Emergency Medicine Grand Rounds
Updated February 2014
External
ar
Earache is common. Very common. By the
time they’re three, over 80% of Boston’s kids get
an ear infection.1 There are over 25 million medical visits a year for earache,2 and the indirect cost
of earaches (parental work lost time, for example) is over $3.5 billion.3
Two thirds of earaches are caused by acute
otitis media or otitis externa, but one third are
referred pain from a great variety of places: the
ear has lots of different nerve connections.4
Common causes for earache other than otitis
media, otitis externa or barotrauma (diving,
explosions) include, in order of frequency: 5-7
·· abscessed or carious teeth
·· temporomandibular joint (TMJ) pain, either
from an acute posttraumatic temporomandibular joint capsulitis (a bruise of the jaw
joint cartilage), or chronic TMJ pain
·· cervical spine pain
·· cervical lymphadenitis (swollen infected
lymph nodes in the neck)
·· tonsillitis
·· post-tonsillectomy pain
·· acute parotitis (inflammation of the parotid
salivary gland in the cheek, whether from
viral, bacterial or non-infectious causes)
If you examine the ear of someone with earache and it is normal, consider the alternatives.
If the earache is worse with range of motion
of the jaw, and with biting down, and you find
tenderness just anterior to the tragus of the
ear, where you can feel the TMJ as it is opened
and closed, it’s a TMJ problem. If the patient
recently took a punch to the opposite side of
the jaw, it’s probably acute posttraumatic TMJ
capsulitis (bruised cartilage) or even maybe a
tear of the cartilage meniscus that floats in the
middle of the TMJ; if more chronic, it may be
arthritis: TMJ syndrome.
If the ear looks normal, but when you examine the mouth, you find a tooth that is tender
when you tap it with a gloved finger or tongue
blade, especially if there are visible cavities or
redness or swelling near the root, then the cavity or periapical abscess is causing the earache.
Keith Conover, M.D., FACEP
Department of Emergency Medicine
University of Pittsburgh
Earache with a normal ear exam but tender
cervical lymph nodes below the ear indicates
cervical lymphadenitis, which may cause pain
interpreted as earache.
Many people have sore throat and earache
at the same time. If the ear exam is normal, it’s
tonsillar pain radiating to the ears. Sometimes,
people just complain of an earache without
complaining of a sore throat, and when you
examine the ears, they’re normal, but the throat
shows obvious tonsillitis. Even a lingual tonsillitis – hard or impossible to see on exam of the
oropharynx – may cause pain referred to the
ear. Peritonsillar cellulitis or abscess may cause
severe unilateral ear pain with a normal ear
exam.
On the other hand, otitis externa
may be hard to detect by looking
in the ear; there may be just slight
swelling of the external canal, without redness or maceration. And,
some people normally have somewhat small and constricted external
canals. One clue is that the external
canal may be a bit out-of-round,
with a narrow valley or crevice
at the bottom. If only one ear is
affected, you can compare with
the unaffected ear canal. But the
most important part of the physical
diagnosis of otitis externa is tenderSevere Otitis Externa
ness of the tragus or tenderness of
the pinna. In simple terms, press
on the tragus (the small fleshy protuberance in
front of the ear canal), and pull on the pinna
(the large major portion of the ear behind and
above the ear canal). If either is tender, the
patient likely has otitis externa.
The remainder of this handout deals with the
external ear and traumatic perforated tympanic
membrane. A separate handout discusses otitis
media (check http://www.conovers.org/ftp/).
1
Barotrauma and Traumatic Tympanic Perforation
The most common way to get a perforated
tympanic membrane (AKA ruptured eardrum,
though in the ED the preferred term seems to
be “perfed TM”)
is from getting hit
in the ear, usually
from
domestic
violence or a street
or bar fight.8 You
can also get a ruptured TM from a
blast injury (even
if just fireworks),
from diving, from
climbing or flying
to high altitude, or
from accidentally
jabbing it with a
Q-tip.
If you have a
perforated TM, you usually (~80% of the time)
feel fullness, have hearing loss, and sometimes
get tinnitus (ringing in the ear). If someone
gets severe vertigo after a ruptured tympanic
membrane, it might be a perilymphatic fistula
or rupture of the round window in the inner ear.
