From wax build-up to infections, ear problems are common yet easily treated
How does otitis media present in children?
Key features of otitis media include severe earache, fever, general unwellness and dulled hearing. Other key signs include pulling or tugging the ear, irritability, poor feeding, disturbed sleep, coughing, rhinorrhoea, loss of balance and lack of response to sounds.
What is the role of nasal drops in otitis media?
While there is no evidence for the efficacy of topical ear drops, nasal drops containing a decongestant or antihistamine may help alleviate mucous membrane swelling in the nose and throat. This unblocks the Eustachian tube, which may help mucus drain from the middle ear.
How can patients prevent recurrent otitis externa?
It is important to keep the ear dry while swimming by using a swim cap or earplugs, and to avoid introducing objects such as cotton buds into the ear canal. Placing cotton wool pieces coated with Vaseline in the outer ear while showering can help stop shampoo or soap entering the ear.
Otitis media is an accumulation of fluid or mucus in the space between the eardrum and inner ear. If bacteria infiltrate this built-up mucus, then a middle ear infection results. Acute otitis media onsets rapidly, producing symptoms including severe earache, fever and general unwellness in children (eg sickness, vomiting and lethargy) and dulled hearing.
Detecting an ear infection in infants and young children can be challenging. Otitis media should always be considered a potential culprit when faced with a hot, crying, fractious baby.1
Other key signs include:
* pulling or tugging the ear
* poor feeding
* disturbed sleep
* loss of balance
* lack of response to sounds.2
Occasionally the eardrum itself may perforate, causing pus to leak out of the ear and opening the area up to the risk of re-infection.
Chronic otitis media is a recurring condition with milder symptoms but, as the infection persists over time, can cause more damage than an acute episode. Pus or discharge from the ear is more common in chronic cases.2 Other potential causes include a blocked Eustachian tube, permanently perforated eardrum or tissue growth inside the middle ear (cholesteatoma). Children with compromised immunity, small Eustachian tubes or large adenoids may be more susceptible to otitis media.The main cause of otitis media is the common cold, with infection spreading from the nose or throat to the middle ear through the Eustachian tube. Other potential causes include a blocked Eustachian tube, permanently perforated eardrum or tissue growth inside the middle ear (cholesteatoma). Children with compromised immunity, small Eustachian tubes or large adenoids may be more susceptible to otitis media.
A diagnosis of otitis media is based on clinical symptoms and examination of the ear. In most patients, the eardrum appears red or yellow with a bumpy texture and may bulge outwards under the pressure of accumulated mucus in the middle ear. Most simple cases of otitis media do not require antibiotics, with 80 per cent of episodes resolving spontaneously within three to four days without treatment.2,3 However, the BNF recommends treatment with a systemic antibacterial if:3
* there is no improvement after 72 hours, or earlier if there is evidence of deterioration
* the child is systemically unwell
* there is a high risk of serious complications, for example if the patient is immunosuppressed or has cystic fibrosis
* mastoiditis is present
* the child is under two and both ears are affected
There is no evidence for the efficacy of topical ear drops in managing otitis media, but OTC nasal drops containing a decongestant or antihistamine may help alleviate mucous membrane swelling in the nose and throat.2 This unblocks the Eustachian tube and can facilitate drainage of mucus from within the middle ear. In all instances, simple analgesics should be recommended to manage the pain and fever associated with acute otitis media.
The cornerstone of treatment for chronic otitis media is rigorous cleaning of the ear using microsuction, which may be sufficient to completely eradicate long-standing infection.
