1. OTIC PRODUCTS (1)

2. Before recommending any OTC product to a person with an ear disorder, the pharmacist should recognize the symptoms of various disorders & their corresponding pathophysiology for accurate evaluation & treatment of the case

3. OTC products use for the ear
Home remedies and OTC products are usually restricted to the self-limiting disorders that are related ONLY to the external ear
In such cases, OTC products may be used effectively to aid the normal body defenses and to improve the integrity of the skin that lines the auricle and the external auditory canal.

4. Anatomy & Physiology
Keywords: auricle (pinna), external auditory canal, cartilage, thin skin, highly vascularised, lobule, fatty tissue, tragus;
absence of subcutaneous layer  makes auricular skin subject to frostbite despite rich supply of superficial blood vessels;
External auditory canal (24 mm in adults): transmission & protection
Skin in the farther portions of the canal, contains hair follicles, exocrine glands & apocrine glands
frostbite
A cold injury that is accompanied by pallor, numbness and a loss of cold sensation.
apocrine
<physiology> Form of secretion in which the apical portion of the cell is shed, as in the secretion of fat by cells of the mammary gland. The fat droplet is surrounded by apical plasma membrane and this has been used experimentally as a source of plasma membrane.

5. Tympanic membrane Normally: smooth, transluscent, pearl-gray
Concave and oval with thickness of mm
The contineous skin layer of the EAC forms the outer tympanic membrane layer
The middle layer is fibrous tissue
Internal layer is mucous membrane continous with the lining of the middle ear
Function: 1. transmits sound waves 2. protection to middle ear

7. Protection of the ear: (1) lubricates skin (2) traps foreign bodies
Hair: trap foreign material in a waxy network (outer half of the canal).
Cerumen (ear wax)= milky fatty fluid (apocrine glands) + oily secretions (of sebaceous. exocrine glands)
(1) lubricates skin (2) traps foreign bodies
(3) Contains antimicrobials such as lysozymes
- semisolid: expelled to the outside by jaw movement during talking & chewing
Skin of normal healthy ext auditory canal: waxy water-resistant with pH that prevents pathologic bacterial and fungal growth
ceruminous glands

8. Ear Disorders
Disorders of the ear are very common and usually cause discomfort
Patients often complain of earache, impacted ear, running ear, cold in the ear or itching in the ear or combination of the symptoms
What causes ear disorder/discomfort?

9. Causes of Ear Disorders
Disease of the auricle (the most external portion of the ear)
Disease of the external auditory canal
Disease of the middle ear
Disease of the other area of the head & neck (tongue, mandibles, oropharynx, tonsils or paranasal sinuses) referred pain to the ear. In this case, self-treatment is not suitable refer to doctor

10. Causes of ear conditions
Hairs, size of ear canal, its cerumen provide barrier protection against foreign bodies
Acidic pH & integrity of skin layer  are defense mechanisms against infection
Any predisposing factor that breaks down these mechanisms (e.g. warm & humid climate, water, sweating) cause tissue maceration breaks down protective barrier and changes pH expose skin to infection
Trauma: e.g. improper cleaning of the ear or improper fitting of ear plugs or hearing aids, involuntary scratching or rubbing of the ear may cause fissures in the epidermis of ear canal which creates culture area for bacteria & fungi

11. Notes:
The skin that covers the auricle is especially susceptible to bleeding because: (1) lack of flexibility afforded by subcutaneous layer of fat (2) large blood supply to the area
The skin is highly innervated disproportionate otalgia when inflammation is present
Children suffer from more middle ear conditions that do adults (why?)

12. Disorders of the External Ear
Otitis Externa
One of the most common diseases of the ear
A v painful & annoying inflammation of the skin lining ext auditory canal, often due to infection
The ext auditory canal is a blind cul-de-sac lined with skin: dark and very well suited to collect moisture
Prolonged exposure to moisture will disrupt the integrity of epithelial cells & raise pH above 5-7 range more prone to bacterial & fungal infections

14. Otitis Externa
Causative organisms: pseudomonas, staphylococcus, protues & bacillus. Fungi can be causative in some cases (otomycosis)
Complications: inflammation may lead to inflammation & destruction of the tympanic membrane may progress & perforate the membrane spread infection to middle ear intense pain and discomfort
Inflammation that causes edema provokes severe pain that is disproportionate to any visible swelling
Pain increases during chewing

