foreign body ear dr edo
TRANSCRIPT
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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
Anniko M. European Manual of Medicine: Otorhinolaryngology Head and Neck Surgery. Springer-Verlag. 2010.
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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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Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.
cerumen Veil of cerumen
acumullation
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Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.
Inspisated hard cerumen Oriental wax
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Colours of Cerumens
Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.
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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
Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.
The most effective ceruminolytics have an aqueous base.
Sodium bicarbonateHydrogen peroxideDistilled water
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LR/EO 21American Academy of Family Physicians. 2007
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Ineffective Ceruminolytics
Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.
Oily based solution are not effective
cerumol cerumenex Olive oil
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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
Anniko M. European Manual of Medicine: Otorhinolaryngology Head and Neck Surgery. Springer-Verlag. 2010.
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Automastoidectomy secondary to keratosis obturans
Hawke M, Bingham B, Stammberger H, Benjamin B. Diagnostic Handbook of Otorhinolaryngology. 2005.
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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.