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Earwax

 

Excessive earwax is a very common condition.  It causes conductive hearing impairment if significantly block the ear passage.  Earwax dissolving solution need to be instilled prior to its removal.  Traditionally, Higginson ear syringe was used to flush warm saline at body temperature.  Present day techniques include earwax suctioning/toilet under microscope view and electric-driven saline irrigation.

A close-up view showing direction of water jet

towards posterosuperior aspect of the ear canal.

 

Watch video of earwax @ YouTube 

Watch video of earwax removal by syringing technique @ YouTube

 

 

 

Micro Ear Toilet of Long-Standing Impacted Earwax.

 

 

 

 Stuck Earwax At Its Worst!

 

Further readings:

1.Subha ST, Raman R. The role impacted caerumen in hearing loss. Ear Nose Throat J. 2006 Oct;85(10):650, 652-3.

2.Lum CL, Jeyanthi S, Prepageran N, Vadivelu J, Raman R. Antibacterial and antifungal properties of human caerumen. J Laryngol Otol. 2009 apr;123(4):375-8. Epub 2008 Aug 11. 

3.Paula McGrath.  Secretion secrets: things you didn't know about earwax @ BBC Health, 16 March 2014

Earwax: Endoscopic View Before & After Syringing

The typical appearance of an adequately     The appearance after syringing done.

soften earwax.  Minor abrasion seen due                      (same patient)

to cotton tip injury used by patient to self

                   clean the ear. 

 

 

 

Endoscopic findings in a patient complaining of right earache few days after syringing done for earwax removal.  The osseous ear meatus appeared inflamed and focal haematoma seen (H). Minor residual soft earwax visible posteriorly (W).  Possible other complications include eardrum perforation and ear canal skin laceration or abrasion, (TM- tympanic membrane) 

Earwax Removal Without Prior Softening With Otic Drops

 

 

This technique is usually performed for small to moderate amount of earwax impaction in whom who needs quicker relief of ear blockage and hearing loss.  However, near complete occlusion is also feasible to be removed.  Gentle manipulation with cold instruments and suctioning under good microscopic view are required.  If it becomes intolerable and difficulty encountered, the procedure should be deferred to another date.  Adequate earwax softening solution prescribed.  Complications include ear canal  abrasion, laceration, bruise, tympanic membrane injury and secondary infection.

Otoendoscopic Evidence of Self Ear Cleaning Using Cotton Bud or Similar Materials

Earwax smearing onto eardrum surface.    Rippling/wavy epithelial surface of the

                                                             canal secondary to superficial scarring.

Presence on avulsed hair in osseous meatus or on eardrum surface.

Dry earwax flakes in osseous meatus with some sticking onto eardrum surface.

 

 

Crumbs or earwax pieces close to eardrum edge.  

 

 

Similar dry flakes in another patient close to the eardrum. 

 

Impacted earwax with bruises of ear canal wall.

Deeply rolled-over wax layer with partly visible eardrum at the background.

Earwax ball deeply impacted into osseous external auditory meatus.

False Tympanic Membrane with Keratosis Obturans Formation

Obliterated ear canal by bulging membrane (arrow) which formed complicating auditory meatus and temporomandibular joint injuries following motor-vehicle accident.  It felt soft and cystic.  Excision was performed under general anaesthesia.  Trapped haemoseous secretion and keratin flake/impissated material found and removed.

Part of trapped materials removed behind the false tympanic membrane.

Representative high resolution CT-scan in coronal cut showing the lesion (+).

Keratosis Obturans: Secondary-Acquired Stenosis of External Ear Canal

Crescentic dashed area depicts formed membrane secondary to longstanding keratosis obturans with had caused ear canal narrowing.  Arrows - keratin material discovered during micro-ear toilet which was removed.  The membrane was excised to regain optimal opening for ease of ear cleaning during outpatient follow-up.

Keratosis Obturans: An Intraoperative View

Red dash - granulation tissue, K - keratin, (*) - earwax, TM - tympanic membrane, while line - handle of malleus (right).

Endoscopic view 1 week later showing resolving granulations and more obvious dip of the osseous canal floor.  The eardrum (TM) appeared retracted with the tympanic cartilaginous ring became visible.  (Arrow -  handle of malleus)

 

 

 

 

 Keratosis obturan materials removed.

Endoscopic view of the ear canal 2 weeks after successful clearance and completion of antibiotic therapy (same patient as depicted in the video above).  No residual keratin or granulation tissue seen.

Keratosis Obturans with Granulation Polyps Formation

TM - tympanic membrane, arrows - granulation polyps.

