External Ear Disorders

Introduction
The outer ear consists of the external part of the ear (pinna or auricle) and the ear canal (external auditory meatus. Disorders of the outer ear include blockages, infections (external otitis and perichondritis), eczema, and tumors. The outer ear is also prone to certain types of injury. a

Blockages
Earwax (cerumen) may block the ear canal. Even large amounts of wax often produce no symptoms. Symptoms can range from itching to a loss of hearing. A doctor may remove the earwax by gently flushing out the ear canal with warm water (irrigation). However, if a person has had a perforated eardrum, irrigation is not used because water can enter the middle ear if the perforation is still present. Similarly, irrigation is not used if there is any discharge from the ear, because the discharge may be coming from a perforated eardrum. In these situations, a doctor may remove earwax with a blunt instrument, an instrument with a loop at the end, or a vacuum device.

Earwax solvents help soften wax, but they usually must be followed by irrigation, because the solvent rarely dissolves all of the wax. People should not attempt earwax removal at home with cotton swabs, bobby pins, pencils, or any other implements. Such attempts usually just pack the wax in more and can damage the eardrum. Soap and water on a washcloth provide adequate external ear hygiene

Other blockages can occur when people, particularly children, put foreign objects, such as beads, erasers, and beans, into the ear canal. Usually, a doctor removes such objects with a blunt hook or small vacuum device. Sometimes metal and glass beads can be flushed out by irrigation, but water causes some objects, such as beans, to swell, complicating removal. Objects that are deep in the canal are more difficult to remove because of the risk of injury to the eardrum. A general anesthetic is used when a child does not cooperate or when removal is particularly difficult.

Insects, particularly cockroaches, may also block the ear canal. To kill the insect, a doctor fills the canal with mineral oil or a numbing agent. This measure also provides immediate pain relief and enables the doctor to remove the insect.

External Otitis
External otitis is infection of the ear canal.

External otitis may affect the entire canal, as in generalized external otitis, or just one small area, as in a boil (furuncle) or pimple.

Causes
A variety of bacteria or, rarely, fungi can cause generalized external otitis. Certain people, including those who have allergies, psoriasis, eczema, or scalp dermatitis, are particularly prone to external otitis. Injuring the ear canal while cleaning it or getting water or irritants such as hair spray or hair dye in the canal often leads to external otitis. External otitis is particularly common after swimming in fresh water pools, in which case it is sometimes called swimmer's ear. Earplugs and hearing aids make external otitis more likely, particularly if these devices are not properly cleaned.

Symptoms and Diagnosis
Symptoms of generalized external otitis are itching and pain. Sometimes an unpleasant-smelling white or yellow discharge drains from the ear. The ear canal may have no swelling, slight swelling, or in severe cases be swollen completely closed. If the ear canal swells or fills with pus and debris, hearing is impaired. Usually, the canal is tender and hurts if the external ear (pinna) is pulled or if pressure is placed on the fold of skin in front of the ear canal. To a doctor looking into the ear canal through an otoscope (a device for viewing the canal and eardrum), the skin of the canal appears red and swollen and may be littered with pus and debris.

Boils cause severe pain. When they rupture, a small amount of blood and pus may leak from the ear.

Prevention and Treatment

Swimmer's ear may be prevented by putting drops of a solution containing half rubbing alcohol and half vinegar in the ear before and after swimming. The person should avoid swimming in polluted water, using hair spray, and spending much time in warm, humid climates.

Attempting to clean the canal with cotton swabs interrupts the normal, self-cleaning mechanism and can push debris toward the eardrum, where it accumulates. Also, these actions may cause minor damage that predisposes to external otitis.

To treat generalized external otitis from any cause, a doctor first removes the infected debris from the canal with suction or dry cotton wipes. After the ear canal is cleared, hearing often returns to normal. Usually, a person is given antibiotic ear drops to use several times a day for up to a week. Some ear drops also contain a corticosteroid to reduce swelling and analgesics to reduce pain. Often, external otitis is successfully treated with ear drops containing vinegar.
Bacteria do not grow as well once the normal acidity of the ear canal is restored. If the ear canal is very swollen, a doctor inserts a small wick in the canal to allow the drops to penetrate.

Analgesics such as acetaminophen codeine may help reduce pain for the first 24 to 48 hours, until the inflammation begins to subside. An infection that has spread beyond the ear canal cellulitis may be treated with an antibiotic given by mouth.

Treatment of boils depends on how advanced the infection is. In an early stage of infection, a heating pad can be applied for a short time and analgesics can be given to help relieve pain; the heat may also help speed healing. A boil that has come to a head is cut open to drain the pus. An antibiotic is then applied directly to the area or given by mouth.

Injury
A number of different injuries can affect the outer ear. A blunt blow to the external ear can cause bruising between the cartilage and the layer of connective tissue around it (perichondrium). When blood collects in this area, the external ear becomes swollen and purple. The collected blood (hematoma) can cut off the blood supply to the cartilage, allowing that portion of the cartilage to die, leading in time to a deformed ear. This deformity, called a cauliflower ear, is common among wrestlers, boxers, and rugby players.

A doctor cuts open the hematoma and removes the blood with suction. After the hematoma is empty, the doctor applies a compression dressing, which is left on for 3 to 7 days to keep the hematoma from coming back. The dressing keeps the skin and perichondrium in their normal positions, allowing blood to reach the cartilage again.

If a cut (laceration) goes all the way through the ear, the area is cleansed thoroughly and the skin is sewn back together and a dressing is applied to protect the area and allow the cartilage to heal. The cartilage is not sewn.