If you see such a patient in the ED, you should
consult an otolaryngologist (ENT) urgently.9
About 90% of civilian perforations will heal in a
month with no treatment.8,10 Explosion-related
blast injuries from war tend to be larger, to
have similar symptoms (83% with symptoms)
and not to heal as well (only 48% spontaneously heal).11 From the bombings in 1974 in
Birmingham, England, we know that very large
perforations (80% or more of the TM) do not
heal spontaneously, and that smaller perforations (<80% of the surface of the TM) tend to
heal spontaneously; the authors of the study
say that you should allow a month for healing
of each 10% of the tympanic membrane that is
lost.12
For at least 2 weeks after a perfed TM, you
should not clean the external ear canal (no
Q-tips), unless there is visible contamination or
evidence of infection, in which case use gentle
suction and mopping to remove the debris.13 Ear
drops don’t help;8 they may well cause harm.13
Both antibiotic ear drops and ear irrigation
make infection more likely.13 Since moisture
makes infection more likely, teach patients to
keep the ear dry.
Unless there is a severe infection, oral
antibiotics don’t help.8 If there is a severe
infection, prescribe something that covers
both Pseudomonas aeruginosa and methicillinresistant Staphylococcus aureus. Appropriate
antibiotics include the quinolones ciprofloxacin (CIPRO), levofloxacin (LEVAQUIN), and
moxifloxacin (AVELOX, VIGAMOX). If
someone is allergic to quinolones, there is no
other oral agent adequate against Pseudomonas.
A badly infected TM in a quinolone-allergic
patient needs IV antibiotics.
Advice from a Canadian ENT from World
War II still seems to the point:
The correct treatment of recent rupture of a
drum in the forward areas is important and the
following are approved principles:
(a) It is essential that no drops or no powder be
instilled in the ear. No syringing should be done
and no peroxide used.
(b) If there is reason to suspect that the drum
may be ruptured, but there is still some doubt
because of blood or wax in the canal, leave the
ear strictly alone.
(c) The soldier should be warned to keep water
out of his ear and avoid violent blowing of his
nose.
(d) A plug of sterile cotton should be placed in
the canal and evacuation arranged to the nearest
otologist.14
The only exception is that a referral to an
ENT is not urgent, as no additional treatment
is appropriate for at least three months. ENTs
generally wait 3-6 months for healing to occur
before considering surgical repair.13 Early surgical repair is worse than simply waiting for three
or more months.15
Otitis Externa
Otitis externa (swimmer’s ear, tropical
ear) is inflammation of the external ear canal. It
2
usually starts with itching, then mild pain, then
serous (clear) discharge. Later there is severe
pain and tenderness, particularly when you push
on the tragus or pull on the pinna.16 People often
complain of partial deafness from swelling of the
tympanic membrane, or mechanical blockage of
the swollen external ear canal or from purulent
debris.
You’re more likely to get otitis externa in the
summer in temperate climates, or in tropical
or subtropical climates. This is probably from
high humidity and sweating, though it certainly
occurs in the winter. I’ve seen winter otitis
externa from working out on a treadmill while
wearing earbuds, and from wearing ear protectors while using a jackhammer; the common
thread seems to be getting sweaty while your
ears are plugged or covered.
You have a one-in-ten chance of getting otitis
externa at some time in your life (maybe as a
kid or maybe as an adult, but rarely when you’re
under 2 years old)17 but only a one-in-a-hundred chance of getting it in both ears.18,19
Your external ear canal is protected by cerumen (ear wax). Cerumen is a combination of
dead skin cells and secretions from glands in
the canal. It is acidic, contains lysozyme (an
antibacterial enzyme), and probably helps
keep you from getting bacterial and fungal
infections.20-22
Many things make otitis externa more likely.
Moisture in the external ear canal is a major
cause: swimming for a long time, or frequently,
without drying the external ear canal afterwards; sweating a lot for a prolonged period;
or wearing earplugs or earbuds (in-ear speakers for mobile devices) all make it more likely.
Breaks in the normal protection of skin and
cerumen (earwax) are key: local injury, perhaps from cleaning the ear with Qtips or worse
things, makes it more likely.23 Water contaminated with lots of bacteria getting in the ear
may make it more likely, too.23
Stages of Otitis Externa
Otitis externa is officially classed into preinflammatory, acute inflammatory, and chronic stages.
