As our ears are prove to dust, sunlight, cold winds, pollutants etc. it is not surprising that many a complications occured in or outside the ear. Some common ailments related to ear are given here under.
IMPACTED WAX OR CERUMEN
Wax is composed of secretion of sebaceous glands, ceruminous glands, hair, desquamated epithelial debris, keratin and dirt.
Sebaceous and ceruminous (modified sweat glands) open into the space of the hair follicle. Sebaceous glands provide fluid rich in fatty acids while secretion of ceruminous gland is rich in lipids and pigment granules. Secretion of both these glands mixes with the desquamated epithelial cells and keratin shed from the tympanic membrane and deep bony meatus to form wax.
Wax has a protective function as it lubricates the ear canal and entraps any foreign material that happens to enter the canal. Normally only a small amount of wax is secreted, which dries up and is later expelled from the meatus by movements of the jaw. As some people sweat more than others, the activity of ceruminous glands also varies, excessive wax may be secreted and deposited as a plug in the meatus. Certain other factors like narrow and tortuous ear canal, stiff hair or obstructive lesion of the canal, e.g. exostosis, may favour retention of wax. It may dry up and form a hard impacted mass.
Patient usually presents with impairment of hearing or sense of blocked ear. Tinnitus and giddiness may result from impaction of wax against the tympanic membrane. Reflex cough due to stimulation of auricular branch of vagus may sometimes occur. The onset of these symptoms may be sudden when water enters the ear canal during bathing or swimming and the wax swells up. Long standing impacted wax may ulcerate the meatal skin and result in granuloma formation (wax granuloma).
Treatment of wax consists in its removal by syringing or instrumental manipulation. Hard impacted mass may sometimes require prior softening with wax solvents.
Technique of syringing the ear. Patient is seated with ear to be syringed towards the examiner. A towel is placed round his neck. A kidney tray is placed over the shoulder and held snugly by the patient. Patient’s head is slightly tilted over the tray to collect the return fluid.
Pinna is pulled upwards and backwards and a stream of water from the ear syringe is directed along the posterosuperior wall of the meatus. Pressure of water, built up deeper to the wax, expels the wax out. It wax is tightly impacted, it is necessary to create a space between it and the meatal wall for the jet of water to pass, otherwise syringing will be ineffective or may even push the wax deeper. Ear canal should be inspected from time to time to see if all wax has been removed. Unnecessary syringing should be avoided.
At the end of the procedure, ear canal and tympanic membrane must be inspected and dried with a pledget of cotton. Any ulceration seen in meatal wall as a result of impacted wax is protected by application of suitable antibiotic ointment. Normally, boiled tap water cooled to body temperature is used. If it is too cold or too hot it would stimulate the labyrinth, as in caloric testing, and cause vertigo. Too much force used in syringing may rupture the rympanic membrane especially when it has already been weakened by previous disease. Patient complains of intense pain and may become giddy and even faint. It is necessary before syringing to ask the patient for any past history of ear discharge or an existing perforation. A quiescent otitis media may be reactivated by syringing.
Instrumental manipulation. It should always be done by skilled hands and under direct vision. Cerumen hook, scoop or Jobson Home probe are often used. First, a space is created between the wax and meatal wall, the instrument is passed beyond the wax, and whole plug then dragged out in a single piece. If it breaks, syringing may be used to remove the fragments.
Occasionally, if the wax is too hard and impacted, to be removed by syringing or instruments, it should be softened by drops of 5% soda bicarb in equal parts of glycerine and water instilled two or three times a day for a few days. Hydrogen peroxide, liquid paraffin or olive oil may also achieve the same result. Commercial drops containing cerumolytic agents like paradichlorobenzene 2% can also be used and above methods tried again.
FOREIGN BODIES OF EAR
Non-living. Children may insert a variety of foreign bodies in the ear; the common ones often seen are—a piece of paper or sponge, grain seeds (rice, wheat, maize), slate pencil, piece of chalk or metallic ball bearings. An adult may present with a broken end of match stick used for scratching the ear or an overlooked cotton swab. Vegetable foreign bodies tend to swell up with time and get tightly impacted in the ear canal or may even suppurate.
Methods of removing a foreign body include:
□ Forceps removal
□ Syringing
□ Suction
□ Microscopic removal with special instruments
□ Postaural approach.
Soft and irregular foreign bodies like a piece of paper, swab or a piece of sponge can be removed with fine crocodile forceps.
Most of the seed grains and smooth objects can be removed with syringing. Smooth and hard objects like steel ball bearing should not be grasped with forceps as they tend to move inwards and may injure the tympanic membrane. In all impacted foreign bodies or in those where earlier attempts at extraction have been made, it is preferable to use general anaesthetic and an operating microscope. Occasionally, postaural approach is used to remove foreign bodies impacted in deep meatus, medial to the isthmus or those which have been pushed into the middle ear.
Unskilled attempts at removal of foreign bodies may lacerate the meatal lining, damage the tympanic membrane or the ear ossicles. Living. Flying or crawling insects like mosquitoes, beatles, cockroach or an ant may enter the ear canal and cause intense irritation and pain. No attempt should be made to catch them alive. First, the insect should be killed by instilling oil (a household remedy), spirit or chloroform water. Once killed, the insect can be removed by any of the methods described above.
MAGGOTS IN THE EAR
Flies may be attracted to the foul-smelling ear discharge and lay eggs which hatch out into larvae called maggots. They are commonly seen in the month of August, September and October. There is severe pain with swelling round the ear and blood-stained watery discharge. Maggots may be seen filling the ear canal.
Treatment consists of instilling chloroform water to kill the maggots which can later be removed by forceps. Usually, such patients have discharging ears with perforation of the tympanic membrane, and syringing may not be advisable.
CAUSES OF EUSTACHIAN TUBE OBSTRUCTION
□ Upper respiratory infection (viral or bacterial)
□ Allergy sinusitis
□ Nasal polypi
□ DNS
□ Hypertrophic odenoids
□ Nasopharyngeal tumour/mass
□ Cleft palate
□ Submucous cleft palate
□ Down syndrome
□ Functional
EXAMINATION OF EUSTACHIAN TUBE
Pharyngeal end of the eustachian tube can be examined by posterior rhinoscopy, rigid nasal endoscope or flexible nasopharyngoscope. The extrinsic causes which obstruct this end can be excluded.
Tympanic end of the tube can be examined by microscope or endoscope, if there is a pre-existing perforation. Eustachian tube endoscopy or middle ear endoscopy can be done with very fine flexible endoscopes. Simple examination of tympanic membrane with otoscope or microscope may reveal retraction pockets or fluid in the middle ear. Similarly, movements of tympanic membrane with respiration point to patulous eustachian tube.
Further assessment of function of the tube can be seen by valsalva, politzerisation, Tonybee and other tests already described.
Aetiologic causes of eustachian tube dysfunction can be assessed by thorough nasal examination including endoscopy, tests of allergy, CT scan of temporal bones and of paranasal sinuses. MRI may be required to exclude multiple sclerosis in patulous eustachian tube.