EAR: Foreign Body, Cerumen Impacted and Keratosis Obturans

Literature Reading

EDO WIRA CANDRA

Otorhinolaryngology Department Hasan Sadikin Hospital Faculty of Medicine Padjadjaran University Bandung Indonesia 2011
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Anatomy of the external ear

The external ear : auricle & external auditory canal (EAC) 2.5 cm in length , 9 mm high , 6.5 mm wide. The lateral third elastic cartilage The narrowest part of EAC isthmus (between the fibrocartilaginous and the bony canal) The skin of the fibrocartilaginous canal is bound to the perichondrium In the osseous part the skin is much thinner and closely adherent to the periosteum, and is devoid of hair follicles and ceruminous glands, whereas these are present in the cartilaginous part. easily traumatized during manipulations (e. g. wax removal with cotton tips)

Anniko M. European Manual of Medicine: Otorhinolaryngology Head and Neck Surgery. Springer-Verlag. 2010. (9):43-54.

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Anatomy
The subcutaneous layer

of the cartilaginous portion (1 mm thick) :

hair follicles sebaceous glands ceruminous glands

The skin of the osseous

canal does not have subcutaneous elements and is only 0.2 mm thick

Lalwani AK. Current Diagnosis and treatment in otolaryngology head and neck surgery. 2 nd edition. McGraw-Hill. 2007. Anniko M. European Manual of Medicine: Otorhinolaryngology Head and Neck Surgery. Springer-Verlag. 2010.

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Anatomy
Ceruminous glands

modified apocrine sweat glands surrounded by myoepithelial cells; organized into apopilosebaceous units

Cerumen
prevents canal maceration, antibacterial properties acidic pH

contribute to an inhospitable environment for pathogens

Lalwani AK. Current Diagnosis and treatment in otolaryngology head and neck surgery. 2nd edition. McGraw-Hill. 2007.

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FOREIGN BODIES
A variety of foreign bodies Any objects small enough

may be discovered in the EAC

Diagnosis : easy using the

to enter the EAC can become prospective foreign bodies

(animate, inanimate, or mineral objects)

operating microscope and a small blunt hook

Found most frequently in

They may cause symptoms

the pediatric age group or in mentally retarded patients

of irritation, pain, and hearing loss

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a . Sand particles can be seen along the anterior wall of EAC

b . A piece of paper has been forgotten inside EAC secondary infection (external otitis) of the skin c . A metallic hearing aid component, with secondary infection of the skin of the EAC d. Insect on the surface of tympanic membrane
Anniko M. European Manual of Medicine: Otorhinolaryngology Head and Neck Surgery. Springer-Verlag. 2010.

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A plastic beads

Insects : bees, flies, mosquitos, cockroach

Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.

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Foreign Bodies Removal

Removal is done with a small blunt hook or aural crocodile forceps
without anaesthesia or under general anaesthesia (in children)

Syringing is effective for small plastic or metallic foreign bodies but not for organic foreign bodies, which may swell with water
The main harm by a foreign body in the EAC is caused by its

careless removal!
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Instrument used in the removal of aural foreign bodies

Dhillon RS, East CA. An Ilustrated colour text: Ear, Nose , Throat and Head and Neck Surgery. 2 nd Edition. Hartcourt .2000.

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important

The removal safely done under direct visualization, preferably under an operating microscope with the patient in a supine position Instruments helpful for this task (alligator forceps, ring curettes, and hooks) Inanimate objects located lateral to the isthmus of the canal are removed with an alligator forceps or by placing a hook or ring curette behind it and pulling it out Suctioning with Frazier suction catheters is useful in removing an object with a smooth surface that is hard to grasp Irrigation can be used in certain instances. Objects located medial to the isthmus of the canal are more difficult to remove and may require local or general anesthesia

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CERUMENS
most common and routine otologic problem Cerumen is a combination of the secretions produced by

sebaceous (lipid-producing) and apocrine (ceruminous) glands admixed with desquamated epithelial debris forms an acidic coat that aids in the prevention of EAC infection

The pH 6.5 to 6.8 in the normal EAC There are genetically and racially determined differences in the

physical characteristics (appearance and consistency and may be associated with immunoglobulin and lysozyme content)

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 The geriatric and mentally retarded

populations have a tendency to accumulate excess cerumen

10 % of children

5% of normal healthy adults

up to 57 % of older patients in nursing homes 36 % of patients with mental retardation

American Academy of Family Physicians. 2007

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 Some patients make routine

attempts to remove cerumen with cottonnswabs making it worse by pushing cerumen medially

The canal may be irrigated with

warm water, either with a syringe or with a pressure-driven irrigating bottle

Before starting to remove

The canal is straightened by

cerumen, one should make sure that the patient does not have a history of tympanic membrane perforation !!

pulling the auricle up and back. The water stream is directed along the superior canal wall, and outflow is caught in a basin held below the ear

If perforation is suspected

irrigation method should not be used !!

