1. Blocked or painful ears Wax and otitis media Mike Smith ENT Consultant Hereford County Hospital and Worcester Royal Hospital UK 2009

2. Ear canal: 2-3cm long CartilageBone Outer 1/3Inner 2/3 SkinThickThin Glands1. Cerumen 2. Sebum None Hair1. Fine 2. Thick (older men) None

3. What is wax?  Cerumen In hair follicles. Thin sweat like secretion. Long coiled tubes with muscle walls.  Sebum In hair follicles. Secrete Oily fluid.  Epithelial debris  Hairs Shed, and mat with secretions.  Dust, sand, f.b.’s etc

4. Functions of wax  Waterproofing layer  Protective layer from trauma  Cleansing by migration outward with dust, foreign material (e.g. sand, grommets)  Acid pH is antiseptic  Contains antibacterial agents

5. Canal Skin Migration  Squamous epithelium and keratin / dead skin Moves from drum centre along canal to meet the secretions in outer canal  Keratosis Obturans Failure of migration. Epithelial build up and canal expansion. Rare.

6. Health education  Harmful : Scratching Cotton buds (‘Nothing smaller than elbow’)  False : ‘Wax is dirty and must be removed’ ‘Wax often causes reduced hearing’  Ear ‘candling’ and other gadgets

7. Problems with wax?  Hearing loss Non-obstructive wax (no loss) Apparent total obstruction (hearing loss 5dB) Totally obstructed canal (conductive hearing loss 45dB)  Otitis Externa Damp, itchy  Hearing aid

8. Treatment options  Solvent drops  Manual Syringe  Electric pulsed irrigation  Aural speculum and loops/hooks  Microscopic suction

9. Wax Solvent Drops  Effectiveness ? Exterol++++ Cerumol+++ Oil++ Waxsol++ Bicarbonate+  Cost  Irritation

10. Ear Syringing  Method Solvent beforehand Straighten canal (Pull up and back) Water at 37-38 deg. C Brace nozzle with hand on head Point syringe up and back  After syringing check canal/drum (Dr?)

11. Indications for syringing  Total occlusion  Examination of obscured tympanic membrane  Otitis Externa ( if other cleansing not available)  Foreign body

12. Contra-indications to syringing  Normal wax (be more selective of patients)  Past ear disease or surgery (thin drum)  Perforation (may force debris into middle ear, dislocate ossicle, damage oval/round window, or infect middle ear)  Only hearing ear (no risks)  Recurrent Otitis Externa (keep dry)  Anti-coagulant (care to avoid trauma)  Vegetable f.b.’s (swell)

13. Perfs and pockets

14. Risks of syringing  Complications requiring specialist referral in 1:1000 e.g. pain, dizziness, bleeding, infection, perforation, tinnitus, hearing loss

15. Rupture of ear drum by syringing Study by Sorenson et al 1995  Tested on 10-48 hr post mortem cadavers  Large variations in pressure needed to rupture, but well above that generated by syringing (if TM not atrophic)

16. Treatment of complications  Otitis externa prompt treatment refer if canal occluded by debris or oedema  Perforation specialist referral (it usually heals)  Canal wall bleeding bicarbonate drops follow up to ensure clot clears  Acute sensori-neural hearing loss or vertigo Urgent referral  Refer early if in any doubt. Do not blindly reassure the patient, check

17. Acute Otitis Media  Acute otitis media <3yrs-70% at least one episode  Varieties AOM with discharge AOM with complications Resistant AOM Recurrent AOM AOM on ME Effusion Chronic MEE/Glue ear  Treatment Analgesia Antibiotics? Prophylaxis? Grommets Adenoidectomy Prevention: parental smoking, pre-school Rhinitis Immunity

18. Grommet With Discharge  Grommets/T-tubes Commonest operation ~20% discharge  Acute Organisms same as AOM  Chronic Often Pseud. Or Staph. Biofilms?  Treatment Oral antibiotic? Drops? Water prevention? Tube removal? Adenoids Allergy Immunity IV antibiotics Surgery

19. Ear drops and ototoxicity  Ototoxicity Ototoxicity of the infection itself. Inflammation acts as barrier to RW membrane. Vestibulo-toxicity also an issue. Familial trait / genetic susceptibility. Use endorsed for infected perfs by Am. Acad. of ORL, H & N and ENT-UK Alternatives (ciprofloxacin unlicensed as ear drop in UK so far, but widely used)

20. Complications of AOM  Perforation and otorrhoea  Hearing loss  Glue ear  Mastoiditis  Facial palsy  Meningitis  Chronic Suppurative Otitis Media (CSOM)

21. CSOM  Mucosal Safe? Active/Inactive Discharge character  Treatment None Medical Surgical Squamous Pockets/atelectasis Cholesteatoma Discharge character Treatment Stable pocket Unstable pocket Established cholesteatoma

22. Thankyou