Treatment Options for earwax: Ear Drops, Microsuction, and Manual Removal

earwax, also known as cerumen, can cause discomfort and hearing problems if it builds up in the ear canal. The first-line treatment for earwax is ear drops, which can soften the wax and make it easier to remove. Microsuction is a safer alternative to irrigation, but it is not widely available. Manual removal using a probe is also an option. However, there is little evidence on the effectiveness of these treatments.

Various types of ear drops can be used, including sodium bicarbonate, sodium chloride, olive oil, and almond oil. Cerumol® is a commonly used proprietary agent. However, the British National Formulary warns against using docusate sodium (Waxsol®, Molcer®) or urea hydrogen peroxide (Exterol®, Otex®) as they may irritate the external meatus.

Regardless of the type of ear drop used, the patient should lie with the affected ear uppermost for 5-10 minutes after applying the drops. While using any type of ear drop appears to be better than no treatment, it is uncertain if one type of drop is more effective than another. Therefore, it is important to seek advice from a healthcare professional before attempting to remove earwax at home.

Consider Acoustic Neuroma in Patients with Unilateral Hearing Loss and Tinnitus

Whilst acoustic neuroma is a rare condition, it should be considered in patients who present with unilateral hearing loss and tinnitus, especially if the other ear appears unaffected. A contrast MRI brain is the most appropriate next step to confirm or rule out the diagnosis.

In contrast to Ménière’s disease, which is a possible differential diagnosis but usually not associated with unilateral signs, symptoms of vertigo are not prominent in acoustic neuroma. Therefore, trials of vestibular suppressants such as betahistine are ineffective, and prochlorperazine is not recommended.

It is important to note that hearing loss in acoustic neuroma is progressive, and choosing a hearing aid option may delay intervention. Therefore, prompt diagnosis and treatment are crucial to prevent further complications.

Horizontal nystagmus is a common symptom of vestibular neuronitis, which is caused by inflammation of the vestibular nerve. This condition typically presents with vertigo, nausea, vomiting, and balance problems, but doesn’t cause hearing loss as the cochlear nerve is not affected. The presence of horizontal nystagmus helps to rule out a central cause of vertigo, such as a stroke.

Acoustic neuroma, on the other hand, is characterized by a tumor that compresses the eighth cranial nerve, leading to symptoms such as vertigo, hearing loss, tinnitus, and an absent corneal reflex. Meniere’s disease is another condition that causes sudden episodes of vertigo, hearing loss, and tinnitus, but also involves a sensation of fullness in the ears due to an abnormal amount of endolymph in the inner ear. However, the absence of tinnitus in the patient in the vignette makes these diagnoses less likely.

A posterior circulation stroke can also cause nystagmus, vertigo, and nausea, but these symptoms typically come on suddenly and are accompanied by ataxia, unilateral limb weakness, and an altered mental state. In addition, a central cause of vertigo would result in vertical nystagmus rather than horizontal nystagmus.

Viral labyrinthitis is similar to vestibular neuronitis, but is more likely to cause hearing loss and tinnitus. In vestibular neuronitis, only the vestibular nerve is affected, while hearing is spared.

Understanding Vestibular Neuronitis

Vestibular neuronitis is a type of vertigo that typically occurs after a viral infection. It is characterized by recurrent episodes of vertigo that can last for hours or days, accompanied by nausea and vomiting. Horizontal nystagmus is also a common symptom, but there is no hearing loss or tinnitus.

It is important to differentiate vestibular neuronitis from other conditions such as viral labyrinthitis and posterior circulation stroke. The HiNTs exam can be used to distinguish between these conditions.

Treatment for vestibular neuronitis typically involves medication to alleviate symptoms, such as buccal or intramuscular prochlorperazine for severe cases, or a short course of oral medication for less severe cases. Vestibular rehabilitation exercises are also recommended for patients who experience chronic symptoms.

Understanding the symptoms and treatment options for vestibular neuronitis can help individuals manage this condition and improve their quality of life.

Meniere’s disease is characterized by spontaneous episodes of vertigo lasting minutes to hours, accompanied by unilateral hearing loss and tinnitus. This clinical presentation suggests a diagnosis of Meniere’s disease, which should be confirmed by referral to an ENT specialist and formal audiometry. The cause of Meniere’s disease is unknown, but it may be associated with raised endolymph pressure in the inner ear. Benign paroxysmal positional vertigo, labyrinthitis, and vestibular neuronitis are not likely diagnoses, as they present with different symptoms and characteristics.

Meniere’s disease is a condition that affects the inner ear and its cause is unknown. It is more commonly seen in middle-aged adults but can occur at any age and affects both men and women equally. The condition is characterized by the excessive pressure and progressive dilation of the endolymphatic system. The main symptoms of Meniere’s disease are recurrent episodes of vertigo, tinnitus, and sensorineural hearing loss. Vertigo is usually the most prominent symptom, but patients may also experience a sensation of aural fullness or pressure, nystagmus, and a positive Romberg test. These episodes can last from minutes to hours and are typically unilateral, but bilateral symptoms may develop over time.

The natural history of Meniere’s disease is that symptoms usually resolve in the majority of patients after 5-10 years. However, most patients will be left with some degree of hearing loss, and psychological distress is common. ENT assessment is required to confirm the diagnosis, and patients should inform the DVLA as the current advice is to cease driving until satisfactory control of symptoms is achieved. Acute attacks can be managed with buccal or intramuscular prochlorperazine, and admission to the hospital may be required. Prevention strategies include the use of betahistine and vestibular rehabilitation exercises, which may be beneficial.

