Conditions of the External Ear
Cerumen normally accumulates in the external canal in various amounts and colors. Although wax does not usually need to be removed, impaction occasionally occurs, causing otalgia, a sen-sation of fullness or pain in the ear, with or without a hearing loss. Accumulation of cerumen is especially significant in the geriatric population as a cause of hearing deficit. Attempts to clear the ex-ternal auditory canal with matches, hairpins, and other imple-ments are dangerous because trauma to the skin, infection, and damage to the tympanic membrane can occur.
Cerumen can be removed by irrigation, suction, or instrumenta-tion. Unless the patient has a perforated eardrum or an inflamed external ear (ie, otitis externa), gentle irrigation usually helps re-move impacted cerumen, particularly if it is not tightly packed in the external auditory canal. For successful removal, the water stream must flow behind the obstructing cerumen to move it first laterally and then out of the canal. To prevent injury, the lowest effective pressure should be used. If the eardrum behind the im-paction is perforated, however, water can enter the middle ear, producing acute vertigo and infection. If irrigation is unsuccess-ful, direct visual, mechanical removal can be performed on a co-operative patient by a trained health care provider.
Instilling a few drops of warmed glycerin, mineral oil, or half-strength hydrogen peroxide into the ear canal for 30 minutes can soften cerumen before its removal. Ceruminolytic agents, such as peroxide in glyceryl (Debrox), are available; however, these com-pounds may cause an allergic dermatitis reaction. Using any softening solution two or three times a day for several days is generally sufficient. If the cerumen cannot be dislodged by these methods, instruments, such as a cerumen curette, aural suction, and a binocular microscope for magnification, can be used.
Some objects are inserted intentionally into the ear by adults who may have been trying to clean the external canal or relieve itch-ing or by children who introduce the objects. Other objects, such as insects, peas, beans, pebbles, toys, and beads, may enter or be introduced into the ear canal. In either case, the effects may range from no symptoms to profound pain and decreased hearing.
Removing a foreign body from the external auditory canal can be quite challenging. The three standard methods for removing for-eign bodies are the same as those for removing cerumen: irriga-tion, suction, and instrumentation. The contraindications for irrigation are also the same. Foreign vegetable bodies and insects tend to swell; thus, irrigation is contraindicated. Usually, an in-sect can be dislodged by instilling mineral oil, which will kill the insect and allow it to be removed.
Attempts to remove any foreign body from the external canal may be dangerous in unskilled hands. The object may be pushed completely into the bony portion of the canal, lacerating the skin and perforating the tympanic membrane. In difficult cases, the foreign body may have to be extracted in the operating room with the patient under general anesthesia.
External otitis, or otitis externa, refers to an inflammation of theexternal auditory canal. Causes include water in the ear canal (ie, swimmer’s ear); trauma to the skin of the ear canal, permitting entrance of organisms into the tissues; and systemic conditions, such as vitamin deficiency and endocrine disorders. Bacterial or fungal infections are most frequently encountered. The most common bacterial pathogens associated with external otitis are Staphylococcus aureus and Pseudomonas species. The most com-mon fungus isolated in both normal and infected ears is As-pergillus. External otitis is often caused by a dermatosis such aspsoriasis, eczema, or seborrheic dermatitis. Even allergic reactions to hair spray, hair dye, and permanent wave lotions can cause der-matitis, which clears when the offending agent is removed.
The patient usually reports pain, discharge from the external au-ditory canal, aural tenderness (usually not present in middle ear infections), and occasionally fever, cellulitis, and lymphadenopa-thy. Other symptoms may include pruritus and hearing loss or a feeling of fullness. On otoscopic examination, the ear canal is ery-thematous and edematous. Discharge may be yellow or green and foul smelling. In fungal infections, the hairlike black spores may even be visible.
The principles of therapy are aimed at relieving the discomfort, reducing the swelling of the ear canal, and eradicating the infec-tion. Patients may require analgesics for the first 48 to 92 hours. If the tissues of the external canal are edematous, a wick should be inserted to keep the canal open so that liquid medications (eg, Burow’s solution, antibiotic otic preparations) can be introduced. These medications may be administered by dropper at room tem-perature. Such medications usually combine antibiotic and cor-ticosteroid agents to soothe the inflamed tissues. For cellulitis or fever, systemic antibiotics may be prescribed. For fungal disorders, antifungal agents are prescribed.
Nurses need to teach patients not to clean the external auditory canal with cotton-tipped applicators, to avoid swimming, and not to allow water to enter the ear when shampooing or showering. A cotton ball can be covered in a water-insoluble gel such as petroleum jelly and placed in the ear as a barrier to water con-tamination. Infection can be prevented by using antiseptic otic preparations after swimming (eg, Swim Ear, Ear Dry), unless there is a history of tympanic membrane perforation or a current ear infection.
A more serious, although rare, external ear infection is malignant external otitis (ie, temporal bone osteomyelitis). This is a pro-gressive, debilitating, and occasionally fatal infection of the ex-ternal auditory canal, the surrounding tissue, and the base of the skull. Pseudomonas aeruginosa is usually the infecting organism in patients with low resistance to infection (eg, patients with dia-betes). Successful treatment includes control of the diabetes, ad-ministration of antibiotics (usually intravenously), and aggressive local wound care. Standard parenteral antibiotic treatment in-cludes the combination of an antipseudomonal agent and an ami-noglycoside, both of which have potentially serious side effects.Because aminoglycosides are nephrotoxic and ototoxic, serum aminoglycoside levels and renal and auditory function must be monitored during therapy. Local wound care includes limited débridement of the infected tissue, including bone and cartilage, depending on the extent of the infection.
Exostoses are small, hard, bony protrusions found in the lowerposterior bony portion of the ear canal; they usually occur bilater-ally. The skin covering the exostosis is normal. Many people think exostoses are caused by an exposure to cold water, as in scuba div-ing or surfing. The usual treatment, if any, is surgical excision.
Malignant tumors also may be found in the external ear. Most common are basal cell carcinomas on the pinna and squamous cell carcinomas in the ear canal. If untreated, squamous cell carci-noma may spread through the temporal bone, causing facial nerve paralysis and hearing loss. Carcinomas must be treated surgically.
Gapping earring puncture results from wearing heavy pierced ear-rings for a long time or after an infection, or as a reaction from the earring or other impurities in the earring. One or more gap-ping punctures may result from wearing more than one earring. Whatever its cause, this deformity can only be corrected surgi-cally. The edges of the perforations are excised on the lateral and medial surfaces of the earlobe. Next, the entire tract is removed, joining the above two incisions and resulting in a much larger de-fect that is closed separately on each surface. Then, an antibiotic dressing is applied.