#413: Common Ear Complaints, Ear Exam 101, Cerumen Remedies, and more!  Get an EARful with Dr. Angela Peng!

October 23, 2023 | By Isabel Valdez

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Common Ear Complaints, Tips and (Keratin) Pearls in Primary Care

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!

Claim free CME for this episode at curbsiders.vcuhealth.org!

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Show Segments

• Intro with great pun!
• Rapid fire questions/Picks of the Week
• Case #1: Inner ear complaint
• Ear Exam 101
• Eustachian Tube Dysfunction
• Cholesteatoma
• Case #2: Outer ear complaint
• Malignant otitis externa
• Open tympanic membrane treatments
• Cerumen impaction
• Itchy Ears
• Outro

Pearls from Common Ear Complaints, Ear Exam 101, Cerumen Remedies, and more!  Get an earful with Dr. Angela Peng

1. When examining ears, start with the unaffected ear (to get a good baseline) before looking at the affected ear.
2. Not all ear pain is otologic in origin and instead could be referred from muscular or pharyngeal/laryngeal etiologies.
3. The eustachian tube is hard to explain! Try using pictures and a plumbing analogy. The eustachian tube can get obstructed from sinus fluid that causes negative pressure in the middle ear, causing the eardrum to retract. 
4. Cholesteatoma (keratin pearls) appearance in the middle ear can be misleading; the cholesteatoma can lie deep in the middle ear or the mastoid.
5. If prescribing eardrop combinations that are costly, try writing separate prescriptions for the components or prescribe the ophthalmic version of the medications.
6. Caution patients to never use over-the-counter ear drops in an open eardrum; only prescription drops such as ofloxacin should be considered.
7. To pre-treat cerumen impaction for irrigation, try mineral oil to lubricate the wax and avoid hydrogen peroxide (which actually expands wax and can worsen obstruction!) 
8. Prescription steroid drops can alleviate itch from eczema of the ear.
9. Make at home! Sinus rinse solutions and ear canal disinfecting drops can be made with household ingredients.

Common Ear Complaints, Ear Exam 101, Cerumen Remedies, and more!  Get an earful  with Dr. Angela Peng

(Keratin) Pearls for the Ear Exam

Watch this basic ear exam video from The American Academy of Otolaryngology – Head and Neck Surgery

• Examine BOTH ears: Start by looking at the unaffected ear FIRST to get a baseline, then move to the ear with the complaint. 
• Ear canals: Ear canals are curvy so pull the helix (top of the ear) back to open up the canal and avoid inserting the speculum straight into the canal right away. Inspect the ear canal for redness, fluid, and bones as you advance the speculum 
• Ear drum: Inspect for a perforation; the ossicles are located in the back superior quadrant 
• Middle ear: Check the middle ear for mucus, a growth/mass or cholesteatoma. 
• Fluid: Fluid can vary in color from clear/straw to dull, opaque to red or even purulent. 

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. 

General Approach: Exam and History Basics

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)

Eustachian Tube Dysfunction: It’s Just like Plumbing

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).

When it’s not ETD: Otosclerosis or Cholesteatoma

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.

Otitis Media: Treatment (Keratin) Pearls 

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. 

External Ear Complaints 

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).

Treatment (Keratin) Pearls for Outer Ear Complaints

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.

Ear Drops and Open Eardrum

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.  

Cerumen Impaction

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.

Itchy ears 

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. 

Take Home Points

• Start with a good examination
• Remember to ask about the nasosinal components of the history and exam
• NO instruments in the ear should be used to clean out the earwax; that means no cotton swabs in the ear! 

Links

#379: Hearing Loss, Tinnitus and Meniere’s Disease 

#239: Sinusitis: Its Not That Tricky 

Goal

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. 

Learning objectives

After listening to this episode listeners will…  

1. Implement a systematic approach to ear pain that will help differentiate etiologies (inner vs external) and inform the best treatments
2. Analyze inner ear complaints to design comprehensive care plans beyond the (mis)use of antibiotics
3. Recognize risks factors/behaviors that affect the outer ear and create patient-centric education that improve outer ear health.  
4. Learn when to refer to an ENT specialist

Disclosures

Dr.  Angela Peng reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

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.