Ear conditions
Background
Currently, community pharmacists can only offer help to patients with conditions that affect the external ear and this chapter therefore concentrates on external ear problems. However, with appropriate auroscopical training and further POM to P deregulation of medicines, it is not unrealistic to extend the community pharmacists’ role to include middle ear problems.
General overview of ear anatomy
The external ear consists of the pinna (Fig. 3.1) and the external auditory meatus (EAM, ear canal). Their function is to collect and transmit sound to the tympanic membrane (eardrum).
The pinna consists chiefly of cartilage and has a firm elastic consistency. The EAM opens behind the tragus and curves inwards for approximately 3 cm; the inner two-thirds is bony and the outer third cartilaginous. The skin lining the cartilaginous outer portion has a well-developed subcutaneous layer that contains hair follicles, ceruminous and sebaceous glands.
The two portions of the meatus have slightly different directions; the outer cartilaginous portion is upward and backward where as the inner bony portion is forward and downward. This is important to know when examining the ear.
History taking and physical exam
A thorough and accurate history coupled with a physical examination of the outer ear should be undertaken, as certain symptoms can help decide what structure of the ear the problem originates from (Table 3.1) and its likely cause (Table 3.2).
Table 3.1
Ear symptoms and the affected ear structures
Adapted from C Acomb, Pharmaceutical Journal, August 1991.
Table 3.2
Possible causes of the presenting complaint
| Patient presents with | Possible causes |
| Redness and swelling | Perichondritis, haematoma |
| Discharge | Otitis externa or media. If discharge mucinous, originates from middle ear as EAM has no mucous glands |
| Pain in mastoid area | Otitis media, mastoiditis |
| Pain when pressing tragus or moving pinna | Otitis externa |
Physical examination
After taking a history of the presenting complaint, the ear should be examined. Before performing an examination explain to the patient what you want to do and gain their consent.
2. Next inspect the external ear for redness, swelling and discharge.
3. Then apply pressure to the mastoid area which is directly behind the pinna (If the area is tender this suggests mastoiditis, a rare complication of otitis media).
4. Next move the pinna up and down and manipulate the tragus. If either is tender on movement then this suggests external ear involvement.
5. You should finally examine the EAM. This is best performed using an otoscope, however currently most pharmacists have not had appropriate training in their use. An alternative way to inspect the EAM would be to use a pen torch. Because of the shape of the EAM, when performing an examination the pinna needs to be manipulated to obtain the best view of the ear canal (Fig. 3.2).
Ear wax impaction
Ear wax is produced in the outer third of the cartilaginous portion of the ear canal by the ceruminous glands. Earwax performs a number of important functions, including, mechanical protection of the tympanic membrane, trapping dirt, repelling water and contributing to a slightly acidic medium that has been reported to exert protection against bacterial and fungal infection. Cerumen varies in its composition between individuals but can be broadly divided into two types; ‘wet or sticky’ type of wax, which is common in Caucasians and African-Americans or ‘dry’ that is common in Asian populations.
Prevalence and epidemiology
The exact prevalence rates of ear wax impaction is not clear but studies have shown that 2–6% of the general population suffer from impacted wax and one Scottish survey of GPs reported an average of nine patients per month (range 5 to 50 patients) requesting ear wax removal. However, many more patients self-diagnose and medicate without seeking GP assistance, therefore pharmacists have an important role in ensuring that treatment is appropriate. The high number of presentations may be due to patient misconception that earwax needs to be removed.
A number of patient groups appear to be more prone to ear wax impaction than the general population, for example, patients with congenital anomalies (narrowed ear canal), patients with learning difficulties and those fitted with a hearing aid. The elderly are more susceptible to impaction due to the decrease in cerumen producing glands resulting in drier and harder ear wax.
Aetiology
The skin of the tympanic membrane is unusual. It is not simply shed as skin is from the rest of the body but is migratory. This is because the auditory canal is the body’s only ‘dead end’ and abrasion of the stratum corneum cannot occur. Skin therefore moves outwards away from the ear drum and out along the ear canal. This means that the ears are largely self-cleaning as the ear canal naturally sheds wax from the ear. However, this normal function can be interrupted, usually by misguided attempts to clean ears. Wax therefore becomes trapped, hampering its outward migration.
