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It is one of the commonest otological conditions encountered by Medical Officers. It is important to recapitulate the pathophysiology of the condition for a broader understanding of principles of management and suitable preventive/pre-operative advice to patients.
Pathophysiology: It is more common in children due to:
Infections are usually viral to start with but common organisms like Streptococci, Haemophilus influenzae, Pneumococcus etc., secondarily invade the middle ear. The occlusion of nasopharyngeal end of the Eustachian tube due to inflammatory oedema leads to absorption of air in the middle ear and exudation/transudation of fluid. As the volume of this infected fluid increases, so do the manifest symptoms of heaviness, pain and pyrexia – till the host resistance is overcome, suppuration in the middle ear fluid sets in, resulting in ‘pointing’ or bulging of a segment of tympanic membrane. With clinical acumen for an early diagnosis and correct interventional measures, the pathological process which may vary between few hours to two days, can be stalled decisively. If the patient reports late or the diagnosis is missed, rupture of tympanic membrane results with resolution of acute symptoms. Later, some of these cases continue to have chronic otitis media while in others the membrane heals spontaneously.
Clinical features: An upper respiratory tract infection/‘cold’ usually precedes acute otitis media. The patient may have features of acute/residual sinonasal/throat infection – he may be pyrexial and complain of blocked feeling/pain in the ear – the symptoms/signs varying according to the stage at which he presents – catarrhal or suppurative. At the catarrhal stage, the tympanic membrane (s) are retracted with loss of light reflex, mildly congested with predominant malleolar congestion. Later, the congestion spreads across the entire tympanic membrane (Fig – 1). In an impending rupture, the patient is very restless, will cry for relief and the membrane will bulge, usually postero-superiorly. Tuning fork tests will show mild to moderate conductive hearing loss in the affected ear. No special investigations are required at this stage – if the membrane has ruptured, an aural swab must be taken for culture and antibiotic sensitivity test.
Pathophysiology: A furuncle of external auditory meatus is a Staphylococcal infection of the hair follicle(s) and as these hair follicles are confined to the outer one-third of external auditory meatus, furuncles naturally are seen in this area only. They may occur as single/multiple lesions and may recur in diabetics or debilitated individuals. Damaging the integrity of external auditory meatus skin by self-cleaning efforts with different objects (pins/pens/rather large sized commercial buds), especially after swimming, is a definite predisposing factor.
Clinical features: Patient may present at a very early stage i.e. folliculitis with a very clearly localized mild pain. If the infection does not spread/escalate, all that is required is local application of Ung Neosporin/Soframycin cream.
A patient with well developed furuncle will present with severe ear pain and local tenderness, which is out of proportion to the apparent size of the furuncle. Movements of jaw and pinna and instrumentation are painful. It is important to differentiate between a posterior meatal furunculosis and early mastoiditis. Some of the important differentiating clinical features are as follows:
We as doctors will continue to see patients who present with significant deafness since many years, patients who when spoken to loudly respond adequately. These patients may have intact tympanic membranes – but these are retracted/severely retracted or the tympanic membranes may be scarred and immobile. These cases are the classical end result of neglected Otitis Media with effusion (synonyms: Secretory Otitis Media/glue ear), a condition which is very common in childhood. Otitis Media with effusion is an insidious condition characterized by accumulation of non-purulent, serous/viscid, generally sterile fluid in the middle ear . This effusion occurs due to increased secretory activity of middle ear mucosa (more goblet and mucus cells) and eustachian tube dysfunction.
Clinical features: It's common in children below 10 years of age. Hearing loss of moderate severity, mild, recurrent ear pain and a blocked feeling of the ear, are the usual presenting complaints. The hearing loss may occur in infancy leading to a delayed speech acquisition or the child may be school going and brought because of suspicion of deafness by teachers/parents as the child's oral work is poorer than his written work. If it's of recent onset, the patient may have features of residual upper respiratory tract infection/sinusitis. Otoscopic examination in the early stages will reveal a dull red, mildly congested, retracted tympanic membrane with loss of light reflex and decreased mobility. A retracted tympanic membrane depending on the degree of retraction will have following features – loss of light reflex, prominent lateral process of malleus, prominent sickle shaped anterior/posterior malleolar folds, foreshortening of handle of malleus which thus appears more horizontal while late case may show indrawing and draping of tympanic membrane over the incudostapedial joint postero-superiorly . A thin leash of blood vessels may be seen along the handle of malleus or scattered radially peripherally – giving the tympanic membrane a ‘cartwheel’ appearance. The congestion of the tympanic membrane and the associated symptoms are mild as compared to the marked generalised congestion of acute suppurative otitis media. Fluid level may be seen in the middle ear, if fluid is serous with air bubbles, if Valsalva's manoeuvre is possible (Fig 2). In the late/chronic stages, the tympanic membrane is dull, markedly retracted and immobile. Tuning fork tests/audiometry show conductive deafness, while impedance audiometry shows reduced tympanic membrane compliance and a flat curve with significant negative middle ear pressure (−200 daPa or less).