15. 1. Otitis Externa Types of Otitis Externa: Swimmer’s ear
Acute otitis externa
Chronic ~
Allergic ~
Malignant ~

16. Swimmer’s Ear Bacterial infection caused by tissue maceration:
Accumulation of water in the tympanic recess may contribute to tissue maceration
Also, the cerumen accumulated in the ext auditory canal absorbs water & expands and the trapped water provides a medium for bacterial growth

17. What are the symptoms of swimmer’s ear?
Abnormal
Normal
What are the symptoms of swimmer’s ear?

18. Swimmer’s Ear Symptoms: Pain around the ear Itching Plugged ear
Movement of the ear is painful (especially the tragus)
Discharge of yellowish-greenish thick liquid from the affected ear
Redness and tenderness around the ear and the surrounding tissue
Wisdom teeth may be painful

19. Swimmer’s Ear
With the spread of infection to the surrounding bone, brain and the middle ear, a severe infection called Malignant Otitis Externa (MOE) can occur and contain the following:
Fever if the infection is severe
Neurological symptoms (i.e., confusion, headaches, balance problems, weakness or paralysis on one side) that spread to the inside of the brain and skull.

20. Chronic Otitis Externa
Acute Otitis Externa
Symptoms related to severity of pathologic conditions
Symptoms: mild to moderate pain, that is more prominent upon pulling upward the auricle or pressing the tragus
Chronic Otitis Externa
Caused by persistence of predisposing factors
In people whose ears are exposed to persistent excessive moisture
Most common symptoms: itching which prompt scratching break skin

21. Allergic Otitis Externa

22. Allergic Otitis Externa
= dermatitis of the external auditory canal
Caused by: nickel in earrings, poison ivy, chemicals used to process the rubber or plastic in the hearing aid molds or earphones or type of soap
Symptoms: itching, burning or stinging of the lesions
Often complaints >>> than visible signs (maculopapular rash, formation of vesicles, erythema)

23. 2. Impacted Cerumen Causes:
Accumulation of the ear wax in the external auditory canal
Causes:
Overactive ceruminous glands
Small abnormal narrowing of the canal
Secretion of abnormal cerumen (drier, as in elderly)
Hearing aids or ear plugs prevent migration of cerumen

24. 2. Impacted Cerumen Symptoms:
the most common is sense of fullness or pressure in the ear and
gradual hearing loss
Dull pain is sometimes associated with this disorder

25. 3. Foreign Object in the Ear
Children often insert: small items, candy, pencil erasers, peas, beads etc
Symptoms: may be absent (accidentally) or may cause hearing deficiency, pain during chewing, exudates may form because of secondary bacterial infection
Dried peas or beans may swell during bathing or swimming and become wedged in the bony portion of the canal causing severe pain

26. Q: What should you do if an insect enters in the auditory canal?
A: Olive oil drops will suffocate the insect!

27. 4. Otomycosis It is an external fungal infection of the ear
It is more common in: warmer, tropical or semitropical climates
Most common causative agents: Asperigillus & Candida
Predisposing factors: antibiotics (normal flora), immunosuppression (disease or drug) & DM
Primary complaint of patients with otomycosis is intense itching

28. 4. Otomycosis
Color may vary. Skin lining & canal maybe beefy red and scaly, a musty smelling discharge. Skin maybe eroded or ulcerated with fungal filaments
Asperigellus niger: forms black growth in the canal
If the infection is superficial: patient will experience pruritis, feeling of fullness & pressure in the ear
Fungus leads to the accumulation of debris, exudates and cerumen. In acute cases, fungal infection/growth may block the canal and hearing may be impaired
It is particularly serious in DM because of the microangiopathy & associated manifestations special attention (same with all ear infections)

29. Assessment of otitis externa
The only means by which bacterial or fungal otitis external can be confirmed is by microbiologic culture which is not always practical or necessary
Bacterial infections may be characterized by:
- increased pain with chewing or touching the tragus or auricle;
- other characteristics: lymphadenopathy, feeling of fullness, malaise

