This document provides information on common ear conditions that general practitioners should be familiar with when examining patients. It discusses how to properly examine the ear, including external structures and the tympanic membrane. It describes normal ear anatomy and landmarks. Common conditions covered include ear wax, external otitis, glue ear versus acute otitis media, Eustachian tube dysfunction, ear drum perforations, and cholesteatoma. Diagnostic features and management considerations are provided for each condition.

1. E A RE A R ::
Common conditions the GPs should know
Michael J. LaRouere, M.D, FACS
Board-Certified Otolaryngologist Head and Neck Surgeon
Ann Arbor, Michigan
June 14, 2011

2. ENT Examination
NB:
The canal may be partly straightened by pulling the
pinna backwards and upwards during examination
In infants pull the pinna more horizontally backwards
as the shape of the ear canal is different
Visit: http://uk.youtube.com/watch?v=I3sa2W83iuo&NR=1
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3. Physiology
Anterior
direction
Inferior
Posterior
Anterio
r
Consider the malleus as an
arrow; pointing in the
forward direction
The normal tympanic
membrane should
appear:
. pearly grey
. have a light reflex
. generally concave
. With a visible malleus
Attic
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4. Ear Drum-normal Landmarks An annulus fibrosus or
more commonly referred to
as the eardrum margin.
This is important. Note how
smooth and how ever so
slightly blurry it is.
Um umbo - the end of the
malleus handle and usually
marks the centre of the
drum
Lr light reflex or Cone of
light –is usually seen
antero-inferioirly
At Attic also known as pars
flaccida. Any perforations
here are serious and need
referral. 4

5. Examine out to in
External:
Pinna (shape, colour, position, tenderness, haematoma)
Mastoid
Internal:
The Canal ( skin, spores, foreign bodies, discharge, debris, wax)
The Tympanic membrane (look ant, post, superior/ attic and inferior of malleus)
. Colour( opaque, white, red, patches & translucency)
. Retraction( landmarks behind it more visible)
. Perforation ( safe/ unsafe)
. Discharge (mucopurulent)
Behind the Eardrum
. Fluid behind the drum( meniscus, colour, bubbles)
. Any red bits( glomus tumour, granulations or blood?, white-
cholesteotoma) 5

6. Ear Wax
●
Wax is produced in the outer half of
the ear canal and migrates outwards
along with the canal skin.
Inappropriate instrumentation can
cause impaction.
●
Wax impaction can cause hearing
loss, pain, tinnitus, vertigo, or chronic
cough but not usually discharge.
●
Sudden expansion after getting water
in can cause sudden deafness or pain,
but needs careful exclusion of other
pathology behind it e.g. infection
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7. Management:
Refrain from using cotton buds.
If Symptomatic – use topical meds
Different preparations available none superior to other.
Sodium bicarbonate drops might be better at disintegrating wax,
but can cause dryness of the canal and/ or irritation
. Syringing
. When to refer to ENT clinic:
. Patients known to have a tympanic membrane perforation or previous
ear surgery (need microsuction), only hearing ear
. Syringing fails
. Causes pain or vertigo,
. Hearing loss persists after wax removal.
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8. External Otitis
Infection of the external auditory canal.
Mediterranean ear/Swimmers ear
Commonly unilateral
Gradual onset pruritis, pain, hearing
loss, and ear discharge which
varies in consistency and colour.
Can result in a featureless ext aud-
canal
Risk factors: trauma, water,
Immunosuppression, eczema
Can be fungal- spores might not
always be visible
If treatment fails or otitis externa
recurs
frequently consider sending an ear
swab
for bacterial and fungal microscopy
and culture
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9. Management
Remove or treat any precipitating or aggravating factors
A topical ear preparation for 7 days. Options include preparations
containing:
a. Both a non-aminoglycoside antibiotic + a corticosteroid e.g.
flumetasone–clioquinol (Locorten–Vioform®) ear drops.
b. Both an aminoglycoside antibiotic and a corticosteroid
(contraindicated if the tympanic membrane is perforated).
c. Topical preparations containing only an antibiotic (gentamicin
ear drops are contraindicated if the tympanic membrane is
perforated).
d. Antifungal or ? something containing all three
Aural toilet: if earwax or obstruct topical medication (may require
referral).
Provide appropriate self-care advice 9