Arriving at a differential diagnosis
Ear wax is by far the commonest external ear problem that pharmacists encounter and is the most common ear problem in the general population. Careful questioning along with inspection of the EAM should mean that wax impaction is readily distinguished from other conditions (Table 3.3).
Table 3.3
Specific questions to ask the patient: Ear wax
| Question | Relevance |
| Course of symptoms | The patient usually has a history of gradual hearing loss with ear wax impaction |
| Associated symptoms | Dizziness and tinnitus indicates an inner ear problem and should be referred. Ear wax impaction rarely causes tinnitus, vertigo or true pain |
| History of trauma | Check if the person has recently tried to clean the ears. This often leads to wax impaction |
| Use of medicines | If a patient has used an appropriate OTC medication correctly this would necessitate referral for further investigation and possibly ear-syringing |
Clinical features of ear wax impaction
The key features of ear wax impaction are a history of gradual hearing loss, ear discomfort (to variable degrees) and recent attempts to clean ears. Itching, tinnitus and dizziness occur infrequently. Otoscopical examination should reveal excessive wax.
Conditions to eliminate
It is common practice for people to use all manner of implements to try and clean the ear canal of wax (e.g. cotton buds, hairgrips, and pens). Inspection of the ear canal might reveal laceration of the ear canal and the patient may experience greater conductive deafness because of the wax becoming further impacted. Trauma might also lead to discharge from the ear canal; these cases are probably best referred.
Foreign bodies
Symptoms can mimic ear wax impaction but, over time, discharge and pain is observed. Children are the most likely age group to present with a foreign body in the ear canal and suspected cases need to be referred to a GP.
Trigger points indicative of referral
Ear wax
| Symptoms/signs | Possible danger/reason for referral |
| Dizziness or tinnitus | Suggests inner ear problem; requires further investigation |
| Pain originating from the middle earFever and general malaise in children | Middle ear infection? |
| Associated trauma-related conductive deafnessForeign body in the EAMOTC medication failure | Requires further investigation by doctor |
Evidence base for over-the-counter medication
Cerumenolytics have been used for many years to help soften, dislodge and remove impacted ear wax. Two systematic reviews have been published (Burton & Doree 2009; Hand & Harvey 2004) to determine if pharmacological intervention is effective in wax removal. Each had slightly different inclusion criteria resulting in some trials being included in both but also some trials reviewed in only one of the reviews. All trials reviewed had aspects of poor methodological quality (e.g. lack of clear randomisation and blinding and potential for publication bias as some were company sponsored trials) and were of relatively small size. The findings from these reviews support the use of oil-based softeners, sodium bicarbonate and sterile water over no treatment at all, but no active treatment proved more superior over any other. Further trials between oil-based products and saline reported oil-based products to be significantly better than saline but again showed no differences between each other.
Practical prescribing and product selection
Prescribing information relating to ear wax medicines reviewed in the section ‘Evidence base for over-the-counter medication’ is discussed and summarised in Table 3.4 and useful tips relating to patients presenting with ear wax are given in Hints and Tips Box 3.1.
Table 3.4
Cerumenolytics
Although agents used to soften ear wax have limited evidence of efficacy, they are very safe. They can be given to all patient groups, do not interact with any medicines and can be used in children. They have very few side effects, which appear to be limited to local irritation when first administered. They might, for a short while, increase deafness and the patient should be warned about this possibility.
Cerumol Ear Drops (Arachis – peanut oil, 57.3%): The standard dose for adults and children is five drops into the affected ear two or three times a day repeated for up to 3 days. In between administration a plug of cotton wool moistened with Cerumol or smeared with petroleum jelly should then be applied to retain the liquid.
Cerumol Olive Oil Drops (olive oil 100%): For adults and children, two to three drops should be instilled twice a day for up to 7 days. Like Cerumol, a cotton wool plug should be gently placed in the ear to retain the liquid.
Peroxide-based products (Exterol & Otex range): For adults and children, five drops should be instilled once or twice daily for at least 3 to 4 days. Unlike Cerumol, the patient should be advised not to plug the ear but retain the drops in ear for several minutes by keeping the head tilted and then wipe away any surplus. Patients might experience mild, temporary effervescence in the ear as the urea hydrogen peroxide complex liberates oxygen.
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