30. Assessment of otitis externa
Otomycosis: the most common initial symptom is pruritis (as opposed to deep-seated pain & tenderness typically associated with bacterial infection)
- initially the ear may only reveal mild erythema & edema
- a colorless discharge may or may not be present
- pain usually is not present but occurs in severe cases (increase with chewing, touching tragus or auricle)

31. Disorders of the Middle Ear
Should not be treated with OTC otic products
Should be promptly evaluated and treated by a doctor
The usual treatment is systemic antibiotic therapy
Otitis Media
Chronic Otitis Media
Tympanic Membrane Perforation

32. Otitis Media
Inflammation of the middle ear that occurs most commonly during childhood
Caused by any condition that interferes with the Eustachian tube function, e.g. URT infection, allergy, adenoid lymphadenopathy, cleft palate
Symptoms of Eustachian tube blockage: mild, intermittent pain, mild hearing loss & fullness in the ear.

33. Otitis Media Recurrent Otitis Media:
In children: recurrent episodes of Eustachian tube blockage usually are caused by masses of adenoids that become edematous & block the Eustachian tube opening resulting in otitis media. Adenoidectomy usually prevents future occurrence
In adults: recurrent otitis media may be caused by nasopharyngeal tumors

34. Otitis Media Serous otitis media:
Avoid: nose blowing & sneezing against occluded nostrils worsen condition
Serous otitis media:
of viral origin
Symptoms: sensation of fullness in ear, hearing loss, voice resonance, a hollow sound or popping or cracking noise in the ear during swallowing or yawning
These symptoms are not present in otitis externa

35. Otitis Media Purulent (Suppurative) otitis media:
infection by bacteria purulent discharge
Symptoms: pain, hearing loss and fever (>40°C)
The acute pain is sharp, knifelike & steady (caused by high fluid production in a short period of time), the pressure of fluids in middle ear causes outward tension on the tympanic membrane causes pain.
Steady: pain usually doesn’t worsen with mastication, or with traction applied to auricle or tragus
Nose blowing may force additional purulent mucus into Eustachian tube worsen condition

36. Chronic Otitis Media It occurs most often in young children
Causes: inadequate treatment of previous otitis media or recurrent URT infections
It is also called “glue ear” as long-standing fluid may become more and more viscous.
The most common symptom is sudden onset of impaired hearing (without acute symptoms)
Diagnosis: visual inspection of tympanic membrane which appear to be yellow or orange & less flexible- not perforated but retracted

37. Assessment of otitis media
The only conclusive means of diagnosing otitis media is via complete patient history & physical examination using a pneumatic otoscope
Most commonly in children
Patients may be asymptomatic or feel fullness, cracking or hollow sounds in the ear
Effect is usually bilateral
A bloody purulent foul-smelling discharge flows from infected ear only if tympanic membrane is perforated, after which patient experiences sudden relief from pain

38. How to differentiate between otitis media & otitis externa?

39. Movement of tragus painful Ear canal Eardrum Discharge
Acute Otitis Externa
Acute otitis media
Season
Summer
Winter
Movement of tragus painful
Yes No
Ear canal
Swollen
Normal
Eardrum
Normal (or red)
Perforated or bulging
Discharge
Yes (but through a perforation)
Fever
Hearing
Normal or decreased
Always decreased

40. Tympanic Membrane Perforation
The most common cause: water sports e.g. diving, water skiing etc
Any corrosive agent introduced into the ear
Sudden explosion
Other causes:
- Blows to head with cupped hand
- foreign objects entering ear canal
- forceful irrigation of ear canal

41. Management of tympanic perforation
If the perforation is very small, otolaryngologists may choose to observe the perforation over time to see if it will close spontaneously.
They also might try to patch a cooperative patient's ear-drum in the office.
Surgery (tympanoplasty): there are a variety of surgical techniques, but all basically place tissue across the perforation allowing healing.
Surgery is typically quite successful in closing the perforation permanently, and improving hearing. It is usually done on an outpatient basis.

42. Tympanic Membrane Perforation
Symptoms:
Pain: severe at moment of injury, decreases gradually with time
Hearing acuity diminishes quickly and if not treated, it may lead to otitis media
Other: Nausea, tinnitus, vertigo
Refer to doctor immediately if you suspect a perforated tympanic membrane

43. Finally!
Patients with fever, malaise, lymphadenopathy associated with any ear condition should be thoroughly evaluated by a doctor