A forceful blow to the jaw may fracture the bones surrounding the ear canal and distort the canal's shape, often narrowing it. The shape can be corrected surgically.

Perichondritis
Perichondritis is infection of the cartilage of the external ear.

Injury, burns, insect bites, ear piercing, or a boil on the ear may cause perichondritis. The infection also tends to occur in people whose immune system is weakened and in people who have diabetes. The first symptoms are redness, pain, and swelling of the ear. The person may have a fever. Pus accumulates between the cartilage and the layer of connective tissue around it (perichondrium). Sometimes the pus cuts off the blood supply to the cartilage, destroying it and leading eventually to a deformed ear. Although destructive and long-lasting, perichondritis tends to produce only mild discomfort.

A doctor makes an incision to drain the pus, allowing blood to reach the cartilage again. Antibiotics are given by mouth for milder infections and intravenously for severe infections. The choice of antibiotic depends on how severe the infection is and which bacteria are causing it.

Tumors
Tumors of the ear may be noncancerous (benign) or cancerous (malignant). Most ear tumors are found when a person sees them, or when a doctor looks in the ear because the person notices his hearing seems decreased.

Noncancerous tumors may develop in the ear canal, blocking it and causing hearing loss and a buildup of earwax. Such tumors include small sacs filled with skin secretions (sebaceous cysts), osteomas (bone tumors), and growths of excess scar tissue after an injury (keloids). The most effective treatment is surgical removal of the tumor. After treatment, hearing usually returns to normal.

Basal cell and squamous cell cancers are common skin cancers that often develop on the external ear after repeated and prolonged exposure to the sun. When these cancers first appear, they can be successfully treated by removing them surgically or by applying radiation therapy. More advanced cancers may require surgical removal of a larger area of the external ear.

Ceruminoma (cancer of the cells that produce earwax) develops in the outer third of the ear canal and can spread. Ceruminomas have nothing to do with earwax buildup. Treatment consists of removing the cancer and the surrounding tissue surgically

Adapted from: Merck & Co., Inc

Temporal Bone Fracture

The temporal bone (the skull bone containing part of the ear canal, the middle ear, and the inner ear) can be fractured by a blow to the head.

Temporal bone fractures frequently rupture the eardrum and may also damage the ossicles and the cochlea.

Symptoms include facial paralysis on the side of the fracture and profound hearing loss, which may be conductive, sensorineural, or both. People may have bleeding from the ear, blood behind the eardrum, or patchy bruising of the skin behind the ear. Sometimes, cerebrospinal fluid leaks from the brain through the fracture and appears as clear fluid draining from the ear or nose. Leakage of this fluid indicates that the brain is exposed to infection.

Diagnosis is made with computed tomography (CT). Treatment usually requires an antibiotic given intravenously to prevent infection of the tissues covering the brain (meningitis).

Sometimes, persistent facial paralysis caused by pressure on the facial nerve can be relieved by surgery. Damage to the eardrum and structures of the middle ear is repaired surgically weeks or months later if necessary.

Adapted from: Merck & Co., Inc.

Ruptured Eardrum

Introduction
A ruptured (perforated) eardrum is a tear or a hole in your eardrum (tympanic membrane), the thin membrane that separates your ear canal from your middle ear. This membrane vibrates when sound waves strike it, starting the process of converting sound waves into nerve impulses that travel to your brain. Damage to your eardrum interrupts the hearing process and may impair your hearing.

The eardrum also acts as a barrier to keep outside material, such as bacteria, from entering your middle ear. When your eardrum is ruptured, bacteria can more easily reach your middle ear and cause infection.

A variety of factors can cause a ruptured eardrum. These include a prior infection, injury and noise. Most ruptured eardrums heal within a few weeks without treatment. If the tear or hole in your eardrum doesn't heal by itself, you may need treatment.


Signs and symptoms
A ruptured eardrum can be painful, particularly at first. Signs and symptoms may include:

Sharp, sudden ear pain or discomfort
Clear, pus-filled or bloody drainage from your ear
Sudden decrease in ear pain followed by drainage from that ear
Hearing loss
Ringing in your ear (tinnitus)

Causes
Causes of a ruptured eardrum may include:

Middle ear infection (otitis media). A middle ear infection may cause your eardrum to rupture as the pressure of the fluid in your middle ear increases. Conversely, a ruptured eardrum can lead to an infection because your eardrum is no longer intact, allowing bacteria to enter your middle ear.

Airplane ear (barotrauma). Pressure on your ear, such as during ascent or descent of a flight, can cause your eardrum to rupture.

Injury to your ear (acoustic trauma). Damage to your eardrum can occur from a direct injury, such as if your ear is struck squarely with an open hand.

Foreign objects in your ear. Small objects such as a cotton swab or bobby pin pushed too far into your ear canal can rupture your eardrum. Attempts to clean earwax (cerumen) from your ear can damage your eardrum and cause infection of your outer ear canal (swimmer's ear).

Loud, sudden noise. A sudden, extremely loud noise, such as from an explosion or a firearm, can rupture your eardrum. Your loss of hearing may be great, and ringing in your ear (tinnitus) may be severe. Hearing usually returns partially, and the ringing in your ear often diminishes in a few days. But in some cases it may last indefinitely.

Risk factors
Risk factors for tearing or rupturing your eardrum include:

Fluid buildup from middle ear infection
Cleaning your ear with small objects to clear away earwax buildup or blockage
Excessive scratching of your ear due to itchy ears

Refrain from putting any foreign object inside your ear. Get treatment for middle ear infections promptly.


