Blocked or painful ears
Wax and otitis media
Mike Smith
ENT Consultant
Hereford County Hospital
and
Worcester Royal Hospital
UK
2009
Ear canal:
2-3cm long
Cartilage
Outer 1/3
Skin
Thick
Glands 1. Cerumen
2. Sebum
Hair
1. Fine
2. Thick
(older men)
Bone
Inner 2/3
Thin
None
None
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
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
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.
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
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
Treatment options
 Solvent drops
 Manual Syringe
 Electric pulsed irrigation
 Aural speculum and loops/hooks
 Microscopic suction
Wax Solvent Drops
 Effectiveness ?
Exterol
Cerumol
Oil
Waxsol
Bicarbonate
++++
+++
++
++
+
 Cost
 Irritation
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?)
Indications for syringing




Total occlusion
Examination of obscured tympanic membrane
Otitis Externa ( if other cleansing not available)
Foreign body
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)
Perfs and pockets
Risks of syringing
 Complications requiring specialist referral in
1:1000
e.g. pain, dizziness, bleeding, infection,
perforation, tinnitus, hearing loss
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)
Treatment of complications
 Otitis externa
 Acute sensori-neural
prompt treatment
hearing loss or vertigo
refer if canal occluded by
Urgent referral
debris or oedema
 Refer early if in any doubt.
 Perforation
Do not blindly reassure the
specialist referral
patient, check
(it usually heals)
 Canal wall bleeding
bicarbonate drops
follow up to ensure clot clears
Acute Otitis Media
 Acute otitis media
 Treatment
<3yrs-70% at least one
Analgesia
episode
Antibiotics?
Prophylaxis?
Grommets
 Varieties
Adenoidectomy
AOM with discharge
Prevention: parental
AOM with
smoking, pre-school
complications
Rhinitis
Resistant AOM
Immunity
Recurrent AOM
AOM on ME Effusion
Chronic MEE/Glue ear
Grommet With
Discharge
 Treatment
Oral antibiotic?
Drops?
 Grommets/T-tubes
Water prevention?
Commonest operation
Tube removal?
~20% discharge
Adenoids
 Acute
Allergy
Organisms same as
Immunity
AOM
IV antibiotics
 Chronic
Surgery
Often Pseud. Or Staph.
Biofilms?
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)
Complications of AOM
 Perforation and
otorrhoea
 Hearing loss
 Glue ear
 Mastoiditis
 Facial palsy
 Meningitis
 Chronic Suppurative
Otitis Media (CSOM)
CSOM
 Mucosal
Safe?
Active/Inactive
Discharge character
 Treatment
None
Medical
Surgical
Squamous
Pockets/atelectasis
Cholesteatoma
Discharge character
Treatment
Stable pocket
Unstable pocket
Established
cholesteatoma
Thankyou