Late stages: When fluid is thick/viscid and medical treatment does not help much over 3–4 weeks, the patient should be referred to an ENT centre where the fluid is evacuated through myringotomy. In cases of chronic, recurrent otitis media with effusion, grommet insertion is done for continued aeration of middle ear while simultaneously tackling the causative factor, for example adenotonsillectomy.
Sequelae: The disease does appear to burn itself out by puberty when the tympanic membrane may be scarred and retracted but there is no fluid. Prolonged viscid effusion with eustachian tube dysfunction can lead to thinning out of tympanic membrane, atelectasis (collapse) of middle ear, tympanosclerosis, retraction pockets or ossicular necrosis. The importance of early diagnosis and management of otitis media with effusion, therefore, cannot be simply over-emphasized.
Fungal infection of the external auditory meatus is commonly due to Aspergillus niger/fumigatus or Candida albicans. It is common in hot and humid climate, especially in North-East India and may be seen more after a recent swim.
The cardinal features are ear discomfort/pain, intense itching and a feeling of a ‘wet’ ear with a blocked sensation. Otoscopy reveals congestion and oedema of meatal skin. At the early stages of infection, dry fungal growth can be clearly seen (white/black spores of Aspergillus infection) or there may be a creamy deposit (Candida infection). At a later stage, one will see dirty white debris akin to a wet blotting paper filling up the entire canal over an inflamed meatal skin (Fig 3).
This is one of the commonest conditions in a peripheral medical set up as small children are fond of inserting anything and everything possible into the ears – grains of wheat/pulses, rubbers, metal or plastic beads/objects, stones, paper, cotton-even ball pen tops! Or these foreign bodies may enter external auditory canal accidentally eg. insects. After the ‘Holi’ festival, ‘gulal’ may discolour the external auditory meatus abnormally for many weeks.
Clinical presentation: The child is generally brought by the parents who have seen him insert the foreign body or have been told about the incident. Live insects due to crawling, constant fluttering or biting make the patient, extremely restless and will ensure early presentation. Vegetable foreign bodies like seeds, grains etc, if neglected for 3–4 days, can present with otalgia and otorrhoea.
Diagnosis: This is usually easy from history and otoscopic examination.
Wax or cerumen is secreted by ceruminous glands which are modified sweat glands present in the external auditory meatus. It has useful functions in that it lubricates ear canal, entraps foreign bodies and has an antibacterial action. In normal individuals small amount of wax is secreted which dries up into flakes or a small ball which is expelled spontaneously by epithelial migration or movements of jaw. However, accumulation of wax forms a solid, hard mass, brown or yellowish in colour which is called ‘Impacted wax’. Some people are predisposed to excessive wax secretion. This associated with certain other factors like tortuous, narrow canal, stiff hair and narrowing of ear canal due to obstructive lesions leads to impaction of wax.
Clinical features: Impairment of hearing or sudden blocked feeling after a bath, discomfort in the ear, tinnitus and transient disturbance of balance due to pressure of the wax on the tympanic membrane are the usual symptoms.
Pain in the ear may arise from the lesions of auricle, external auditory meatus or middle ear and mastoid, or it may be referred from lesions of other anatomical structures closeby.
Lesions pertaining to ear: Trauma to auricle/tympanic membrane, impacted wax, furuncle of external canal, otomycosis, otitis externa, acute otitis media, chronic suppurative otitis media with effusion, acute mastoiditis etc.
Lesions causing referred otalgia: Carious tooth, acute tonsillitis or peritonsillitis, post adenoidectomy or post tonsillectomy, lesions of soft palate (eg. aphthous ulcers), epiglottitis, temporo-mandibular joint disorders/malocclusion etc. History and a careful examination will often provide leads to the exact cause.