After cleansing, the ear may be treated with corticosteroid ear drops, an astringent aluminium acetate solution or antibacterial ear ointment. Aluminium acetate is particularly effective for discharge or infection of the mastoid cavity. Systemic therapy may also be required for acute exacerbations of chronic otitis media; amoxicillin or erythromycin are the first choice agents.3
According to the MHRA’s Committee on Safety of Medicines, topical treatment with ototoxic antibiotics such as aminoglycosides or polymyxins is contraindicated in patients with a perforated eardrum.3 However, many specialists continue to use these drops for infections unresponsive to systemic antibiotics, on the basis that the ototoxic threat of the middle ear pus outweighs any risk from the drops themselves.3
Otitis media with effusion is more commonly known as glue ear. It is characterised by fluid build-up in the middle ear without accompanying signs or symptoms of infection. Patients may experience ear discomfort, hearing impairment, recurrent bouts of acute otitis media and frequent upper respiratory tract infections.2 Treatment with systemic antibiotics is not usually warranted, but patients with symptoms that persist for more than a month should be referred for specialist assessment and follow-up.3 Long-term hearing impairment is a significant risk with prolonged glue ear, which may affect language development.3
Also known as ‘swimmer’s ear or ‘tropical ear’, otitis externa is an inflammation of the external ear canal that does not extend beyond the eardrum. There are three different types of otitis externa, categorised according to the spread of the inflammation and the duration of symptoms:2
* localised otitis externa – an infected hair follicle within the ear canal
* acute diffuse otitis externa – widespread inflammation of the ear canal with an accompanying skin rash affecting the outer ear and eardrum
* chronic otitis externa – extensive inflammation and skin rash lasting longer than three months.
Patients with otitis externa may experience itching, redness or swelling of the pinna or ear canal, ear discharge, earache, dulled hearing, a blocked or full feeling in the ear and enlarged glands in the neck/behind the ear.1,2
Although many cases of otitis externa develop spontaneously, key risk factors have been identified, including:1,2
* swimming (increases risk five-fold)
* heat and humidity
* skin conditions such as eczema, psoriasis or seborrhoeic dermatitis
* damage to the ear canal caused by hearing aids, cotton wool swabs or ear syringing
* discharge produced by a middle ear infection.
Bacterial infection with Pseudomonas aeruginosa or Staphylococcus aureus is one of the most common causes of otitis externa. Other direct causes include allergy, irritant reactions and infection with fungal agents.
Otitis externa is diagnosed by examining the ear and can be confirmed by ear swabbing to determine the type of infectious agent. Treatment is simple and effective using antibiotic ear drops or sprays to clear infection, often coupled with steroids to treat inflammation and itch.1
* topical anti-infectives such as neomycin or clioquinol: the duration of treatment must be restricted to around one week with these agents, as excess use may result in fungal infection or bacterial resistance
* aluminium acetate ear drops: these are effective against bacterial infection and inflammation
* chloramphenicol ear drops: caution is required with this treatment as drops contain propylene glycol, which can trigger hypersensitivity reactions in 10 per cent of patients
* solutions containing an anti-infective and corticosteroid: these are used for treating cases where infection is co-present with inflammation and eczema.
* acetic acid 2 per cent solution: this acts as an antifungal and antibacterial in the external ear canal and may be used to treat mild otitis externa.
Patients treated with antibiotic and steroid ear drops should see symptom improvement within six days.2 Severe cases of otitis externa may require referral to a GP for more specialist treatments such as syringing, microsuction, dry swabbing or ear wicks. Alongside treatment recommendations, lifestyle measures can help prevent future bouts of otitis externa in patients prone to recurrence. Patients should be advised to keep ears dry and avoid introducing objects into the ear canal.
Patients should be advised to:3
* place cotton wool pieces coated in Vaseline in the outer ear to stop shampoo or soap entering the ear when showering
* let ears dry naturally
* avoid cleaning the ears with cottonwool balls or towel corners
* never pick or poke at the ears
* keep ears dry when swimming using a swim cap or silicone rubber earplugs.
Excessive ear wax
Ear wax is an oily substance secreted by glands at the entrance to the ear canal. Its function is to clean, protect and lubricate the ear canal, preventing the skin from drying and cracking. There are two different types of ear wax: soft, wet earwax, which is more common in children, and hard, wet earwax, which usually affects adults and is more prone to impaction in the ear canal.