When to seek medical advice
Seek medical care if you have pain or swelling in your ear or drainage from your ear. Discharge of blood or pus may be a sign that your eardrum has ruptured. See your doctor immediately if you develop fever or headache, or if the pain in your ear becomes severe.


Screening and diagnosis
Your doctor will examine your ear to determine if you have a ruptured eardrum by using a lighted instrument (otoscope) to look inside your ear. He or she may refer you to a doctor who specializes in the care of ear, nose and throat disorders (otolaryngologist).

A ruptured eardrum has a tear or a hole in it, and the bones of your middle ear may be visible behind your eardrum. If you have drainage from your ear, your doctor can take a sample of the fluid to be analyzed in the laboratory to determine if bacteria or fungi have caused infection.


Complications
A ruptured eardrum usually isn't serious and often heals on its own without complications. But problems may occur, including:

Hearing loss. Usually, hearing loss is temporary, lasting only until the tear or hole in your eardrum has healed. The larger the tear or hole in your eardrum, the greater your hearing loss tends to be. The location of the tear or hole also may affect the degree of hearing loss. If severe trauma, such as a skull fracture, damages the bones in your middle ear and causes injury to the structure of your inner ear, loss of hearing may be severe and permanent.

Recurrent middle ear infection (chronic otitis media). Persistent or recurrent inflammation or infection of your middle ear caused by a large tear or hole in your eardrum can cause permanent damage and hearing loss.


Treatment
Most ruptured eardrums heal without treatment within a few weeks, although some may take months. If the tear or hole in your eardrum doesn't heal by itself, treatment involves steps to close the perforation. Treatments may include:

Eardrum patch. If the tear or hole in your eardrum is small, an otolaryngologist may seal it with a paper patch. This procedure is done in the doctor's office. Your doctor may touch the edges of your eardrum with a chemical to stimulate growth and then place a thin paper patch on your eardrum. Your ear may need several applications of a patch (up to three or four) before the perforation closes completely.

Surgery. If your doctor determines that a paper patch won't provide prompt and adequate closure of the tear or hole in your eardrum, or if attempts with paper patching fail to heal the damage, you may need surgery. During a procedure called tympanoplasty, your surgeon places a tissue patch across the perforation, allowing it to heal. Tympanoplasty is often successful in closing the tear or hole permanently and restoring hearing. This procedure is done on an outpatient basis, meaning you can go home the same day.

Closing a perforation in your eardrum can:

Prevent water from entering your ear while showering, bathing or swimming, each of which could lead to a middle ear infection
Improve your hearing
Diminish ringing in your ears (tinnitus)

Prevent the development of a skin cyst in your middle ear (cholesteatoma), a cyst that can cause chronic middle ear infections and damage the structure of your ear

Prevention
Follow these tips to avoid a ruptured eardrum:

Get treatment for middle ear infections. Be aware of the signs and symptoms of middle ear infection and seek treatment accordingly. Control the infection before it worsens enough to rupture your eardrum.

Protect your ears during flight. Prevent your ears from popping and your eardrums from rupturing while flying. Don't fly if you have a cold or an active allergy that causes you to be congested. Wear pressure-equalizing earplugs or chew gum during ascent and descent to keep your ears clear.

Keep your ears free of foreign objects. Never attempt to dig out excess or hardened earwax with items such as a cotton swab, paper clip or hairpin. These items can easily tear or puncture your eardrum. Teach children about the damage that can be done by putting foreign objects in their ears.

Guard against excessive noise. Protect your ears from unnecessary damage by wearing protective earplugs or earmuffs in your workplace or during recreational activities if loud continuous noise is present. Keep the volume down when listening to music or television.

Self-care
Try these steps to stay comfortable while your eardrum heals:

Use warmth. Place a warm (not hot) heating pad over or against your ear to help reduce pain.

Keep your ear dry while it's healing. Use earplugs when showering or bathing.

Refrain from cleaning your ears. Give your eardrum time to heal completely.

Use pain relievers. Try aspirin or ibuprofen (Advil, Motrin, others) to help ease your ear pain. Ask your doctor which over-the-counter pain medication is best for you.

Adapted from: Mayo Foundation for Medical Education and Research

Perforated Eardrum

A perforated eardrum is a hole or rupture in the eardrum, a thin membrane that separates the ear canal and the middle ear. The medical term for eardrum is tympanic membrane. The middle ear is connected to the nose by the eustachian tube, which equalizes pressure in the middle ear.

A perforated eardrum is often accompanied by decreased hearing and occasional discharge. Pain is usually not persistent.

Causes Of Eardrum Perforation
The causes of perforated eardrum are usually from trauma or infection. A perforated eardrum can occur:

If the ear is struck squarely with an open hand
With a skull fracture
After a sudden explosion
If an object (such as a bobby pin, Q-tip, or stick) is pushed too far into the ear canal.
As a result of hot slag (from welding) or acid entering the ear canal


Middle ear infections may cause pain, hearing loss, and spontaneous rupture (tear) of the ear-drum resulting in a perforation. In this circumstance, there maybe infected or bloody drainage from the ear. In medical terms, this is called otitis media with perforation.

On rare occasions a small hole may remain in the eardrum after a previously placed PE tube (pressure equalizing) either falls out or is removed by the physician.

Most eardrum perforations heal spontaneously within weeks after rupture, although some may take up to several months. During the healing process the ear must be protected from water and trauma. Those eardrum perforations which do not heal on their own may require surgery.


Effects On Hearing From Perforated Eardrum
Usually, the larger the perforation, the greater the loss of hearing. The location of the hole (perforation) in the eardrum also effects the degree of hearing loss. If severe trauma (e.g. skull fracture) disrupts the bones in the middle ear which transmit sound or causes injury to the inner ear structures, the loss of hearing maybe quite severe.

