Alan Nathan provides some sound advice when it comes to dealing with ear problems
A customer who is about to go on holiday asks for your advice. He tells you that he is flying to his destination, but is terrified because he gets excruciating pain in his ears.
1 What is the condition this man suffers from? What causes it and how can it be relieved?
1 Barotrauma is caused by pressure on the eardrum as air pressure in the cabin increases on the aircraft’s descent. It is more likely to be suffered by people who have had repeated ear infections in childhood, or who have suffered inner-ear damage or injury from other causes. It is also worsened by a current or recent upper respiratory tract infection.
• It is often relieved by the use of a decongestant nasal spray (eg, xylometazoline) just before descent begins or an oral decongestant (eg, pseudoephedrine) taken about an hour before descent. Chewing or sucking (eg, a toffee or boiled sweet) or yawning also helps to equalise pressure in the Eustachian tube and ease pain.
• Valsalva’s manoeuvre can also be used: the nostrils are held tightly closed with the thumb and forefinger while the person tries to blow out through the nose with the mouth closed. An autoinflation device is also available and can be used to relieve barotrauma.
A patient has been diagnosed with ear wax by his GP who has asked him to return in a week to have it syringed out. In the meantime he has been advised to soften it with ear drops and to buy them as it would be cheaper than an NHS prescription charge.
2 What is ear wax and what is available to soften and dissolve it?
3 How should ear drops be used?
2. Ear wax (cerumen) is a complex, oily fluid secreted by sebaceous and apocrine glands in the external auditory canal, which combines with exfoliated skin cells to form a protective waxy layer. This is normally moved outwards by movement of the jaw in speaking and chewing, and removed by washing. In some individuals, however, excessive cohesive cerumen is produced. This forms a waxy plug that affects hearing and causes discomfort. Generally, syringing is necessary to remove ear wax but cerumenolytics can be used in advance to soften, loosen and partially dissolve it. Several approaches are taken, including the use of aqueous and oily solvents and surfactants, and oxygen generation to facilitate the penetration of water into the plug.
Fixed and volatile oils: Ear wax contains a high proportion of oily components, so it is logical to assume that it can be dissolved, at least partially, by oils. The BNF recommends the use of olive oil or almond oil alone to soften wax before removal, and several proprietary ear drop products contain olive oil alone. Arachis (peanut) oil is a constituent of other products, and one contains this, together with rosemary and cajuput oils.
Urea hydrogen peroxide: Several ear drop brands contain 5% urea hydrogen peroxide in a glycerol base. In contact with tissues containing the enzyme catalase, hydrogen peroxide releases its oxygen to create effervescence, which helps to break up wax by a mechanical action. Glycerol assists in softening the wax and urea increases penetration of the solution into the plug.
Sodium Bicarbonate Ear Drops BP contains 5% sodium bicarbonate and 30% glycerol in water. It is recommended as effective in the BNF.
Docusate sodium is a surface active agent that increases water penetration into the wax plug. It is the sole component of two proprietary products.
• It is best to have another person instil the ear drops.
• Before use, the drops should be slightly warmed by holding the container in the hands for a few minutes. • The patient should lay their head on a flat surface such as a table, with the affected ear uppermost.
• The auricle (pinna) should be lifted upwards and backwards in adults, or downward and backwards in children, to straighten the ear canal.
• The requisite number of drops should be instilled.
• The tragus (the small projection in front of the external opening) should be pressed gently once or twice, to assist the drops down the ear canal and to expel air bubbles.
• The patient should remain with their head down for at least five minutes. A cotton-wool plug moistened with the drops should be placed into the ear.
• Unless directed otherwise, the drops should be used night and morning for three or four days before syringing.
A woman brings in her 4-year-old daughter. She says that she recently had a cold and is now complaining of earache. Are there any ear drops she could buy to ease the pain?
4 What would you do in this case, and what would you do if an adult who had a cold told you that he also had earache?
4 Earache in children should always be referred, as otitis media (infection of the middle ear) is fairly common and repeated attacks can lead to permanent damage if not managed properly. Use of an oral analgesic can be advised until a doctor can be seen. In adults, earache may sometimes be associated with an upper respiratory tract infection and, as long as the pain is not severe, can be treated with oral analgesics for up to 48 hours, before referral if the condition does not improve.
A customer tells you that mums on the school run were talking about‘glue ear’. She asks you if you can tell her anything about it.
5 What is ‘glue ear'?
6 What treatments are available for it?
5 Otitis media with effusion (OME), commonly known as ‘glue ear’, is the build-up of fluid in the middle ear and Eustachian tube. It prevents the eardrum vibrating properly, causing hearing loss.
It usually follows an episode of otitis media and occurs most frequently in children between the ages of 1 and 6, although it can affect older children. By age 10, 80% of children will have suffered at least one bout of OME. The condition is uncommon in adults.
6 OME is a self-limiting condition, usually resolving spontaneously within 6-10 weeks. Pharmacological treatment is generally ineffective: antihistamines, decongestants, steroids and antibiotics have been found to be of no benefit1.The use of an autoinflation device – where a balloon is inflated by blowing into it from one nostril, while sealing the other nostril with a finger, resulting in an increase in intranasal pressure and opening of the Eustachian tube to produce a Valsalva manoeuvre to relieve OME – is harmless but evidence for its effectiveness is limited. Myringotomy (an incision into the ear drum) and drainage of fluid with insertion of a ventilation tube (grommet) is sometimes performed in chronic cases, but the effect on hearing loss has been found to be small and diminishing with time2.
1. van Zon A, van der Heijden GJ, van Dongen TM, et al; Antibiotics for otitis media with effusion in children. Cochrane Database Syst Rev. 2012:CD009163. doi: 10.1002/14651858.CD009163.pub2. 2. Browning GG, Rovers MM, Williamson I, Lous J, Burton MJ. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev. 2010:CD001801. doi: 10.1002/14651858.CD001801.pub3.