CONGENITAL Congenital atresia (Greek: a—negative; tretos—bored through) may be of variable severity; there may be a shallow blind pit or no cavity at all.There may be associated absence of the pinna (microtia) and there may be absence or abnormality of the middle or inner ear (Fig. 5.2). In bilateral cases the cochlear function needs to be measured carefully. If it is good, surgery may be considered. Previously an attempt would have been made to fashion an external auditory canal but better hearing results are obtained by the provision of a BAHA (see Chapter 4, page 18). At the same time any malformation of the pinna can be corrected by a prosthesis attached to a similar osseo-integrated titanium implant. Until such surgery is possible (at about age 3–4) the child with bilateral atresia of the external auditory canal will need to wear a bone conductor hearing aid held on by pressure from some sort of headband. In unilateral cases, it is of prime importance to assess the hearing in the unaffected ear. If it is good, operation on the affected side is unnecessary. External ears can be constructed by a plastic procedure or can be replaced by prostheses anchored to the ear by adhesive or by titanium implants in the skull bone. FOREIGN BODY Small children often put beads, pips, paper and other objects into their own ears, but they will usually blame someone else! Adults may get a foreign body stuck in an attempt to clean the ear, e.g. with match sticks, or cotton buds. Although the management is straightforward, several points arise. 1 Syringing is usually successful in removing a foreign body. 2 The chief danger lies in clumsy attempts to remove the foreign body and rupture of the tympanic membrane may result. Do not attempt to remove a foreign body unless you have already developed some skill with instruments. 3 If the child (or adult) is uncooperative, do not persevere but resort instead to general anaesthesia. This does not need to be done as an urgent case but can be added to a routine list. INSECTS Live insects, such as moths or flies, in the outer meatus produce dramatic ‘tinnitus’. Peace is restored by the instillation of spirit or olive oil and the corpse can then be syringed out. WAX WAX IN AN EAR IS NORMAL Wax or cerumen is produced by the ceruminous glands in the outer meatus and migrates laterally along the meatus. Some people produce large amounts of wax but many cases of impacted wax are due to the use of cotton wool buds in a misguided attempt to clean the ears. Impacted wax may cause some deafness or irritation of the meatal skin and is most easily removed by syringing. Ear syringing is a procedure that almost any doctor or nurse is expected to carry out with skill and that the general practitioner should perform with a flawless technique. Attention must be paid to the points listed in Box 6.1. 26 Chapter 6: Conditions of the External Auditory Meatus EAR SYRINGING PROCEDURE: 1 History. Has the patient had a discharging ear? If any possibility of a dry perforation, do not syringe. 2 Inspection. If wax seems very hard, always soften over a period of one week by using warm olive oil drops nightly. In the case of exceedingly stubborn wax, the patient may be advised to use sodium bicarbonate ear drops (BPC), and there are several ‘quickacting’ ceruminolytic agents on the market. Occasionally, a patient reacts badly to the use of the latter and develops otitis externa.They should certainly not be employed in the case of a patient who is known to suffer from recurrent infections of the meatal canal. 3 Towels. Protect the patient well with towels and waterproofs. He will not be amused by having his clothing soaked. 4 Lighting. Use a mirror or lamp. 5 Solution. Sodium bicarbonate, 4–5 g to 500 mL,or normal saline are ideal.Tapwater is satisfactory. 6 Solution temperature. This is vital. It should be 38°C (100°F).Any departure of more than a few degrees may precipitate the patient onto the floor with vertigo. 7 Tools. Metal syringes and Bacon syringes are capable of applying high pressures and the nozzle may also do damage.The preferred instrument is an electrically driven water Continued pump with a small hand-held nozzle and a foot operated control (Fig. 6.1). It provides an elegant means of ear syringing. 8 Direction. Direct stream of solution along roof of auditory canal (Fig. 6.2). 9 Inspection. After removal of wax, inspect thoroughly to make sure none remains.This advice might seem superfluous, but is frequently ignored. 