Ear symptoms are common. There are five main symptoms which include otalgia (ear pain), otorrhea (ear discharge), hearing loss, tinnitus (ringing) and dizziness (see Dizziness).
Ear pain is common and generally indicates a source of inflammation and/ or infection. Infections can affect the external or middle ear.
External ear infections are commonly the result of trauma (from digging, scratching), swimming and abuse of antibiotic ear drops. In addition, there may be discharge and deafness. The infection can involve the whole canal (diffuse) or just a hair follicle (localized). Treatment includes regular and meticulous ear cleaning (best with suction under microscopic guidance), adequate and appropriate antibiotic ear drops (including oral antibiotics if there is significant swelling) and avoidance of water (no swimming) and digging. Severe ear pain in elderly patients with diabetes mellitus should seek immediate medical attention to exclude a potentially fatal condition Malignant Otitis Externa (MOE).
Acute middle ear infections result from an upper respiratory tract infection (URTI) ascending up the Eustachian tube (a tube connecting the back of the nose to the middle ear). Children are more usually affected although the condition can be seen in adults. This is because the eustachian tube is not as well developed in children as in adults to protect the middle ear from nasal infections. Pain results from the build up of pus under pressure in the middle ear. This symptom is accompanied by deafness but no discharge if the eardrum remains intact. The patient may have other constitutional symptoms such as fever and lethargy. Examination of the ear will reveal a red and bulging ear drum. Treatment includes oral antibiotics and pain relief. If symptoms do not resolve after one week, a myringotomy (cut in eardrum) can be performed to release the pus.
Ear pain can also result from conditions around but not involving the ear. The commonest causes of referred otalgia are temporomandibular joint dysfunction, tonsillitis, teeth and gum disorders, throat infection, tongue and thyroid problems. Treatment is targeted at the primary condition.
Ear discharge usually means an infection although certain people with wet wax can present with a brownish discharge which requires no treatment. External and middle ear infections can produce discharge. External ear infections produce a liquid, creamy discharge (figure 1) while middle ear infection has a mucoid consistency and is foul-smelling (especially in cholesteatoma).
Trauma to the external ear canal can result in blood-stained or bloody discharge which can be persistent and profuse.
Sound is normally transmitted from the environment to the external ear where it hits the eardrum which causes it to vibrate. This in turn causes the 3 ossicles (ear bones) in the middle ear to vibrate. These vibrations are carried through to the inner ear which in turn results in a displacement of the inner ear fluids. This displacement results in the excitement of the organ of hearing and electrical impulses are generated which are carried to the hearing centres in the brain via the hearing (cochlear) nerve. Deafness can result when there is a breakdown in this process.
Deafness can be divided into two main types; conductive and sensorineural. Conductive deafness results when there is a failure of sound conduction from the environment to the inner ear. This generally means a problem in the external and middle ear. Sensorineural deafness indicates disease affecting the organ of hearing (sensory) or the hearing nerve (neural). The most common cause of conductive hearing loss is a build up of wax.
Conductive deafness can also result from external ear infections, bony tumors of the external ear, perforation of the ear drum (figure 2), fluid or pus collection in the middle ear or disease that affects the mobility of the ossicular chain (eg. otosclerosis)
Sensorineural deafness is most commonly seen in presbycusis. Certain drugs, noise or acoustic trauma can permanently damage the organ of hearing. Sensorineural deafness can be part of a myriad of symptoms such as dizziness and tinnitus. When affecting only one ear, an MRI must be performed to exclude tumors arising from the hearing and balance nerve (Fig 3).
This is commonly described as a ringing, buzzing, humming sound in the ear. It is commonly but not always related to a certain degree of hearing loss. The ringing is usually only heard by the patient (subjective tinnitus). Sometimes, the ringing can be also heard by the examiner (objective tinnitus). Causes of objective tinnitus include palatal myoclonus, vascular tumors, high riding jugular bulb.
Treatment for tinnitus can be difficult. Simple masking techniques are effective in the majority of patients. For the more severely affecting patient, tinnitus retraining therapy (TRT) is available. This aim of this form of therapy is to habituate the patient’s response to tinnitus. It involves counseling and sound therapy and can last 12 to 18 months depending on the response of therapy (www.tinnitus-pjj.com).