This document discusses ear conditions, focusing on ear wax impaction and otitis externa. It defines the conditions, discusses prevalence and epidemiology, aetiology, clinical features, differential diagnosis, and appropriate over-the-counter treatments. Ear wax impaction is common and usually caused by failed attempts to clean the ear canal. Otitis externa is an inflammation often caused by infection, with Pseudomonas aeruginosa and Staphylococcus as common pathogens. Both conditions present with ear discomfort and possible hearing loss, and are usually treated with cerumenolytics or topical antibiotics without referral.

1. LECTURENO.6 AND 7
EARCONDITIONS
Course Name: Community Pharmacy
Course Code: 0520524
Lecturer: Ms. Asma El-Shara’.
MPH FacultyOf Pharmacy,
Philadelphia University-Jordan

2. Learning outcomes:
 Define Ear wax impaction and otitis externa.
 Explain the prevalence and epidemiology of Ear wax
impaction and otitis externa.
 Describe the aetiology of Ear wax impaction and otitis
externa.
 Describe how to achieve differential diagnosis for Ear wax
impaction and otitis externa.
 Classify the conditions to eliminate.
 Classify evidence base for over-the-counter medication.
2

3. Contents
3
 Ear wax impaction and otitis externa.
 Prevalence and epidemiology.
 Aetiology.
 Differential diagnosis.
 Conditions to eliminate.
 Evidence base for over-the-counter medication.

4. BACKGROUND
 Currently, community pharmacists can ONL
Y offer
help to patients with conditions that affect the
external ear
 Therefore, concentrates on external ear problems.
However, with appropriate auroscopical training and
further POM to Pderegulation of medicines, it is not
unrealistic to extend the community pharmacists' role
to include middle ear problems.

5. EARANATOMY
 PINNA + external auditory meatus (EAM, ear canal) =
collect and transmitsoundto the tympanic membrane
(eardrum).
 The pinna consistschiefly of cartilage and has a firm
elastic consistency.
 The EAM opensbehind the tragusand curves inwards for
approximately 3 cm; the inner two-thirds is bony and the
outer third cartilaginous.
 The skin lining the cartilaginous outer portion has a well-
developed subcutaneouslayer that containshair
follicles, ceruminous and sebaceousglands.
 Thetwo portionsof themeatushaveslightly different
directions; the outer cartilaginousportion is upward
and backward where as the inner bony portionis
forward and downward. This is important to know when
examining the ear.
PINNA

6. PHYSICALEXAMINATION
1. First, wash your hands.
2. Next inspect the external ear for redness, swelling and
discharge.
3. Then apply pressure to the mastoid area which is
directly behind the pinna (If thearea istender this
suggests mastoiditis, a rare complication of otitis media).
4. 4. Next move the pinna up and down and manipulate
thetragus. If either istender onmovementthenthis
suggests external ear involvement.

7. PHYSICALEXAMINATION (continued)
5. You should finally examinetheEAM. This is
bestperformed usinganotoscope,however
currently mostpharmacistshavenothad
appropriate training in their use. An alternative
way to inspect the E
AM would be to usea pen
torch.Becauseof theshapeof theEAM,when
performing anexaminationthepinna needsto
be manipulated to obtain thebest view of the
ear canal

8. PHYSICALEXAMINATION (continued)

9. EARSYMPTOMS AND THEAFFECTEDEARSTRUCTURE

10. POSSIBLECAUSESOF THEPRESENTING COMPLAINT

11. EARWAX IMPACTION (mostlikely cause)
Producedinthe outer third ofthe cartilaginous portion ofthe ear canal bythe
ceruminousglands.
FUNCTIONS:
A- Mechanical protection of the tympanic membrane.
B- T
rapping dirt.
C-R
epelling water.
D- Contributing to a slightly acidic medium that has been reported to exert
protection against bacterial and fungal infection.
COMPOSITION OFCERUMEN:
varies between individuals but can be broadly divided into :
1- 'wet or sticky' type of wax  common in Caucasians and African-Americans .
2- 'dry‘ that is common in Asian populations.