Remaining irrigating solution or

residual cerumen can be suctioned out using a Frazier No. 5 or 7 suction catheter

The irrigation method works

best for soft and greasy cerumen

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 In one study, 35 % of hospitalized patients

older than 65 years had cerumen impaction and 75% of those had improved hearing after documented earwax removal

Lewis-Cullinan C, Janken JK. Effect of cerumen removal on the hearing ability of geriatric patients. J Adv Nurs 1990;15:594-600.

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 An alternative method

epithelium are gently separated from the canal wall grasped with an alligator forceps and teased out
If impaction of hard cerumen persists or is too painful to

remove
sent home + agent to soften the cerumen

(common corticosteroid and antibiotic otic drops, ceruminolytic solutions, or hydrogen peroxide)

Following its use for a few days, the patient is re-

examined and the softened remaining cerumen can be removed with irrigation or suction
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cerumen

Veil of cerumen

Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.

acumullation
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Inspisated hard cerumen

Oriental wax

Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.

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Colours of Cerumens

Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.

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Irrigaton jet technique

Irrigation jet is directed Superiorly and posteriorly
20- to 30-cc syringe with either a plastic catheter from a butterfly needle (being careful to remove the needle and wings) or an 18-gauge plastic intravenous catheter

Probst R, Grevers G, Iro H. Basic Otorhinolaryngology : A step-by-step Learning Guide. Thieme. 2006.

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Effective Ceruminolytics

Sodium bicarbonate

Hydrogen peroxide Distilled water

The most effective ceruminolytics have an aqueous base.

Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.

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American Academy of Family Physicians. 2007

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Ineffective Ceruminolytics

cerumol

cerumenex

Olive oil

Oily based solution are not effective

Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.

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American Academy of Family Physicians. 2007

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Topical aural drop (ceruminolytics)

Dhillon RS, East CA. An Ilustrated colour text: Ear, Nose , Throat and Head and Neck Surgery. 2nd Edition. Hartcourt .2000.

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Primary care physicians may see complications from ear candling including candle wax occlusion, local burns, and tympanic membrane perforation

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KERATOSIS OBTURANS
Definition Rare entity characterized by exaggerated accumulation of keratin in the bony part of the EAC with gradual erosion of the bony walls of the canal. Aetiology Altered mechanism of lateral epithelial migration. In the young, it is frequently associated with sinusitis or bronchiectasis.
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Morphology

Keratin plug

Keratosis obturans

Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.

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Diagnosis
A large plug of compressed keratin occluding the external

canal

The plug should be softened with olive oil and the layers of

keratin removed under the operating microscope

After plug removal, the canal appears wider than normal

(probably from the pressure effect of the keratin plug)

Keratosis obturans should be differentiated from the

cholesteatoma of the EAC, which is defined as an invasion of squamous tissue into a localized area of bony erosion (associated with intermittent otorrhoea and a dull, chronic otalgia)
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Therapy Frequent (every 6 months) cleansing under the microscope. The patient must be instructed to avoid self-cleaning

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Keratosis Obturans
After keratin plug removal the external auditory canal appears wider than normal

Anniko M. European Manual of Medicine: Otorhinolaryngology Head and Neck Surgery. Springer-Verlag. 2010.

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Automastoidectomy secondary to keratosis obturans

Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.

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THANK YOU
Refference: 1. Snow JB, Ballenger JJ. Ballengers Otorhinolaryngology Head and Neck Surgery. 16th Edition . 2003. (8):230-48 2. Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005. (1):1-90 3. Anniko M, Bernal M, Bonkowsky V, Bradley P, Lurato S. European Manual of Medicine: Otorhinolaryngology Head and Neck Surgery. Springer-Verlag. 2010. (9):43-54. 4. Dhillon RS, East CA. An Ilustrated colour text: Ear, Nose , Throat and Head and Neck Surgery. 2nd Edition. Hartcourt .2000. (1):24-29 5. Bull TR. Color Atlas of ENT Diagnosis. 4th Edition. Thieme-Stuttgart. 2003. (2):43-98 6. Probst R, Grevers G, Iro H. Basic Otorhinolaryngology : A step-by-step Learning Guide. Thieme. 2006. (3):207-26 7. Lalwani AK. Current Diagnosis and treatment in otolaryngology head and neck surgery. 2nd edition. McGraw-Hill. 2007.

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