Potential issues associated with ear wax accumulation include dulled hearing, itchiness, discomfort or pain, tinnitus, vertigo or obstruction of the ear canal.2,3,4
A range of OTC products is available for the softening and removal of ear wax. Olive oil, almond oil or sodium bicarbonate ear drops are the treatment of choice as they are less likely to cause irritation than proprietary preparations containing organic solvents.3 Earwax blockages that persist after treatment with ear drops may require irrigation, where the ear canal is flushed with warm water. Irrigation carries a very small risk of ear damage and, as such, is contraindicated in patients with otitis media within the previous six weeks, otitis externa, learning disabilities, cleft palate, a history of eardrum perforation, previous ear surgery and young children.3
Earache is a key symptom of most common ear problems and the pain can usually be managed with simple analgesics such as paracetamol or ibuprofen. Stronger painkillers such as codeine-containing combination analgesics may be needed in the early stages of acute otitis externa.2
Overcoming the difficulties of instilling drops into relatively hard to reach areas is a key issue in treating ear problems. To obtain maximum benefit from treatment, encourage patients to:1
*lie with the affected ear upwards for several minutes after application of drops
* massage the cartilage at the front of the ear canal to push drops deeper into the ear canal
* avoid leaving cottonwool balls in the ear. If balls are used, they should be placed lightly in the outer part of the canal only and changed frequently.
The incidence of ear problems
* Otitis media is the most frequent cause of severe earache in young people.3 Three quarters of cases occur in children under 10.2
* Glue ear (otitis media with effusion) affects about 10 per cent of children and 90 per cent of children with cleft palates.3
* About 1 per cent of the UK population experiences otitis externa each year. Anyone can be affected, but the condition is slightly more common in women.2
* Around 2.3 million people in the UK suffer problems with ear wax each year.2
A customer comes in with her five-year-old son. The boy appears flushed and unwell and rubs his left ear repeatedly.
Customer: Can you recommend something for my son please? He’s suffering from terrible earache.
Pharmacist: When did the pain start?
Customer: Well, he’s had a bad cold for the past few days – then last night he started complaining that his ear hurt. I think he might have a bit of a temperature, too.
Pharmacist: Is the pain only in one ear?
Customer: I think so.
Pharmacist: Have you treated him with anything yet?
Customer: No – I thought I should ask your advice first.
Pharmacist: Is your son otherwise healthy?
Customer: Yes. What do you think it is?
Pharmacist: It sounds like a middle ear infection – probably caused by his cold. It should clear up on its own within a few days.
Customer: Doesn’t he need antibiotics?
Pharmacist: In most cases these middle ear infections resolve on their own within three or four days. But if he doesn’t seem any better after 72 hours, or the pain gets a lot worse, than take him to see your GP. In the meantime, I can suggest something to help with the pain. Is he currently taking any other medication?
Pharmacist: Give him infant paracetamol for now. This should help with the pain and bring his fever down. If there’s no improvement within three days, take him to see your GP.
Helen Boreham is a freelance medical writer with an MSci in medicinal chemistry
1. British National Formulary (BNF) 57
2. NHS Choices. www.nhs.uk
3. Patient UK. www.patient.co.uk
4. Deafness Research UK. www.deafnessresearch.org.uk
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What is the main cause of otitis media? When should otitis media be treated with systemic antibiotics? What causes localised otitis externa? In which patients is ear irrigation contraindicated?
This article discusses common ear problems such as otitis media, glue ear, otitis externa and ear wax. It includes information about causes, symptoms, diagnosis and treatment and advice that pharmacists can give
• Revise your knowledge of otitis media on the Patient UK website at http://tinyurl.com/earproblems01.
• Read more about glue ear and its treatment on the NHS Choices website at http://tinyurl.com/ earproblems02.
• Find out more information about otitis externa from the NHS Choices website at http://tinyurl.com/earproblems03.
• Read the information for patients about earwax on the Clinical Knowledge Summaries website at http://tinyurl.com/earproblems04.
• Review the products kept in your pharmacy for ear problems and think about which ones you would recommend. Make sure your counter assistants are aware of your choices.
Are you now familiar with common ear problems such as otitis media, glue ear, otitis externa and ear wax? Are you confident in your knowledge of their symptoms and treatments?