If the perforated eardrum is due to a sudden traumatic or explosive event, the loss of hearing can be great and ringing in the ear (tinnitus) may be severe. In this case the hearing usually returns partially, and the ringing diminishes in a few days. Chronic infection as a result of the perforation can cause major hearing loss.

Treatment Of The Perforated Eardrum
Before attempting any correction of the perforation, a hearing test should be performed. The benefits of closing a perforation include prevention of water entering the ear while showering, bathing, or swimming (which could cause ear infection), improved hearing, and diminished tinnitus. It also may prevent the development of cholesteatoma (skin cyst in the middle ear), which can cause chronic infection and destruction of ear structures.

If the perforation is very small, otolaryngologists may choose to observe the perforation over time to see if it will dose spontaneously. They also might try to patch a cooperative patient's ear-drum in the office. Working with a microscope, your doctor may touch the edges of the eardrum with a chemical to stimulate growth and then place a thin paper patch on the eardrum. Usually with closure of the tympanic membrane improvement in hearing is noted. Several applications of a patch (up to three or four) may be required before the perforation doses completely. if your physician feels that a paper patch will not provide prompt or adequate closure of the hole in the eardrum, or attempts with paper patching do not promote healing, surgery is considered.

There are a variety of surgical techniques, but all basically place tissue across the perforation allowing healing. The name of this procedure is called tympanoplasty. Surgery is typically quite successful in closing the perforation permanently, and improving hearing. It is usually done on an outpatient basis.

Your doctor will advise you regarding the proper management of a perforated eardrum


Adapted from: American Academy of Otolaryngology--Head and Neck Surgery

Otosclerosis

Otosclerosis is the abnormal growth of bone of the middle ear. This bone prevents structures within the ear from working properly and causes hearing loss. For some people with otosclerosis, the hearing loss may become severe.

How do we hear?
Hearing is a series of events in which the ear converts sound waves into electrical signals and causes nerve impulses to be sent to the brain where they are interpreted as sound. The ear has three main parts: the outer, middle, and inner ear. Sound waves enter through the outer ear and reach the middle ear, where they cause the ear drum to vibrate. The vibrations are transmitted through three tiny bones in the middle ear called the ossicles. These three bones are named the malleus, incus, and stapes (and are also known as the hammer, anvil, and stirrup). The ear drum and ossicles carry the vibrations to the inner ear. The stirrup transmits the vibrations through the oval window and into the fluid that fills the inner ear. The vibrations move through fluid in the snail-shaped hearing part of the inner ear (cochlea) that contains the hair cells. The fluid in the cochlea moves the top of the hair cells, which initiates the changes that lead to the production of the nerve impulses. These nerve impulses are carried to the brain, where they are interpreted as sound. Different sounds stimulate different parts of the inner ear, allowing the brain to distinguish among various sounds, for example, different vowel and consonant sounds. Image of the inner ear

How does otosclerosis cause hearing impairment?
Otosclerosis can cause different types of hearing loss, depending on which structure within the ear is affected. Otosclerosis usually affects the last bone in the chain, the stapes, which rests in the entrance to the inner ear (the oval window). The abnormal bone fixates the stapes in the oval window and interferes with sound passing waves to the inner ear.

Otosclerosis usually causes a conductive hearing loss, a hearing loss caused by a problem in the outer or middle ear. Less frequently, otosclerosis may cause a sensorineural hearing loss (damaged sensory cells and/or nerve fibers of the inner ear), as well as a conductive hearing loss.

What causes otosclerosis?
The cause of otosclerosis is not fully understood, although research has shown that otosclerosis tends to run in families and may be hereditary, or passed down from parent to child. People who have a family history of otosclerosis are more likely to develop the disorder. On average, a person who has one parent with otosclerosis has a 25 percent chance of developing the disorder. If both parents have otosclerosis, the risk goes up to 50 percent. Research shows that white, middle-aged women are most at risk.

Some research suggests a relationship between otosclerosis and the hormonal changes associated with pregnancy. While the exact cause remains unknown, there is some evidence associating viral infections (such as measles) and otosclerosis.

What are the symptoms of otosclerosis?
Hearing loss is the most frequent symptom of otosclerosis. The loss may appear very gradually. Many people with otosclerosis first notice that they cannot hear low-pitched sounds or that they can no longer hear a whisper.

In addition to hearing loss, some people with otosclerosis may experience dizziness, balance problems, or tinnitus. Tinnitus is a sensation of ringing, roaring, buzzing, or hissing in the ears or head that accompanies many forms of hearing loss.

How is otosclerosis diagnosed?
An examination by an otolaryngologist (ear, nose, and throat physician) or otologist (ear physician) is needed to rule out other diseases or health problems that may cause these same symptoms. An audiologist is a hearing health care professional who is trained to identify, measure, and rehabilitate hearing impairment and related disorders. An audiologist uses a variety of tests and procedures to assess hearing and balance function. The audiologist may produce an audiogram (a graph that shows a person's hearing sensitivity) and a tympanogram (a graph that shows how well the middle ear functions to conduct sound). Discuss these results with your audiologist/otologist.

How is otosclerosis treated?
In many cases surgery is an option for treatment of otosclerosis. In an operation called a stapedectomy, a surgeon (otolaryngologist or otologist) bypasses the diseased bone with a prosthetic device that allows sound waves to be passed to the inner ear. It is important to discuss the risks and possible complications of this procedure, as well as the benefits, with the surgeon. In rare cases, surgery can worsen the hearing loss.