10 Drying.Mop excess solution from meatal canal. Stagnation predisposes to otitis externa. Box 6.1 Ear syringing procedure. OTITIS EXTERNA Otitis externa is a diffuse inflammation of the skin lining the external auditory meatus. It may be bacterial or fungal (otomycosis), and is characterized by irritation, desquamation, scanty discharge and tendency to relapse.The treatment is simple, but success is absolutely dependent upon patience, care and meticulous attention to detail. CAUSES Some people are particularly prone to otitis externa, often because of a narrow or tortuous external canal. Most people can allow water into theirears with impunity but in others otitis externa is the inevitable result. Swimming baths are a common source of otitis externa. Poking the ear with a finger or towel further traumatizes the skin and introduces new organisms. Further irritation occurs, leading to further interference with the ear, so causing more trauma. A vicious circle is set up. Otitis externa may occur after staying in hotter climates than usual, where increased sweating and bathing are predisposing factors. Underlying skin disease, such as eczema or psoriasis, may occur in the ear canal and produce very refractory otitis externa. Ear syringing, especially if it causes trauma, may result in otitis externa. PATHOLOGY A mixed infection of varying organisms is not infrequent, the most commonly found types being: • Staphylococcus pyogenes; • Pseudomonas pyocyanea; • diphtheroids; 28 Chapter 6: Conditions of the External Auditory Meatus SYRINGING AN EAR Fig. 6.2 The stream of solution when syringing an ear should be directed along the roof of the external auditory canal. • Proteus vulgaris; • Escherichia coli; • Streptococcus faecalis; • Aspergillus niger (Fig. 6.3); • Candida albicans. SYMPTOMS 1 Irritation. 2 Discharge (scanty). 3 Pain (usually moderate, sometimes severe, increased by jaw movement). 4 Deafness. SIGNS 1 Meatal tenderness, especially on movement of the pinna or compression of the tragus. 2 Moist debris, often smelly and keratotic, the removal of which reveals red desquamated skin and oedema of the meatal walls and often the tympanic membrane. MANAGEMENT Scrupulous aural toilet is the key to successful treatment of otitis externa. No medication will be effective if the ear is full of debris and pus. Investigation Investigation of the offending microorganism is essential. A swab should be sent for culture and it is prudent to mention the possibility of fungal infection in your request, especially if the patient has already had topical antibiotic treatment. Aural toilet Aural toilet must be performed and can be done most conveniently by dry mopping. Fluffed-up cotton wool about the size of a postage stamp is applied to the Jobson Horn probe and, under direct vision, the ear is cleaned with a gentle rotatory action. Once the cotton wool is soiled it is replaced. Pay particular attention to the antero-inferior recess, which may be difficult to clean. Gentle syringing is also permissible to clear the debris. Dressings If the otitis externa is severe, a length of 1 cm ribbon gauze, impregnated with appropriate medication, should be inserted gently into the meatus, and renewed daily until the meatus has returned to normal. If it does not do so within 7–10 days, think again!. The following medications are of value on the dressing: 1 8% aluminium acetate; 2 10% ichthammol in glycerine; 3 ointment of gramicidin, neomycin, nystatin and triamcinolone (Tri-Adcortyl); 4 other medication may be used as dictated by the result of culture. If fungal otitis externa is present, dressings of 3% amphotericin, miconazole or nystatin may be used. If the otitis externa is less severe and there is little meatal swelling, it may respond to a combination of antibiotic and steroid ear drops. The antibiotics are usually those that are not given systemically. The antibiotics most commonly used are neomycin, gramicidin and framycetin. Remember that prolonged use may result in fungal infection or in sensitivity dermatitis. Prevention of recurrence Prevention of recurrence is not always possible; the patient should be advised to keep the ears dry, especially when washing the hair or showering.A large piece of cotton wool coated in Vaseline and placed in the concha is advisable, and if the patient is very keen to swim it is worthwhile investing in custom-made silicone rubber earplugs. The use of a proprietory preparation of spirit and acetic acid prophylactically after swimming is useful in reducing otitis externa. Equally important is the avoidance of scratching and poking the ears. Itching may be controlled with antihistamines given orally, especially at bedtime. If meatal stenosis predisposes to recurrent infection, meatoplasty (surgical enlargement of meatus) may be advisable. 