Appearance of ear due to acute infection

Excluding the presence of acute infection is important and mostly achieved through careful history taking. Otoscopy provides additional information and in acute otitis media (AOM), a distinctly red, yellow or cloudy eardrum is usually seen (Figure 2).

There may also be moderate to severe bulging of the eardrum, with loss of normal landmarks and an air-fluid level behind the drum which indicates a middle ear effusion. In severe cases there may be perforation of the eardrum and/or discharge in the ear canal.

Otitis externa (OE) appears as a red, some-times swollen ear canal with potential debris (desquamated skin) or discharge indicating inflammation and irritation of the ear canal, often accompanied by narrowing due to the swelling.

The eardrum may be partially obscured by the swelling but should generally appear normal if the infection is confined to the external ear.

Although more common in children, do not be surprised to encounter a foreign body, such as a bead, cotton bud or other item used in an attempt to remove earwax in the ear canal, when investigating recent hearing loss.

Earwax

Impacted wax blocking the ear is the commonest cause of temporary deafness in adults. As stated, wax will appear as a yellowy, orange or brown deposit on otoscopy. An estimated 4 per cent of the UK population need earwax management each year.

Earwax is a normal physiological substance found in the ear canal. It is produced by ceruminous glands, which are modified sweat glands lying within the ear canal itself.

The wax (cerumen) aids removal of skin debris and dirt from the ear canal and cleans, lubricates and protects the ear canal lining. It also has antibacterial properties.

Wax is usually soft and works its way out of the ear, but excessive build-up of hard earwax with hair and skin debris can develop in some people. Cotton wool buds, or other objects like match sticks, should never be poked into the ear to clean or clear it as any wax is pushed further in and it is possible to damage the eardrum.

The ear can often be unblocked by using ear drops, which soften the wax and may allow it to run out. Many people who have recurrent problems with wax recognise their symptoms and will purchase ear drops to help prevent it from building up.

If this is not adequate to clear the problem, the ear drops will usually have softened the wax enough to enable its removal using electronic irrigation or microsuction. In some people with more complicated ear problems, removal of wax by an ENT specialist might be necessary.