If the hearing loss is mild, surgery may not be an option. Also, on occasion, some hearing loss persists after surgery. A properly fitted hearing aid may help some people with otosclerosis in situations that include persistent hearing loss. A hearing aid is designed to compensate for a hearing loss by amplifying sound. An audiologist can discuss the various types of hearing aids available and make a recommendation based on the specific needs of an individual.

What research is being done on otosclerosis?
Scientists are conducting research to improve understanding of otosclerosis. Genetic studies continue in order to identify the gene or genes that may lead to this disorder. Other researchers are studying the effectiveness of lasers currently used in surgery, of amplification devices, and of various stapes prostheses. Improved diagnostic techniques are also being examined and developed.

Adapted from: National Institute on Deafness and Other Communication Disorders

Earwax

Never put anything smaller than your elbow in your ear! Cotton swabs are for cleaning bellybuttons, not ears. You have probably heard these admonitions from relatives and doctors since childhood…read on to find out what they meant.

The Outer Ear And Canal
The outer ear is the funnel-like part of the ear you can see on the side of the head, plus the ear canal (the hole which leads down to the eardrum).

The ear canal is shaped somewhat like an hourglass-narrowing part way down. The skin of the outer part of the canal has special glands that produce earwax. This wax is supposed to trap dust and dirt particles to keep them from reaching the eardrum. Usually the wax accumulates a bit, dries out and then comes tumbling out of the ear, carrying dirt and dust with it. Or it may slowly migrate to the outside where it can be wiped off. The ear canal may be blocked by wax when attempts to clean the ear push wax deeper into the ear canal and cause a blockage. Wax blockage is one of the most common causes of hearing loss.

Should You Clean Your Ears?
Wax is not formed in the deep part of the ear canal near the eardrum, but only in the outer part of the canal. So when a patient has wax blocked up against the eardrum, it is often because he has been probing his ear with such things as cotton-tipped applicators, bobby pins, or twisted napkin corners. These objects only push the wax in deeper. Also, the skin of the ear canal and the eardrum is very thin and fragile and is easily injured.

Earwax is healthy in normal amounts and serves to coat the skin of the ear canal where it acts as a temporary water repellent. The absence of earwax may result in dry, itchy ears.

Most of the time the ear canals are self-cleaning; that is, there is a slow and orderly migration of ear canal skin from the eardrum to the ear opening. Old earwax is constantly being transported from the ear canal to the ear opening where it usually dries, flakes, and falls out.

Under ideal circumstances, you should never have to clean your ear canals. However, we all know that this isn't always so. If you want to clean your ears, you can wash the external ear with a cloth over a finger, but do not insert anything into the ear canal.

What Are the Symptoms of Wax Buildup?
partial hearing loss, may be progressive
tinnitus, noises in the ear
earache
fullness in the ear or a sensation the ear is plugged


Self Treatment For Earwax
Most cases of earwax blockage respond to home treatments used to soften wax if there is no hole in the eardrum. Patients can try placing a few drops of mineral oil, baby oil, glycerin, or commercial ear wax removal drops, such as Debrox®, Mack's® Wax AwayTM, Murine®, or Physicians' ChoiceTM in the ear. These remedies are not as strong as the prescription wax softeners but are effective for many patients. Rarely, people have allergic reactions to commercial preparations. Detergent drops such as hydrogen peroxide or carbamide peroxide may also aid in the removal of wax. Patients should know that rinsing the ear canal with hydrogen peroxide (H2O2) results in oxygen bubbling off and water being left behind-wet, warm ear canals make good incubators for growth of bacteria. Flushing the ear canal with rubbing alcohol displaces the water and dries the canal skin. If alcohol causes severe pain, it suggests the presence of an eardrum perforation.

When Should I See My Doctor?
If you are uncertain whether you have a hole (perforation or puncture) in your eardrum, consult your physician prior to trying any over-the-counter remedies. Putting eardrops or other products in your ear in the presence of an eardrum perforation may cause an infection. Certainly, washing water through such a hole could start an infection. In the event that the home treatments discussed in this leaflet are not satisfactory, or if wax has accumulated so much that it blocks the ear canal (and hearing), your physician may prescribe eardrops designed to soften wax, or he may wash or vacuum it out. Occasionally, an otolaryngologist (ENT specialist) may need to remove the wax using microscopic visualization.

Other Possible Causes of Hearing Loss
perforated eardrum
middle ear infection (otitis media)
external ear infection (otitis externa)
acoustic trauma

Adapted from: American Academy of Otolaryngology--Head and Neck Surgery

Cholesteatoma

A cholesteatoma is a skin growth that occurs in an abnormal location, the middle ear behind the eardrum. It is usually due to repeated infection, which causes an ingrowth of the skin of the eardrum. Cholesteatomas often take the form of a cyst or pouch that sheds layers of old skin that builds up inside the ear. Over time, the cholesteatoma can increase in size and destroy the surrounding delicate bones of the middle ear. Hearing loss, dizziness, and facial muscle paralysis are rare but can result from continued cholesteatoma growth.


Causes Of Cholesteatoma
A cholesteatoma usually occurs because of poor eustachian tube function as well as infection in the middle ear. The eustachian tube conveys air from the back of the nose into the middle ear to equalize ear pressure ("clear the ears"). When the eustachian tubes work poorly perhaps due to allergy, a cold or sinusitis, the air in the middle ear is absorbed by the body, and a partial vacuum results in the ear. The vacuum pressure sucks in a pouch or sac by stretching the eardrum, especially areas weakened by previous infections. This sac often becomes a cholesteatoma. A rare congenital form of cholesteatoma (one present at birth) can occur in the middle ear and elsewhere, such as in the nearby skull bones. However, the type of cholesteatoma associated with ear infections is most common.