Solitary granulation (X) one week after removal of keratosis obturan lesions.  An antibiotic course was prescribed.

Keratosis Obturans

 

Abnormal epithelial migration and turnover in the presence of impated earwax predispose to localized or generalized cumulation of keratin and desquamated epithelium in the ear canal.  In longstanding cases, these result in bony resorption and expansion aliken to flask or hour-glass appearance.  The above figure shows a widened ossous meatus and a local whitish keratin layer on the floor of ear canal in a patient who just had an ear toilet performed for recurrent ear wax.

Endoscopic view of right ear canal during micro-ear toilet.  Top left image shows keratosis obturans material (KO), and top right image upon completion of procedure with the patient lying down in supine position. 

[TM - tympanic membrane, A - anterior, I - inferior, S - superior]

  

   This image shows the effect of long standing keratosis obturans

on the ear canal appearance after successful treatment given.

[stars- shallow defect secondary to bony resorption]

 

The normal external auditory meatus for comparison.

 

Watch video of keratosis obturans and suction clearance @ YouTube

The Ossicles as Seen in Atectatic Eardrum in a Previously Treated Keratosis Obturans

                              1- malleus, 2- incus, arrow- stapes

Keratosis Obturans with Mastoid Erosion

TM - tympanic membrane, arrow - chorda tympani, (+) - mastoid cavity, X - epitympanum. 

 

Close up view of eroded posterior ear canal wall with mastoid cavity in view (+). 

Epithelial Pearl

Painless round swelling with soft consistency arising from the anterior wall of the introitus skin (arrow).  

 

"Pearl'" over cartilaginous ear canal.

"Pearl'" of bony ear canal.

Osteoma

Exostoses

 

 

 

 

Suggested reference:

 

Ursick JA, Fayad JN. External auditory canal exostosis. Ear Nose Throat J. 2013 Jan;92(1):13.

Diffuse Exostoses and Osteomata of The External Auditory Canal

Viral Warts of The External Ear Canal

Warts involving cartilaginous external canal of the left ear. 

Close-up view of the lesions. 

Otitis Externa- Swimmer's Ear by Dr Zoran Becvarovski

Acute Otitis Externa

Figure shows an inflamed left osseous meatus due to acute otitis externa.

Another example of swimmer's ear.

 Diffused inflammation of ear canal 

A diffusely inflamed and narrowed ear canal.  (+) - tympanic membrane.

Otomycosis

 

Otomycosis presents with ear itchiness, blockage, reduced hearing, and pain.  There is superficial inflammation caused by various fungal species including candida and aspergillus.  Fungal hyphae, micelium, and wet-paper appearance of ear canal skin are amongst its typical findings

. 

 Otomycosis occuring along handle of malleus.

 

Fungal hyphae with surroundings wet paper appearance.

 

Mycelium of fungus involving osseous meatus.

Another example of otomycosis with obvious mycelium seen (ellipse).

Severe otomycosis caused by Aspergillus niger.

Otomycosis with visible rim of central perforation at the background.

Otomycosis with co-existing small eardrum perforation.

Appearance of the ear canal after topical antifungal

powder spray applied post-aural toilet.

Minute yellowish tufts/grains of otomycosis at it early stage of infection.

 

Watch video of otomycosis @ YouTube

 

Hidden perforation made visible after ear toilet...it's a double perforation of TM!

 

 

Video of otomycosis removal by suctioning under microscope view.  Topical antifungal powder spray was applied at the end of procedure (white salt grain appearance).

 

Video of otomycosis suction clearance under endoscopic view.

 

Watch video of suction clearance of otomycosis @ YouTube

Furunculosis

                              Figure 1                                       Figure 2

 Figure 3

Figure 4

 

Figure 1: Furunculosis with pointing pus arising from hair-bearing area of ear canal

Figure 2: Diffuse inflammation with ear canal occlusion. Tragal tenderness present.

Figure 3: Furunculosis (circle) which spontaneously burst a day earlier causing purulent discharge with blood stain.  Incision or aspiration is usually not perform due to fear of spreading the infection leading to perichondritis,

Figure 4. A recently burst furuncle (arrow) which responded favourably with oral antibiotic.  (T - tragus).

Furunculosis with Abscess Formation

 Purulent ear discharge from burst furuncle with abscess formation.

 

 

An indurated tender swelling involving postero-inferior post auricular and upper neck area with lymphadenitis.  The child responded well to treatment consisting intravenous antibiotic, micro-ear toilet, antibiotic impregnated wick, and suitable anaelgesia.  Pus culture grew Staphylococcus aureus.

 

 

Healed lesion 2 weeks later with restored post-auricular sulcus. 

 

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