30 Chapter 6: Conditions of the External Auditory Meatus infection in your request, especially if the patient has already had topical antibiotic treatment. Aural toilet Aural toilet must be performed and can be done most conveniently by dry mopping. Fluffed-up cotton wool about the size of a postage stamp is applied to the Jobson Horn probe and, under direct vision, the ear is cleaned with a gentle rotatory action. Once the cotton wool is soiled it is replaced. Pay particular attention to the antero-inferior recess, which may be difficult to clean. Gentle syringing is also permissible to clear the debris. Dressings If the otitis externa is severe, a length of 1 cm ribbon gauze, impregnated with appropriate medication, should be inserted gently into the meatus, and renewed daily until the meatus has returned to normal. If it does not do so within 7–10 days, think again!. The following medications are of value on the dressing: 1 8% aluminium acetate; 2 10% ichthammol in glycerine; 3 ointment of gramicidin, neomycin, nystatin and triamcinolone (Tri-Adcortyl); 4 other medication may be used as dictated by the result of culture. If fungal otitis externa is present, dressings of 3% amphotericin, miconazole or nystatin may be used. If the otitis externa is less severe and there is little meatal swelling, it may respond to a combination of antibiotic and steroid ear drops. The antibiotics are usually those that are not given systemically. The antibiotics most commonly used are neomycin, gramicidin and framycetin. Remember that prolonged use may result in fungal infection or in sensitivity dermatitis. Prevention of recurrence Prevention of recurrence is not always possible; the patient should be advised to keep the ears dry, especially when washing the hair or showering.A large piece of cotton wool coated in Vaseline and placed in the concha is advisable, and if the patient is very keen to swim it is worthwhile investing in custom-made silicone rubber earplugs. The use of a proprietory preparation of spirit and acetic acid prophylactically after swimming is useful in reducing otitis externa. Equally important is the avoidance of scratching and poking the ears. Itching may be controlled with antihistamines given orally, especially at bedtime. If meatal stenosis predisposes to recurrent infection, meatoplasty (surgical enlargement of meatus) may be advisable. 30 Chapter 6: Conditions of the External Auditory Meatus NB. Do not make a diagnosis of otitis externa until you have satisfied yourself that the tympanic membrane is intact. If the ear fails to settle, look again and again to make sure that you are not dealing with a case of otitis media with a discharging perforation. FURUNCULOSIS Furunculosis of the external canal results from infection of a hair follicle and so must occur in the lateral part of the meatus. The organism is usually Staphylococcus; the pain is often out of proportion to the visible lesion. SYMPTOMS Pain is as severe as that of renal colic and the patient may need pethidine. The pain is made much worse by movement of the pinna or pressure on the tragus. Deafness Deafness is usually slight and due to meatal occlusion by the furuncle. There is often no visible lesion but the introduction of an aural speculum causes intense pain. If the furuncle is larger, it will be seen as a red swelling in the outer meatus and there may be more than one furuncle present. At a more advanced stage, the furuncle will be seen to be pointing or may present as a fluctuant abscess. TREATMENT The insertion of a wick soaked in 10% ichthammol in glycerine (Glyc & Ic) is painful at the time but provides rapid relief. Flucloxacillin should be given parenterally for 24 h, followed by oral medication. Analgesics are necessary; the patient will often need pethidine and is not fit for work. Recurrent cases are not common—exclude diabetes and take a nasal swab in case the patient is a Staphylococcus carrier. EXOSTOSES Exostoses or small osteomata of the external auditory meatus are fairly common and usually bilateral.They are much more common in those who swim a lot in cold water, although the reason is not known. There may be 2 or 3 little tumours arising in each bony meatus.They are sessile, hard, smooth, covered with very thin skin and when gently probed are often exquisitely sensitive. Their rate of growth is extremely slow and they may give rise to no symptoms, but if wax or debris accumulates between the tympanic membrane and the exostoses, its removal may tax the patience of the most skilled manipulator. In such cases, surgical removal of the exostoses may be indicated and is carried out with the aid of the operating microscope and drill. MALIGNANT DISEASE Malignant disease of the auditory meatus is rare and usually occurs in the elderly. If confined to the outer meatus, it behaves like skin cancer and can be treated by wide excision and skin grafting. If it spreads to invade the middle ear, facial nerve and temporomandibular joint, it is a relentless and terrible affliction. Pain becomes intractable and intolerable and there is a blood-stained discharge from the ear. Treatment then is by radiotherapy, radical surgery or a combination of the two.Treatment is not possible in some cases, and the outlook is poor in the extreme.