Ear Wax 

Outer Ear Infection: Otitis externa 

Middle Ear Infection: Otitis media 

Inner Ear Infection: Labyrinthitis 

Glue Ear/Ear Effusions 

Holes in the Ear Drum: (ear drum perforations: both acute/traumatic & chronic) 

Hearing Problems 

Vertigo 

Benign Paroxysmal Positional Vertigo (BPPV) 

Meniere’s Disease 

Tinnitus 

Ear Pain 

The ear is made up of the outer ear (pinna) and ear canal, the middle ear (behind the ear drum) and inner ear (cochlea – which controls hearing and balance).

 

 

 

 

Ear Wax

Ear wax is made from modified sweat glands in the outer ear. It naturally migrates out of the ear at about the same rate as your finger nails grow. The biggest problem that prevents wax from coming out of the ear is the use of cotton buds. These just push wax back down the ear canal. Olive oil or wax dissolving ear drops are useful to stop wax building up in the ear canal. If it is too blocked then the ear canal can be cleaned out with ear microsuction, using a microscope and a very small suction machine. 

Outer Ear Infection (Otitis Externa)

This is usually caused by swimming in infected water, exposure of water to the ears, use of cotton buds (keys, matchsticks, pens), excessive cleaning of the ears, eczema, and occasionally by ear syringing

Treatment is with ear drops such as Sofradex or Gentisone HC. Ear spray (Otomize) can also be given. It is useful to clean the ear out (ear toilet or microsuction) by using a small suction machine under the microscope. This is usually well tolerated. An ear swab is taken to send off to the laboratory. This allows the bacteria to be grown, to check that the bacteria are sensitive to the drops given. If antibiotics are given, the best choice in a child is Augmentin and in an adult is Ciprofloxacin. Sometimes antibiotic ointment is placed in the ear as it stays in contact with the ear canal longer than drops.

It is very important to avoid the use of cotton buds as this makes things worse. It is also important to prevent water getting into the ear when you have a shower or a bath. This is best done using clean cotton wool with Vaseline mixed up in it. This allows you to use a new piece of cotton wool each time.

When swimming it is important to avoid water getting in your ears. There are many types of earplugs available at your local chemist. You can also get swim plugs made that are molded to your ears. These are excellent in preventing water from getting in your ears. Children can also use headbands to prevent water getting in the ears. 

Middle Ear Infection (Otitis Media)

This is very common in children although can occur in adults also. In children they are related to the adenoids (link to picture) being enlarged. Ear infections are also more common in winter, with colds, in boys, in children who attend nursery and in children whose parents smoke. They cause pain and fever, and if the ear drum perforates, ear discharge. They are usually viral, but if the infection persists, it can be bacterial in origin. In adults they can occur following a cold or after barotrauma (scuba diving and air flights). Treatment of ear infections is always pain relief (Paracetamol), and if the infection persists then antibiotics are used. Recurrent ear infections can sometimes resolve if an extended (one month) course of antibiotics is used. However if they persist, they may require insertion of ventilation tubes (grommets)

Glue Ear

Glue ear is a collection of fluid behind the ear drum, in the middle ear. This is much more common in children, although it can occur in adults after colds or barotrauma. It commonly causes hearing loss. This can be a problem for children at school. Glue ear can spontaneously resolve. However if it persists (longer than three months) and is associated with ear infections or hearing loss, then it is treated by insertion of ventilation tubes (grommets). Glue ear causing hearing loss only can be managed with a hearing aid. Sometimes an Otovent can be helpful (particularly in an older child or adult) to promote resolution of glue ear. Occasionally glue ear can present in adults, perhaps after an air flight, especially with a concurrent upper respiratory infection (common cold). This often resolves spontaneously. If it does not, sometimes both antibiotics and steroid nasal sprays are used to help the fluid clear. Occasionally adults may require insertion of ventilation tubes (grommets) also. In adults this can be performed under local anaesthetic in the clinic.

If you have glue ear in one ear only (unilateral) you should be directly referred to see me, as I need to check the back of the nose to make sure there is no problem around the opening of the Eustachian tube. 

Inner Ear Infection (Labyrinthitis)

Labyrinthitis is usually viral and causes severe vertigo, nausea and vomiting. It does not generally cause hearing loss. Headache and visual problems are unusual and if severe are minor compared to the severe vertigo. More severe headache can occur with migraine. Labyrinthitis does not cause loss of consciousness. It does not cause hearing loss. Treatment is usually supportive with medicines such as Prochlorperazine (Stemetil) to treat vertigo. Sometimes it is better to use Buccastem. This is also Prochlorperazine, but is taken under the tongue, and therefore is absorbed directly into the blood stream. Diazepam can also be used to treat severe vertigo. Both Prochlorperazine and Diazepam should be used only in the severe phase of labyrinthitis. After this, they can delay the recovery of vertigo by delaying the inner ear and brain compensatory mechanisms. To help with this I recommend Cawthorne Cooksey exercises

Holes in the Ear Drum (ear drum perforations: both acute/traumatic and longstanding)

Ear drum perforations can be due to trauma (cotton buds etc, deep sea diving injuries {problems with equalisation}) or infection. They can also be long standing, particularly if you have had a lot of ear infection as a child. Over 90% of traumatic ear drum perforations heal spontaneously. It is very rare that they need surgery to repair the drum. It is important to look after the ear until the drum heals. It is important to keep the ear dry. Ear plugs should be used when you are washing your hair. Cotton wool with Vaseline mixed up in it is an excellent ear plug to use until the ear drum heals. The drum takes about 6 weeks to heal. If after this period of time the hole is still present, then you should be referred to have the ear drum perforation repaired. Provided the hole in your ear drum is clean, you do not need to treat it with antibiotics or ear drops. Long standing ear drum perforations usually require repair. This operation is called a myringoplasty or tympanoplasty (myrinx is the Greek word for membrane). 