12. PREVALENCEAND EPIDEMIOLOGY
 The exact prevalence rates of ear wax impaction is not
clear.
 2-6% of the general population suffer from impacted wax
 oneScottishsurveyof GPsreported anaverage of nine
patients per month (range 5 to 50 patients) requesting ear
wax removal.
 However,manymorepatients self-diagnose and medicate
without seekingGP assistance, therefore pharmacistshave
an important role in ensuring that treatment is appropriate.
 The high number of presentations may be due to patient
misconception that earwax needs to be removed.

13. PREVALENCEAND EPIDEMIOLOGY (continued)
 A number of patient groups appear to be more
prone to ear wax impaction thanthegeneral
population:
Patients with congenital anomalies (narrowed ear
canal).
 Patients with learning difficulties and those fitted
with a hearing aid.
 The elderly are more susceptible to impaction due
to the decrease in cerumenproducing glands
resulting in drier and harder ear wax.

14. Aetiology
 Theskinof thetympanicmembraneisunusual.It isnotsimply
shed as skin is from the rest of the body but is migratory. This
isbecausetheauditory canal isthebody's only 'dead end'
and abrasionof the stratum corneumcannot occur.
 Skintherefore movesoutwards away from the ear drumand
outalong theear canal.Thismeansthat theears are largely
self-cleaning as the ear canal naturally shedswax from the
ear. However,thisnormalfunctioncanbe interrupted, usually
by misguided attempts to clean ears. Wax therefore becomes
trapped, hampering its outward migration.

15. Arriving at a differential diagnosis

16. CLINICALFEATURESOF EARWAX IMP
ACTION
The key features of ear wax impaction are:
1- A history of gradual hearing loss
2- Ear discomfort (to variable degrees).
3- R
ecent attemptsto cleanears.
 Itching, tinnitus and dizziness occur infrequently.
 Otoscopical examination should reveal excessive
wax.

17. Conditions to eliminate
 A. T
raumaof theear canal
 use all manner of implements to try and clean the
ear canal of wax (e.g. cotton buds, hairgrips, and
pens).
 Inspection of the ear canal might reveal laceration
of theear canal and thepatient mayexperience
greater conductive deafnessbecause of the wax
becoming further impacted.
Trauma might also lead to discharge from the ear
canal; these cases are probably best referred.

18.  B
. Foreignbodies
 Symptoms can mimic ear wax impaction but, over
time, discharge and pain is observed.
 Children are themostlikely age group to present
with a foreign body in the ear canal and suspected
cases need to be referred to a GP
.
Conditions to eliminate (continued)

19. Conditions to eliminate (continued)

20. Evidence base for over-the-
counter medication
 Studies:
 The findings fromreviewssupport the use of oil-
based softeners, sodium bicarbonate and sterile
water over no treatment at all, but no active
treatment proved more superior over any other.
 Oil-based products to be significantly better than
saline but again showed no differencesbetween
each other.

21. Practical prescribing: Summary of
medicines for ear wax

22. Practical prescribing and product
selection
Cerumenolytics:
A. Oil-basedproducts
1. Cerumol Ear Drops (Arachis- peanut oil, 57.3%)
2. Cerumol Olive Oil Drops (olive oil 100%).
3. Earex(Arachis- peanut oil, almondoil & camphor
oil in equal parts)
B
. P
eroxide-basedproducts(Exterol EtOtex range).
C
. W
ater-basedproducts(e.g. sodiumbicarbonate).
1. Docusate (Waxsol, Molcer)
D.Glycerin basedproducts(Earex AdvanceEtEarexPlus)

24. OTITIS EXTERNA

25. Background
 Otitis externa refers to generalised inflammation
throughout the EAM and isoften associated with
infection.
 It usually occurs as an acute episode but may
become chronic (greater than 3 months) in children.

26. Prevalence and epidemiology
 The lifetime prevalence of acute otitis externa is
10% and a GP will see approximately 16 new
cases per year.
 It ismorecommoninhotand humidclimatesand in
westernsociety the number of episodes increasesin
the sum
mer months.
 P
eople who swim are FIVE times more likely than
non-swimmers to contract it.
 It iscommonerinadults and reported to be slightly
more common in women than men.

