Ear care: pharmacy treatment
Ear problems can be unpleasant and are a common reason for people seeking advice from a pharmacy. There are only two ear conditions that can be treated without medical referral, ear wax and mild otitis externa, although the range of over-the-counter products may suggest otherwise.
Ear wax is produced by sebaceous glands inside the ear, where it protects, cleans and lubricates the skin. Ear wax can be soft — as is more common in children — or hard, and may be wet or dry. It only causes problems if more is produced than is naturally lost, when it can lead to a blocked, painful or itchy ear or sometimes tinnitus. Individuals who are at increased risk of experiencing a build up of ear wax include:
- Those who have ear canals that are narrow, not fully formed, or contain a lot of hair or benign growths
- Anyone who tends to produce a large amount of wax or wax that is particularly hard (this is often the case for older people)
- People who have a history of impacted ear wax or ear infections
- People who have learning difficulties
The most effective method of removing hardened or impacted ear wax is irrigation. This involves squirting body temperature water into the ear canal under gentle pressure, and is also called syringing. However, softening drops are frequently recommended for a few days before the procedure or as a preventive measure for those who experience repeated problems. OTC drops for this purpose contain a softening agent such as arachis, almond or olive oil, docusate or glycerol, and some also contain an agent that releases oxygen in the ear to help remove hardened wax, eg, urea or hydrogen peroxide. Ear drops can be tricky to use, so it is worth checking administration technique with anyone making OTC purchases (see Panel, p8). Irrigation should not be used for those who have a perforated eardrum, have experienced one in the last year or have symptoms that may suggest one, or anyone with recent otitis media or current severe otitis externa, a foreign object in the ear, a cleft palate (even if it has been repaired), grommets (see later) or those who have had ear surgery within the previous 18 months. Alternatives to irrigation include suctioning or manual removal of ear wax.
As with many minor ailments, prevention is better than cure. Although ears should be kept clean, using cotton buds or similar as a cleaning aid can push ear wax deeper into the ear and cause it to impact. Hearing aids and earplugs can also stop the natural loss of ear wax from the ear canal, so should be removed and cleaned regularly.
Otitis externa is inflammation of the outer ear canal. It is sometimes referred to as swimmer’s ear, as repeated water exposure can strip the protective lining of the auditory canal, making it more prone to inflammation. Other causes include a break in the ear lining, an infection or irritation caused by an object such as a hearing aid or ear plug, or a chemical such as hair dye. Usually only one ear is affected. Symptoms of otitis externa include pain or discomfort, discharge, itching and hearing loss. There may be tenderness when moving the jaw, and the lymph glands in the neck may be swollen.
OTC remedies contain acetic acid, an antifungal and antibacterial, or the antifungal clotrimazole. One of the products available also contains choline salicylate, a mild analgesic. However, anyone who has anything other than mild symptoms or who has suffered for several days should be referred to a GP for examination and possible prescribing of an antimicrobial or corticosteroid ear preparation, oral antibiotics or treatment for an underlying condition that may have led to the otitis externa, eg, eczema. Anyone who has suffered from otitis externa is at risk of recurrence, but there are a few preventive measures that can be taken. These include good management of skin conditions such as eczema or psoriasis, not inserting objects into the ears, using an acidifying product before and after swimming to keep the ears clean, and keeping the ears as dry as possible by using a shower cap, swimming cap or ear plugs (made of wax or mouldable silicon) and drying them using a hairdryer on a gentle setting after swimming or washing.
There are a number of other ear conditions that are likely to present in the pharmacy but which require medical referral.
Otitis media, or inflammation of the middle ear, commonly affects young children. This is because their eustachian tubes are almost flat which facilitates the movement of infection to the middle ear, whereas the eustachian tube in adults is more upright and closes during sneezing or coughing. Otitis media is usually due to bacterial or viral infection and is often associated with a cold. The symptoms generally include fever, malaise, vomiting, irritability and pain due to pus — and therefore pressure — building up behind the eardrum. Discharge indicates that the eardrum has burst, and is usually associated with a sudden reduction in pain. Some cases will resolve with analgesics and antipyretics, but antibiotics may be prescribed if symptoms are severe.
Otitis media with effusion
Otitis media with effusion, also known as glue ear, is a common childhood condition, particularly in winter, and occurs when the middle ear fills with mucus. This causes hearing loss, which is the most common symptom of the condition, but sufferers may also report mild pain, irritability and problems with sleep or balance. If the condition persists in young children, speech and language development may be delayed. Most cases resolve within three months without treatment, but persistent cases may require a small incision in the ear drum to drain the mucus and insert a tube (called a grommet) that allows air into the middle ear. This immediately restores hearing, but means that the patient is at risk of water entering the middle ear during washing and swimming. Grommets usually fall out after a few months and the incision heals spontaneously.
Tinnitus is the term used when sounds are heard in one or both ears, and is a symptom rather than a condition in itself. It is often described as a ringing sound, though patients may experience other noises, and is worse when the environment is quiet, eg, when they are trying to sleep at night. Tinnitus has a number of causes including impacted earwax, a cold, a blow to the head or exposure to a loud noise and treatment hinges on addressing the cause.
A blocked ear can have a number of causes, ranging from a cold or hay fever to air travel. The cause is unequal pressure on each side of the eardrum, due to mucus or inflammation in the eustachian tube or changing air pressure. Swallowing or chewing is usually sufficient to open the eustachian tube and equalise the air pressure on each side of the eardrum, otherwise breathing out with the mouth closed and the nose pinched (the Valsalva manoeuvre) can help achieve the same effect.
Another problem for which people may seek pharmacy advice is noise reduction, whether it is people wanting to protect their own (or someone else’s) ears at a concert, or people complaining that they can’t sleep due to their partner’s snoring. Noise-reducing earplugs reduce the amount of noise that reaches the ears but without losing the sound quality, ie, music can still be heard, but at a reduced volume. Mainstream products tend to be made of foam or silicon, both of which allow a snug fit in the ear canal and are either disposable or suitable for a limited number of uses. People who require regular noise reduction, eg, musicians, may have earplugs custom made out of solid material for repeated use. Anyone using earplugs in bed needs to check the fit carefully because not only does the shape of the ear canal change when lying down, but also the pressure of the head against the pillow may cause discomfort if the ear plug sticks out at all.
Administering ear drops
It is important that patients use their ear drops correctly to get most benefit:
Ear drops should be discarded 28 days after opening. Writing the date of opening on the label will remind patients when they need to be thrown away.
Citation: Community Matters URI: 11103556
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