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).

Fig. 3.1 The pinna.

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.

1. First, wash your hands

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).

Fig. 3.2 Inspection of the external auditory meatus. Above: in children; below: in adults.

Ear wax impaction

Background

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.

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

Trauma of the ear canal

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 ear Fever and general malaise in children	Middle ear infection?
Associated trauma-related conductive deafness Foreign body in the EAM OTC 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.