27. AETIOLOGY
 Primary infection, contact sensitivity or a
combination of both causes otitis externa.
 Pathogensinclude
 Pseudomonasaeruginosa.
 Staphylococcusspp.
 Streptococcuspyogenes.
 Fungal overgrowth with Aspergillus niger is also seen
especially after prolonged antibiotic treatment.

28. AETIOLOGY (continued)
Certain local or general factorscanprecipitate
otitisexterna.
Local causes include trauma or discharge from
the middle ear
 General causes include seborrhoeic
dermatitis, psoriasis and skin infections.

29. ARRIVING ATA DIFFERENTIAL DIAGNOSIS

31. CLINICAL FEATURESOF OTITIS EXTERNA
A- Otitis externa is characterised by itching andirritation,
which, depending on the severity, can become intense.
B- This provokes the patient to scratch the skin of the
EAM, resulting in trauma andpain.
C- Otorrhoea (ear discharge) follows and the skin of the EAM
can become oedematous, leading to conductivehearing
loss.
D- On examination, the ear canal or external ear, or both,
appear red, swollen, or eczematous.

32. CLINICAL FEATURESOF OTITISEXTERNA(continued)
Notes:
 Patients might not present until pain becomes a
prominent feature.
 There should be a period when irritation is the
only symptomapparent.
 Chewing and manipulation of the tragus and
pinna can exacerbate pain.

33. CONDITIONS TO ELIMINATE
Likely causes
ACUTEOTITISMEDIA
 A rapidly accumulating effusion in the middle ear (acute otitis
media) is most common in children aged 3 to 6 years old.
 In older children, ear pain/earache is the predominant feature
and tends to be throbbing.
 In young children this is often manifested as irritability or
crying with characteristic ear tugging/rubbing.
 Systemic symptoms can also be present suchas fever and loss
of appetite.
 Examination  Reveal a red/yellow and bulging tympanic
membrane.

34. CONDITIONS TO ELIMINATE (continued)
 Pain resolves on rupture of the tympanic membrane, which
releases a mucopurulent discharge.
 Treatment
 Over three-quarters of episodesresolvewithin 3 days without
treatment and current UK guidelines do not advocate the routine
use of antibiotics.
 Patients should be managed with analgesia (paracetamol or
ibuprofen) unless they are systemically unwell or are under 2
years of age and have discharge. These cases should be
referred for GP consideration of antibiotics.

35. CONDITIONS TO ELIMINATE(continued)
 Childrenmaydeveloprecurrentotitis media and
isknown as'glue ear'.
 Theconditionissymptomlessapart fromimpaired
hearing,butcanhave a negative impact ona
child'slanguageandeducationaldevelopment.

36. CONDITIONS TO ELIMINATE (continued)
Unlikely Causes
DERMA
TITIS
 Allergic, contact, seborrhoeic and atopic forms of
dermatitis can occur on the external ear.
 Itch is a prominent symptom and could be mistaken for
otitis externa
 however there should be no ear pain or discharge
associated with dermatitis.
 In addition, in seborrhoeic and atopic formsskin
involvement elsewhere should be obvious.

37. CONDITIONS TO ELIMINATE (continued)
Very Unlikely Causes
A. PERICHONDRITIS
 In severe cases of otitis externa the inflammation can
spread from the outer ear canal to the pinna,
B.TRAUMA
 Recent trauma (e.g. blow to the head) can cause an
auricular haematoma (cauliflower ear) non-urgent
referral.
C.MALIGNANT TUMOURS
 Any elderly patient presenting with an ulcerative or
crusting lesion needs referral.

38. R
E
FER
RAL..WHEN??

39. PRACTICAL PRESCRIBINGAND PRODUCT SELECTION

40. R
eference
Rutter , P
. Community Pharmacy, Symptoms,
Diagnosisand T
reatment. Third Edition. China:
Churchill Livingstone;2013. P: 67- 74.