Cholesteatoma Symptoms
Initially, the ear may drain, sometimes with a foul odor. As the cholesteatoma pouch or sac enlarges, it can cause a full feeling or pressure in the ear, along with hearing loss. (An ache behind or in the ear, especially at night, may cause significant discomfort.) Dizziness, or muscle weakness on one side of the face (the side of the infected ear) can also occur. Any, or all, of these symptoms are good reasons to seek medical evaluation.

Is It Dangerous?
Ear cholesteatomas can be dangerous and should never be ignored. Bone erosion can cause the infection to spread into the surrounding areas, including the inner ear and brain. If untreated, deafness, brain abscess, meningitis, and rarely death can occur.

Treatments For Cholesteatoma
An examination by an otolaryngologist-head and neck surgeon can confirm the presence of a cholesteatoma. Initial treatment may consist of a careful cleaning of the ear, antibiotics, and ear drops. Therapy aims to stop drainage in the ear by controlling the infection. The extent or growth characteristics of a cholesteatoma must also be evaluated.

Large or complicated cholesteatomas usually require surgical treatment to protect the patient from serious complications. Hearing and balance tests, x-rays of the mastoid (the skull bone next to the ear), and CAT scans (3-D x-rays) of the mastoid may be necessary. These tests are performed to determine the hearing level remaining in the ear and the extent of destruction the cholesteatoma has caused.

Surgery is performed under general anesthesia in most cases. The primary purpose of the surgery is to remove the cholesteatoma and infection and achieve an infection-free, dry ear. Hearing preservation or restoration is the second goal of surgery. In cases of severe ear destruction, reconstruction may not be possible. Facial nerve repair or procedures to control dizziness are rarely required. Reconstruction of the middle ear is not always possible in one operation; and therefore, a second operation may be performed six to twelve months later. The second operation will attempt to restore hearing and, at the same time, inspect the middle ear space and mastoid for residual cholesteatoma.

Admission to the hospital is usually done the morning of surgery, and if the surgery is performed early in the morning, discharge maybe the same day. For some patients, an overnight stay is necessary. In rare cases of serious infection, prolonged hospitalization for antibiotic treatment may be necessary. Time off from work is typically one to two weeks.

Follow-up office visits after surgical treatment are necessary and important, because cholesteatoma sometimes recurs. In cases where an open mastoidectomy cavity has been created, office visits every few months are needed in order to clean out the mastoid cavity and prevent new infections. In some patients, there must be lifelong periodic ear examinations.

Summary
Cholesteatoma is a serious but treatable ear condition which can only be diagnosed by medical examination. Persisting earache, ear drainage, ear pressure, hearing loss, dizziness, or facial muscle weakness signals the need for evaluation by an otolaryngologist-head and neck surgeon.

Adapted from: American Academy of Otolaryngology--Head and Neck Surgery

Autoimmune Inner Ear Disease

Autoimmune inner ear disease (AIED) is an inflammatory condition of the inner ear. It occurs when the body's immune system attacks cells in the inner ear that are mistaken for a virus or bacteria. AIED is a rare disease occurring in less than one percent of the 28 million Americans with a hearing loss.


How Does the Healthy Ear Work?
The ear has three main parts: the outer, middle and inner ear. The outer ear (the part you can see) opens into the ear canal. The eardrum separates the ear canal from the middle ear. Small bones in the middle ear help transfer sound to the inner ear. The inner ear contains the auditory (hearing) nerve, which leads to the brain.

Any source of sound sends vibrations or sound waves into the air. These funnel through the ear opening, down the ear, canal, and strike your eardrum, causing it to vibrate. The vibrations are passed to the small bones of the middle ear, which transmit them to the hearing nerve in the inner ear. Here, the vibrations become nerve impulses and go directly to the brain, which interprets the impulses as sound (music, voice, a car horn, etc.).


Symptoms Of AIED
The symptoms of AIED are sudden hearing loss in one ear progressing rapidly to the second ear. The hearing loss can progress over weeks or months. Patients may feel fullness in the ear and experience vertigo. In addition, a ringing, hissing, or roaring sound in the ear may be experienced. Diagnosis of AIED is difficult and is often mistaken for otitis media until the patient develops a loss in the second ear. One diagnostic test that is promising is the Western blot immunoassay.

Treatment For AIED?
Most patients with AIED respond to the initial treatment of steroids, prednisone, and methotrexate, a chemotherapy agent. Some patients may benefit from the use of hearing aids. If patients are unresponsive to drug therapy and hearing loss persists, a cochlear implant maybe considered.

History Of AIED
Until recently it was thought that the inner ear could not be attacked by the immune system. Studies have shown that the perisacular tissue surrounding the endolymphatic sac contains the necessary components for an immunological reaction. The inner ear is also capable of producing an autoimmune response to sensitized cells that can enter the cochlea through the circulatory system.

Adapted from: American Academy of Otolaryngology--Head and Neck Surgery

Ear Related problems - Airplane Ear

Introduction
You've just settled in for a long, relaxing flight. But then you start to feel pressure and discomfort in your ears. Then there's some pain. And sounds are somewhat muffled. You may be experiencing a condition known as airplane ear.

Also called barotrauma or barotitis media, airplane ear is a condition of discomfort associated with your middle ear. The cause is rapid changes in altitude and air pressure. Often airplane ear occurs when you fly while you have a cold, congested nose, nasal allergy, or throat or sinus infection (sinusitis). It can also occur when you drive in the mountains or go scuba diving. Although the condition is usually just a minor annoyance, airplane ear may result in temporary ear pain and hearing loss.