Immediate referral to an ENT specialist or emergency department is necessary for individuals experiencing acute sensorineural hearing loss. This is considered an emergency and requires urgent audiology assessment and a brain MRI. According to NICE CKS guidelines, individuals with sudden onset hearing loss (unilateral or bilateral) within the past 30 days, without any external or middle ear causes, should be referred within 24 hours. Additionally, those with unilateral hearing loss accompanied by focal neurology, head or neck injury, or severe infections such as necrotising otitis externa or Ramsay Hunt syndrome should also be referred urgently. Referral to a specialist other than ENT or non-urgent referral options are incorrect.

When a patient experiences a sudden loss of hearing, it is crucial to conduct a thorough examination to determine whether it is conductive or sensorineural hearing loss. If it is the latter, known as sudden-onset sensorineural hearing loss (SSNHL), it is imperative to refer the patient to an ear, nose, and throat (ENT) specialist immediately. The majority of SSNHL cases have no identifiable cause, making them idiopathic. To rule out the possibility of a vestibular schwannoma, an MRI scan is typically performed. ENT specialists administer high-dose oral corticosteroids to all patients with SSNHL.

Distinguishing a Branchial Cyst from Other Neck Swellings

A swelling located in front of the anterior border of the sternomastoid muscle at the junction of its upper and middle thirds is likely a branchial cyst, which is a remnant of the second branchial cleft. It commonly appears in the second or third decade of life and may enlarge during upper respiratory tract infections. The cyst can range in size from 1-10 cm and is typically painless, although it may become tender during an acute stage. Unlike an infected lymph node, there is no overlying punctum, and it is not attached to any underlying structures. Ultrasound can confirm the cystic nature of the lesion. An enlarged thyroid lobe is an incorrect diagnosis as it moves with swallowing. A sebaceous cyst usually has an overlying punctum, and a thyroglossal cyst is typically located midline and rises with swallowing or tongue protrusion.

Middle Ear Infection Caused by Upper Respiratory Tract Infection

The bacteria responsible for an upper respiratory tract infection (URTI) can travel up the eustachian tubes and cause an infection in the middle ear. This can lead to the tympanic membrane becoming retracted, making the handle and short process of the malleus more prominent. As pressure builds up in the middle ear, the eardrum may become distended and bulge outwards, accompanied by severe otalgia, systemic toxicity, fever, and tachycardia.

If the tympanic membrane perforates, severe pain followed by a sudden improvement is likely to occur. The raised pressure within the middle ear is the main cause of the severe pain, often accompanied by systemic symptoms. Once the tympanic membrane ruptures, the pressures will equalize, and the pain will decrease dramatically. For more information on acute otitis media, visit the NICE Clinical Knowledge Summaries website.

Suspected Nasopharyngeal Carcinoma

The suspicion is that the patient may have an underlying nasopharyngeal carcinoma, likely related to smoking, which is causing a blocked left nostril and bloody, serous discharge. It is important not to delay referral to an ear, nose, and throat (ENT) specialist by performing investigations through the GP outpatient radiology service. Imaging of the sinuses may be appropriate to determine the extent of any tumor, but this would be done as part of the pre-surgery workup rather than as outpatient GP investigations. A trial of intranasal steroids is not appropriate as a diagnosis of allergic rhinitis is unlikely, and this would waste valuable time in addressing any underlying tumor. Nasopharyngeal cancers are more common in people from southern China, including Hong Kong, Singapore, Vietnam, Malaysia, and the Philippines.

The presence of vertigo, tinnitus, and hearing loss are key indicators for the diagnosis of Meniere’s disease, which is a common cause of dizziness. Other factors such as recurrent otitis media and family history of otosclerosis may be misleading. Audiometry is a recommended test for Meniere’s disease, while CT head is useful for otosclerosis and MRI scan is the preferred diagnostic tool for acoustic neuroma.

Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo that occurs suddenly when there is a change in head position. It is more prevalent in individuals over the age of 55 and is less common in younger patients. Symptoms of BPPV include dizziness and vertigo, which can be accompanied by nausea. Each episode typically lasts for 10-20 seconds and can be triggered by rolling over in bed or looking upwards. A positive Dix-Hallpike manoeuvre, which is indicated by vertigo and rotatory nystagmus, can confirm the diagnosis of BPPV.

Fortunately, BPPV has a good prognosis and usually resolves on its own within a few weeks to months. Treatment options include the Epley manoeuvre, which is successful in around 80% of cases, and vestibular rehabilitation exercises such as the Brandt-Daroff exercises. While medication such as Betahistine may be prescribed, it tends to have limited effectiveness. However, it is important to note that around half of individuals with BPPV may experience a recurrence of symptoms 3-5 years after their initial diagnosis.

Treatment Options for Otitis Media with Effusion in Children

Otitis media with effusion is a common condition in children, but it is usually self-limiting and resolves within 12 months. While there is no proven benefit from medication, there are several treatment options available.

Observation is a viable option, as a period of watchful waiting is unlikely to result in any long-term complications. However, if signs and symptoms persist, referral for a hearing test after 6-12 weeks or to a specialist in ear, nose, and throat (ENT) may be necessary.

Antibiotics are not indicated in cases where there are no symptoms or signs of active infection. Intranasal corticosteroids and oral antihistamines are also not recommended by The National Institute for Health and Care Excellence (NICE) for the treatment of otitis media with effusion in children.

Nasal decongestants, such as pseudoephedrine, may provide temporary relief for stuffy nose and sinus pain/pressure caused by infection or other breathing illnesses, but they are not indicated for children with glue ear.

In summary, the best course of action for otitis media with effusion in children is often observation, with referral to a specialist if necessary. Other treatment options should be carefully considered and discussed with a healthcare provider.