Get an earful from ENT expert Dr. Angela Peng about how to approach common ear concerns, basic ear exam skills, safely clearing earwax and more!
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Watch this basic ear exam video from The American Academy of Otolaryngology – Head and Neck Surgery
How to hold the otoscope: Hold the otoscope with your right hand when inspecting the right ear and left hand when inspecting the left ear. Let your hand rest on the patient’s cheek as you use the otoscope, and use the other hand to pull up the top of the ear.
What about the insufflation bulb? It will be pretty hard for you to do this because you need a proper size speculum (otherwise air will escape and invalidate the exam). If possible, Dr. Peng recommends an audiogram and tympanogram to show how the eardrum is moving.
Start with a good ear exam, working your way from the outer ear (to inspect for external lesions) to the middle ear. As always, the history helps with your differential diagnosis list (eg history of chronic ear infections or sinus issues contributing to eustachian tube disorders).
If all looks well, examine the structures immediately outside the ear such as the musculature which can cause myofascial pain from the temporomandibular joint (TMJ) or the muscles of mastication. If pain is related to mouth opening, consider TMJ syndrome. Inspect further into the throat; unilateral ear pain can be a presenting symptom for pharyngeal or laryngeal issues that can range from tonsillitis to oropharyngeal cancers. Imaging with a neck CT with contrast can be the next step in diagnostics if nothing is seen on fiberoptic laryngoscopy.
Pearl: Ramsay Hunt Syndrome stems from herpetic lesions of the external ear and is associated with facial nerve paralysis (Jeon and Lee, 2023)
The eustachian tube lies open between the inner ear and the nose and drains into the back of the nose. Muscles attached to the eustachian tube help open it up as patients chew or swallow. Nasal/sinus fluid from a host of issues can back up into the ear as the eustachian tube fills up and closes shut. Chewing gum, yawning or any other motion that stretches open the muscles attached to the eustachian tube will in turn open it and help drain its contents. A pro-tip from Dr. Peng is to use a picture of the anatomy of the inner ear and sinuses to demonstrate the location of the eustachian tube when talking about pathology.
How do we know it’s Eustachian Tube Dysfunction (ETD)? The exam may show a scarred or opaque eardrum from recent infection, or the eardrum could be retracted over the ossicles (can look like plastic film wrap covering the bones) due to negative pressure changes. The history may point towards chronic rhinosinusitis which is associated with ETD (Wu et al, 2020). Dr. Peng recommends the use of nasal steroids and/or oral antihistamines in such cases. When symptoms persist, Dr. Peng suggests adding a nasal antihistamine before escalating treatment to allergy shots (Bal and Deshmukh, 2022). Tympanostomy or ear tubes can be used in cases where eustachian tube dysfunction does not resolve with conservative measures. ET balloon dilation is a relatively new procedure that could be used in select candidates (Froehlich et al, 2020).
Otosclerosis should be considered when conductive hearing loss is the more prominent presenting symptom; ear pain or infections are less often seen as part of otosclerosis. Patients with chronic otitis media and severe eustachian tube dysfunction are at higher risk of developing cholesteatomas. Cholesteatomas are thick white “cheesy” particles called keratin pearls. These are usually noted in the weakest spot of the eardrum, the posterior superior quadrant. The size of the cholesteatoma can be deceiving as it could be deep in the middle ear or the mastoid (Shurmann et al, 2022; Wong et al, 2022). Both chronic otitis media and cholesteatoma pose a risk of hearing loss; our expert recommends referral to ENT as soon as possible (Pusalkar, 2015). Additional clinical practice guidelines can be found from the American Academy of Otolaryngology-Head and Neck Surgery.
Treat an acute presentation of otitis media with oral antibiotics, such as amoxicillin-clavulanate acid and consider adding intranasal steroids or antihistamines. While using antibiotic ear drops for otitis media is not recommended, a treatment option for an irritated or edematous eardrum is the use of otic steroid drops such as dexamethasone. In cases with severe sinonasal involvement, Dr. Peng uses oral steroids to decrease the inflammation (McCoul et al, 2023). Recurrent infections can lead to chronic otitis media which puts the patient at risk for severe hearing loss, meningitis or other intracranial pathology. Refer to ENT for frequent acute otitis media, chronic otitis media and/or any suspicion for complications like hearing loss.
Otitis externa is the term for an infection of the outer ear and can be roughly divided into bacterial or fungal etiology. Bacterial otitis externa often appears purulent whereas fungal otitis externa will present with friable skin, white cottage cheese debris or fuzzy appearing debris from hyphae. In the rare occurrence that you see black debris in the ear canal, this could be aspergillus which could be very serious (patients with poorly controlled diabetes are at particular risk). Malignant or necrotizing otitis externa refers to osteomyelitis of the temporal bone and presents with pain that extends beyond the ear but also radiates around the head. Dr. Peng reminds us that the symptoms are not always congruent with the severity of the disease and recommends a high index of suspicion for malignant otitis externa disease especially in patients with diabetes (Gonzalez et al, 2021).
Dr. Peng suggests getting a culture of the ear canal when in doubt to inform correct treatment, particularly if there has been no improvement after initial treatment. Dr. Peng recommends ofloxacin with dexamethasone as first-line treatment for otitis externa (Jackson and Geer, 2023). Since these combo ear drops can be very expensive, she suggests using the ophthalmic version of the separate ingredients to treat the outer ear (expert opinion). The rationale: ophthalmic drops are pH balanced and are less irritating if used in the ear even if the eardrum is perforated. (n.b. while you can use eye drops in the ear, NEVER use ear drops in the eyes). To prevent otitis externa, she suggests making a disinfecting mixture that can be applied to the ear after swimming. To make this solution, mix one part of rubbing alcohol with one part distilled white vinegar and apply a couple of drops in the ear canal.
Patients should NOT be using over-the-counter ear drops at all if the eardrum is perforated. Ofloxacin otic can be used in the setting of an open eardrum (Li et al, 2022). If cost is an issue, ophthalmic drops can be used in this setting as well.
Depending on the impaction, cerumen could be loosened with a couple of drops of mineral oil every other day until it comes out on its own or with lavage (Horton et al, 2020). Irrigation can pose a risk of infection if water gets trapped behind the impacted cerumen. Patients with perforated eardrums or tubes should not be irrigated. In Dr. Peng’s practice, she does not recommend using hydrogen peroxide because it swells the cerumen rather than dislodges it. Once the ear canal is clean, using mineral oil on a weekly basis may help prevent an obstruction. For patients who use earplugs or hearing devices, cerumen gets impacted more easily thus these patients should clean their devices regularly.
Eczema or psoriasis in the ear canal can often be confused for an infection. Dr. Peng recommends using fluocinolone oil drops to lubricate the ear canal, which can lessen the wax burden, and also reduce inflammation.
Listeners will develop a comprehensive approach to diagnosing and treating common ear complaints in the primary care setting and systematically assess the best time to refer to specialists.
After listening to this episode listeners will…
Dr. Angela Peng reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Valdez I, Peng A, Williams PN, Watto MF. “#413: Hear Everything from Earwax to Eustacian Tube Woes with Dr. Angela Peng. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date October, 23, 2023.
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Producer, Writer, Show Notes, Cover Art and Infographics: Isabel Valdez, PA-C
Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP
Reviewer: Leah Witt, MD
Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP
Technical Production: PodPaste
Guest: Angela Peng, MD
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