meniere’s, tumour • In children: infection in utero, glue ear, meningitis, injury

Ototoxic Drugs

• Chemotherapeutics - Cisplatin • Antibiotics - Aminoglycosides • Loop diuretics - Furosemide • Antimalarials - Mefloquine • NSAID - aspirin

Slide 31 of 35 MPHM14 OSPAP Ear Lecture

WEEK 31 Management

• clinic • Hearing aids • Cochlear implant

Slide 32 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Summary of Ear disorders

Outer Ear Middle Ear Inner Ear

Otitis Externa Otitis Media Vertigo

Tumour Glue ear Hearing impairment Trauma Trauma / perf eardrum Excessive wax Otosclerosis

Furuncles Foreign bodies

Slide 33 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Red flag symptom summary

• Pain/discharge • Deafness/Tinnitus • Trauma/swelling/foreign body • • Abnormal lesion/blister/ulcer • C/I to use of ear drops e.g. dermatitis, erythema • Persistent vertigo • Persistent wax

• Accompanying symptoms: N & V , Neck stiffness

Slide 34 of 35 MPHM14 OSPAP Ear Lecture WEEK 31 Further reading

• Minor illness or Major Disease by Clive Edwards & Paul Stillman • Symptoms in the Pharmacy by Blenkinsopp and Paxton

Slide 35 of 35 MPHM14 OSPAP Ear Lecture