Ear pain associated with flying is due to unequal pressure between your middle ear and the cabin of the airplane.

Usually, self-care steps can relieve the symptoms of airplane ear in a short time. However, a severe case of barotrauma may require you to see your doctor

Signs and symptoms
Airplane ear can occur in one or both ears. Signs and symptoms may include:

Moderate discomfort or pain in your ear
Feeling of fullness or stuffiness in your ear
Slight hearing loss
Ringing in your ear (tinnitus)
Dizziness
If airplane ear is severe or prolonged, you may experience:

Severe middle ear pain
A pressure feeling in your ear similar to being underwater
Moderate to severe hearing loss
Bleeding from your ear

Causes
Airplane ear occurs when your eardrum bulges outward or retracts inward as a result of a difference in air pressure. The air pressure in your middle ear usually is the same as that in your outer ear, because of the eustachian tube, which connects your middle ear to the back of your nose. When you swallow or yawn, the eustachian tube opens and allows air to flow into or out of your middle ear, equalizing the pressure.

If your eustachian tube is blocked, differences in pressure can occur between the two sides of your eardrum. When the pressure in your middle ear can't be equalized, your ear feels plugged. When this happens, your eardrum can't vibrate normally, so sounds are muffled or blocked. You may also have ear pain resulting from your eardrum being stretched

Risk factors
The common cold is a frequent cause of a blocked eustachian tube that can result in airplane ear. Other factors that can lead to airplane ear include a sinus infection or a nasal allergy, such as hay fever. A stuffy nose often involves stuffy ears because your swollen membranes block the opening of the eustachian tube.

Children are especially vulnerable because the eustachian tube in a child's ear is narrower than that in an adult's, making blockage more common. Scuba divers and mountain climbers often experience barotrauma. Water-skiers, too, are vulnerable. Being slapped or hit on the ear — as when falling and hitting water at high speed — can cause a rapid change in pressure within the ear.

When to seek medical advice
If your symptoms don't disappear within a few hours or if pain persists, see your doctor. He or she can examine your ear and, if indicated, refer you to a doctor who specializes in the care of ear disorders (otolaryngologist). See your doctor if you develop new signs and symptoms, especially fever, severe ear pain or drainage from your ear.

Screening and diagnosis
Your doctor will examine your ear to determine if you've experienced barotrauma, using a lighted instrument to look inside your ear. A slight outward or inward bulging of your eardrum indicates barotrauma. If your condition is severe, small capillaries in your middle ear may have burst, pooling blood behind your eardrum. Signs and symptoms of severe barotrauma may mimic those of an ear infection.

Complications
Possible complications of airplane ear include:

Ruptured or perforated eardrum
Ear infection
Hearing loss
Airplane ear usually isn't serious and responds to self-care. Hearing loss is almost always temporary.

Treatment
Treatment of airplane ear focuses on relieving your symptoms. If self-care attempts don't relieve your discomfort within a few hours or if the condition is severe, you may need to see a doctor. Your doctor may suggest these treatments:

Medications. Decongestant nasal sprays, oral decongestants or oral antihistamines may relieve nasal congestion and allow your eustachian tube to open. Antibiotics may prevent ear infection, if barotrauma is severe.

Surgery. Surgical treatment of airplane ear is rarely necessary. If your eustachian tube won't open with other treatments, however, your doctor may make an incision in your eardrum to allow pressure to equalize and fluid to drain (myringotomy). If you're prone to airplane ear and must fly often, your doctor may surgically place tubes in your eardrums to aid fluid drainage, ventilate your middle ear and equalize the pressure between your outer ear and middle ear.

Prevention
Follow these tips to avoid airplane ear:

Reconsider travel plans. Don't fly with a cold or upper respiratory congestion or infection unless necessary.

Use an over-the-counter decongestant nasal spray. When you're asked to buckle your seat belt before takeoff, spray about four vigorous puffs in each side of your nose while holding shut the opposite side. Be sure to have chewing gum or peppermint in your mouth so that you are swallowing at the same time. This will mask the medication's bitter taste and place the spray closer to the opening of your eustachian tube.

Cautious use of oral decongestant pills. Oral decongestants may be helpful if taken 30 minutes to an hour before an airplane flight. However, if you have a heart disease, heart rhythm disorders or high blood pressure or you've experienced possible medication interactions, avoid taking an oral decongestant unless your doctor approves. Men age 50 and older may experience serious side effects after taking decongestants containing pseudoephedrine (Actifed, Sudafed), including a sudden enlargement of their prostates requiring an immediate visit to the local emergency room and placement of a urinary catheter.

Time your medication. If you have allergies, take your medication before your flight.

Suck candy or chew gum during flight. This encourages swallowing. Yawning also activates the muscles that open your eustachian tube.

Clear your ears regularly upon takeoff and landing. Do this by gently blowing while pinching your nostrils with your mouth closed (Valsalva maneuver). Repeat several times during descent to equalize the pressure between your ears and your environment.

Avoid sleeping during descent. This allows you to make sure you're swallowing enough to keep your ears clear.

Have infants and young children drink fluids during ascent and descent. This encourages swallowing. A pacifier may also help. Give acetaminophen (Tylenol, others) 30 minutes before takeoff to help control any discomfort that may occur. Decongestants in young children generally aren't recommended.

Talk to your doctor. If you've recently had ear surgery, consult your doctor before you fly.

Try filtered earplugs. These slowly equalize the pressure against your eardrum during takeoff and landing. You can purchase these at drugstores, airport gift shops or your local hearing clinic.