Hearing Problems

Hearing problems can be secondary to middle ear problems such as glue ear, acute otitis media and ear drum perforations. More commonly it is due to age related hearing loss, or long-term noise exposure. This is usually best managed with a hearing aid. Unilateral or asymmetrical hearing loss may have to be investigated with an MRI scan to make sure the inner ear and hearing nerve are not affected.

Sudden inner ear hearing loss is an ENT emergency and medical attention should be sought immediately. Sometimes steroids and carbogens can be helpful to restore hearing (if given early). 

Vertigo

Vertigo has many causes. These include:

  • Central (brain) problems such as migraine, wear and tear (ministrokes), strokes, headache, fits, turns, blackouts, seizures, head injury, brain tumours (acoustic neuroma)
  • Ear
  • Acute labyrinthitis
  • Inner ear barotrauma
  • Benign Paroxysmal Positional Vertigo (BPPV or movement provoked vertigo)
  • Labyrinthine fistula (cough, sneeze)
  • Caloric effect
  • Post-concussion syndrome
  • Meniere’s disease/Endolymphatic Hydrops
  • Following middle ear surgery
  • Vestibular neuronitis
  • Trauma – head injury, ear surgery, etc
  • Cardiovascular lesions:
  • Vertibrobasilar insufficiency
  • Strokes
  • Low blood pressure
  • Heat beat rhythm problems

You will note that it is rare for a bacterial infection or a structural ear problem to cause vertigo. Therefore it is often not possible to treat vertigo with antibiotics or surgery. Most commonly the inner ear needs to rehabilitate (readjust) after there has been an inner ear problem such as acute labyrinthitis. This can take up to three months. Cawthorne Cooksey (inner ear balance) exercises can be helpful in the recovery of acute labyrinthitis.

Benign Paroxysmal Positional Vertigo (BPPV)is vertigo that is brought on by a specific head movement. This is always the same movement. It is due to loose otoliths in the inner ear. The Epley’s manoeuvre (canalith repositioning procedure) is often used to treat this, and it often works!

Ménière’s Disease

Ménière’s disease presents with episodic vertigo lasting several hours. Treatment includes low salt diet, Betahistine (Serc) and Bendroflumethiazide. Prochlorperazine (Stemetil or Buccastem) can be used to treat the acute vertigo and nausea. Buccastem is useful as it is absorbed under the tongue and gets into the blood stream quickly. In severe cases of Ménière’s disease, treatment can include intratympanic Gentamicin. This is performed under local anaesthesia and can be very helpful in preventing severe frequent attacks. Some patients get some benefit with the use of the Meniett device.

See also Ménière’s disease information sheet

Tinnitus Retraining

Tinnitus is defined as a hallucination of sound i.e. hearing a sound that does not come from the outside world. It is commonly associated with age related hearing loss. The sound originates not in the outer or middle ear at all, but most commonly from the inner ear and the ‘hearing pathway’ to that part of the brain responsible for ‘conscious awareness’ of sound. Occasionally tinnitus may occur because there is wax in the outer ear or if there is fluid in the middle ear. More often the outer and middle ear are normal. Indeed there may only be an age related hearing loss.

Tinnitus Retraining Therapy (TRT) is one of the better ways of managing tinnitus. The idea is to block tinnitus-related brain activity from reaching the level of the brain where it is perceived, and from activating the brain stem and autonomic nervous systems — to habituate tinnitus perception and tinnitus-induced reactions.

Click here for information on Tinnitus Retraining Therapy.

Click here for information on the results of Tinnitus Retraining Therapy.

Tinnitus is also managed by avoiding caffeine (all tea/coffee/chocolate), tonic water and Aspirin (although your doctor may advise you take Aspirin to avoid a heart attack or a stroke, and clearly if this is the case, it is important to take it). Sometimes people with tinnitus take Betahistine (one tablet three times a day). Others try Ginkgo Biloba, although there is no good evidence to support the use of this for tinnitus. Tinnitus maskers and hearing aids are also used.  The Tinnitus Clinic now offer neuromodulation to help tinnitus suffers, which has been very successful.

Websites that offer good information regarding tinnitus are:

The British Tinnitus Association

The Tinnitus Clinic

The Tinnitus and Hyperacusis Centre 

Ear Pain

Ear pain often occurs when there is local infection, impacted ear wax, inflammation or trauma. In these situations, the cause and treatment are often straight forward. However on other occasions the pain can be referred from the throat. This is commonly seen in children with tonsillitis, who complain of ear pain also. This is called ‘referred pain’. Sometimes in adults this pain can also come from the tonsil, and is seen in some people with growths of the tonsil. Ear pain can also originate from the jaw joint (temporomandibular dysfunction) and can be seen in those people who grind their teeth at night. Soft diet, analgesics and sometimes mouth guards, are used in the treatment of this.

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