Foreign Body Ear Dr EDO

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EDO WIRA CANDRA

EAR: Foreign Body, Cerumen Impacted and Keratosis Obturans

Literature Reading

Otorhinolaryngology Department – Hasan Sadikin HospitalFaculty of Medicine – Padjadjaran University – Bandung

Indonesia2011

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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

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

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

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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 may be discovered in the EAC

Diagnosis : easy using the operating microscope and a small blunt hook

Found most frequently in the pediatric age group or in mentally retarded patients

Any objects small enough to enter the EAC can become prospective foreign bodies(animate, inanimate, or mineral objects)

They may cause symptoms of irritation, pain, and hearing loss

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a . Sand particles can be seen along the anterior wall ofEAC

b . A piece of paper has been “forgotten”inside EAC secondary infection (externalotitis) of the skin

c . A metallic hearing aid component, withsecondary infection of the skin of the EAC

d. Insect on the surface of tympanic membrane


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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. 2nd 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

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

If perforation is suspected irrigation method should not be used !!

The irrigation method works best for soft and greasy cerumen

The canal may be irrigated with warm water, either with a syringe or with a pressure-driven irrigating bottle

The canal is straightened by 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

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

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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

acumullation

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Inspisated hard cerumen Oriental wax

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Colours of Cerumens


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Irrigaton jet technique

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

Irrigation jet is directed Superiorly and posteriorly

20- to 30-cc syringe with either a plasticcatheter from a butterfly needle (being carefulto remove the needle and wings) or an18-gauge plastic intravenous catheter

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Effective Ceruminolytics


The most effective ceruminolytics have an aqueous base.

Sodium bicarbonateHydrogen peroxideDistilled water

LR/EO 21American Academy of Family Physicians. 2007

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Ineffective Ceruminolytics


Oily based solution are not effective

cerumol cerumenex Olive oil

LR/EO 23American 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

Keratosis obturans

Keratin plug

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 removalthe external auditory canal appears wider than normal


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Automastoidectomy secondary to keratosis obturans


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THANK YOURefference:

1. Snow JB, Ballenger JJ. Ballenger’s 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.

Foreign Body Ear Dr EDO

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