Drink plenty of water to avoid dehydration. Avoid alcohol and caffeine, because they constrict your blood vessels and may increase the risk of ruptured capillaries.

Self-care
If your ears become plugged during flight, try clearing them by inhaling and then gently exhaling while holding your nostrils closed and keeping your mouth shut. Repeat as necessary to relieve discomfort. If your ears are still blocked a few hours after landing, see your doctor

Adapted from: Mayo Foundation for Medical Education and research

Anatomy of Human Ear

The ears are paired sensory organs comprising the auditory system, involved in the detection of sound, and the vestibular system, involved with maintaining body balance/ equilibrium. The ear divides anatomically and functionally into three regions: the external ear, the middle ear, and the inner ear. All three regions are involved in hearing. Only the inner ear functions in the vestibular system.

Anatomy of the Ear
The external ear (or pinna, the part you can see) serves to protect the tympanic membrane (eardrum), as well to collect and direct sound waves through the ear canal to the eardrum. About 1¼ inches long, the canal contains modified sweat glands that secrete cerumen, or earwax. Too much cerumen can block sound transmission.


The middle ear, separated from the external ear by the eardrum, is an air-filled cavity (tympanic cavity) carved out of the temporal bone. It connects to the throat/nasopharynx via the Eustachian tube. This ear-throat connection makes the ear susceptible to infection (otitis media). The eustachian tube functions to equalize air pressure on both sides of the eardrum. Normally the walls of the tube are collapsed. Swallowing and chewing actions open the tube to allow air in or out, as needed for equalization. Equalizing air pressure ensures that the eardrum vibrates maximally when struck by sound waves.

Adjoining the eardrum are three linked, movable bones called "ossicles," which convert the sound waves striking the eardrum into mechanical vibrations. The smallest bones in the human body, the ossicles are named for their shape. The hammer (malleus) joins the inside of the eardrum. The anvil (incus), the middle bone, connects to the hammer and to the stirrup (stapes). The base of the stirrup, the footplate, fills the oval window which leads to the inner ear.

The inner ear consists of a maze of fluid-filled tubes, running through the temporal bone of the skull. The bony tubes, the bony labyrinth, are filled with a fluid called perilymph. Within this bony labyrinth is a second series of delicate cellular tubes, called the membranous labyrinth, filled with the fluid called endolymph. This membranous labyrinth contains the actual hearing cells, the hair cells of the organ of Corti.

There are three major sections of the bony labyrinth:
1. The front portion is the snail-shaped cochlea, which functions in hearing.
2. The rear part, the semicircular canals, helps maintain balance.
3. Interconnecting the cochlea and the semicircular canals is the vestibule, containing the sense organs responsible for balance, the utricle and saccule.

The inner ear has two membrane-covered outlets into the air-filled middle ear - the oval window and the round window. The oval window sits immediately behind the stapes, the third middle ear bone, and begins vibrating when "struck" by the stapes. This sets the fluid of the inner ear sloshing back and forth. The round window serves as a pressure valve, bulging outward as fluid pressure rises in the inner ear. Nerve impulses generated in the inner ear travel along the vestibulocochlear nerve (cranial nerve VIII), which leads to the brain. This is actually two nerves, somewhat joined together, the cochlear nerve for hearing and the vestibular nerve for equilibrium.

How We Hear - The Auditory System
All sounds (music, voice, a mouse-click, etc.) send out vibrations, or sound waves. Sound waves do not travel in a vacuum, but rather require a medium for sound transmission, e.g. air or fluid. What actually travels are alternating successions of increased pressure in the medium, followed by decreased pressure. These vibrations occur at various frequencies, not all of which the human ear can hear. Only those frequencies ranging from 20 to 20,000 Hz (Hz = hertz = cycles/sec) can be perceived.

In hearing, air-borne sound waves funnel down through the ear canal and strike the eardrum, causing it to vibrate. The vibrations are passed to the small bones of the middle ear (ossicles), which form a system of interlinked mechanical levers: First, vibrations pass to the malleus (hammer), which pushes the incus (anvil), which pushes the stapes (stirrup). The base of the stapes rocks in and out against the oval window - this is the entrance for the vibrations. The stapes agitates the perilymph of the bony labyrinth. At this point, the vibrations become fluid-borne. The perilymph, in turn, transmits the vibrations to the endolymph of the membranous labyrinth and, thence, to the hair cells of the organ of Corti. It is the movement of these hair cells which convert the vibrations into nerve impulses. The round window dissipates the pressure generated by the fluid vibrations, thus serves as the release valve: It can push out or expand as needed. The nerve impulses travel over the cochlear nerve to the auditory cortex of the brain, which interprets the impulses as sound.

How We Balance - The Vestibular System
The semicircular canals and vestibule function to sense movement (acceleration and deceleration) and static position. The three semicircular canals lie perpendicular to each other, one to sense movement in each of the 3 spatial planes. At the base of the canals are movement hair cells, collectively called the crista ampullaris. Depending on the plane of movement, the endolymph flowing within the semicircular canals stimulates the appropriate movement hair cells. Static head position is sensed by the vestibule, specifically, its utricle and saccule, which contain the position hair cells. Different head positions produce different gravity effects on these hair cells. Small calcium carbonate particles (otoliths) are the ultimate stimulants for the position hair cells.

The hair cells for both position and movement create nerve impulses. These impulses travel over the vestibular nerve to synapse in the brain stem, cerebellum, and spinal cord. No definite connections to the cerebral cortex exist. Instead, the impulses produce reflex actions to produce the corrective response. For example, a sudden loss of balance creates endolymph movement in the semicircular canals that triggers leg or arm reflex movements to restore balance.

Adapted from: PATTS