10. Glue Ear vs. Otitis Media
Factors suggestive of a diagnosis of glue ear include:
. frequent attacks of otitis media
. it is unusual for children to get multiple resolving episodes of otitis
media
. prolonged signs
. otitis media will usually resolve within 6 weeks and certainly within
three months
Other risk factors: cleft palate ,Down's syndrome, allergy, family history
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11. Eustachian Tube Dysfunction
A severely
retracted
eardrum.
Margins are
very clear as
is the malleus
and it looks
very sunken.
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12. Eustachian Tube dysfunction
Chronic blockage of the Eustachian tube is called Eustachian tube
dysfunction. The eustachian tube becomes congested and swollen so
that it may temporarily close; this prevents air flow behind the ear
drum and causes ear pressure, pain or popping just as you
experience with altitude change when travelling on an airplane or an
elevator.
This can occur when the lining of the nose becomes irritated and inflamed,
narrowing the Eustachian tube opening or its passageway.
Illnesses like the common cold or influenza.
Others: pollution, cigarette smoke, allergic rhinitis, obesity
Rarely nasal polyps, cleft palate, skull base tumour
12

13. Eustachian Tube Dysfunction
. Chronic ETD may reveal retraction pockets or collapsed middle ear
disease with erosion of incus/stapedius. Difficulty auto-inflating
the ear drum
. Generally the fluid clears spontaneously over a period of several
weeks
. The efficacy of treatments such as nasal decongestants, oral
decongestants, antihistamines is unclear
. Antibiotics may help prevent infection in cases of severe
barotrauma
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14. ETD & Children
Young children (esp 1 to 6 years) at particular risk because of very narrow
Eustachian tubes. Also, they may have adenoid enlargement that can block
the opening of the Eustachian tube.
Eustachian tube in infants and young children runs horizontally, rather than
sloping downward from the middle ear. Thus, bottle-feeding should be
performed with the infants’ head elevated, in order to reduce the risk of
milk entering the middle ear space. The horizontal course of the
Eustachian tube also permits easy transfer of bacteria from the nose to
the middle ear space.
Most children older than 6 years have outgrown this problem and their
frequency of ear infections should drop substantially.
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15. Ear Drum Perforations
●
Safe vs Unsafe Perforations
●
Safe perforations
. may allow infection to enter the middle ear
. conductive deafness
●
Unsafe perforations
. in fact represent a retraction of the tympanic membrane.
. essentially a part of the drum becomes sucked inwards and may
gradually enlarge.
.when the retraction becomes extensive, keratinous debris builds up in
the retraction and may become infected and an acquired cholesteatoma
develops
15

16. Unsafe perforations are
a)In the attic or
b)In the posterior region. These are
often linear rather than oval
c)Or involve the eardrum margin
Anything else is generally Safe.
i.e.
a) In the anterior region or
b) In the inferior region
c) And not involving the eardrum
margin
MAKE SURE YOU ALWAYS INSPECT THE ATTIC
AREA ON OTOSCOPY!
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17. Cholesteotoma
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Aa three dimensional epidermoid structure exhibiting independent growth,
replacing middle ear mucosa, resorbing underlying bone, and tending to
recur after removal." There is usually a persistent or recurrent scanty
cream coloured offensive discharge and progressive hearing loss due
to ossicular destruction or toxin induced sensory hearing loss.
Otoscopy : a pearly white mass usually in the pars tensa +/- discharge and
sometimes erosion of the bone. A perforation is usually present, but is
not always visible due to overlying keratin. Granulation tissue or polyps
may be seen due to chronic inflammation and sometimes retraction
pockets are present.
A crust adherent to the tympanic membrane is indicative of a
cholesteatoma. They can be reviewed after a short course of steroid or
ceruminolytic ear drops, but if it is persistent or reveals an underlying
abnormality then you should refer