In the preinflammatory stage, dampness in
the external ear canal causes swelling of the
lining of the canal. This weakens the skin and
obstructs the glands that secrete cerumen.
Looking in the ear with an otoscope, you may
see nothing other than slight swelling of the
lining of the external canal, which may cause
a narrow valley or crevice at the bottom of the
ear canal. You may see that the lining of the
external canal is a bit whitish from the effects
of moisture. Sometimes you will see cerumen
that is, rather than the characteristic medium
yellow or brown, quite soft and pale, and sometimes even whitish, again from the effects of
moisture.19
If it’s at the mild acute inflammatory stage,
you will see redness and mild swelling of the
lining of the external ear canal, and perhaps
some mild serous (clear) discharge. If it’s at the
moderate acute inflammatory stage you will have
worsening pain, and on exam, you see purulent
discharge and enough swelling that it’s hard to
see the tympanic membrane. Tenderness on
pressing on the tragus or pulling on the pinna
is a hallmark of otitis externa. If the tympanic
membrane is red, and there is suspicion of acute
otitis media, pneumatic otoscopy may show
normal mobility which rules out acute otitis
media.16
If it’s gotten to the severe inflammatory stage
the ear canal is so swollen, and has so much
purulent discharge, that it’s completely blocked,
and you can’t see the tympanic membrane. You
may even find swelling and redness outside the
external ear canal, or swollen lymph nodes,
particularly below and anterior to the ear.
If the infection spreads outside the ear,
particularly when there is osteomyelitis (bone
infection) of the temporal bone, we call this
malignant otitis externa. Some say that “malignant” is a misnomer and we should use “necrotizing otitis externa” instead, as the process
is infectious and not cancerous. But everyone
tends to ignore this and still call it malignant
otitis media; the non-medical meaning of
“malignant” probably still applies pretty well.24
Chronic otitis externa lasts more than a
month, or occurs four or more times in one
year.20 That’s a problem for ENT specialists and
not emergency medicine specialists (or urgent
care or primary care physicians) and we won’t
deal with it further here.
When, due to severe otitis externa, you can’t
see the tympanic membrane with your otoscope, it’s hard to tell if you’re dealing with bad
otitis externa or otitis media with tympanic
rupture. But the treatment for moderate to
severe otitis externa and for otitis media with a
ruptured tympanic membrane are the precisely
same: ear drops.16,25 When the canal is very
swollen, you can put in an expanding ear wick
to guide the ear drops down deep into the ear,
Elements of the
diagnosis of
diffuse acute
otitis externa
·· Rapid onset (generally
within 48 hours) in the
past 3 weeks, AND
·· Symptoms of ear
canal inflammation
which include:
·· otalgia (often severe),
itching, or fullness,
WITH OR WITHOUT
·· hearing loss or jaw
pain,* AND
·· Signs of ear canal
inflammation that include:
·· tenderness of the tragus,
pinna, or both OR
·· diffuse ear canal edema,
erythema, or both
WITH OR WITHOUT
·· otorrhea, regional
lymphadenitis, tympanic
membrane erythema,
or cellulitis of the pinna
and adjacent skin
*Pain in the ear canal and
temporomandibular joint region
intensified by jaw motion.
from the American Academy of
Otolaryngology–Head and Neck
Surgery Foundation (AAOHNSF) 2014 Clinical Practice
Guideline: Acute Otitis Externa
3
which likely will make the patient better faster.19
The most common infecting bacterium is
Pseudomonas aeruginosa, the next most common is Staphylococcus aureus; Staphylococcus
epidermis and a scattering of other bacteria
are much less common, and fungi such as
Aspergillus even less common. It’s not uncommon to have a mixture, usually Pseudomonas
and Staph together.
Without treatment, only 15% of patients will
be better after 10 days. If you prescribe ear
drops, whether antiseptic or antibiotic (or, surprisingly, steroid drops alone), 65-80% of your
patients will be better at 10 days.26
Ear Drops
Many substances have been used to treat otitis
externa, on the whole successfully, and this dates
back thousands of years.27,28 Vinegar in particular
has been used for otitis externa and other infections at least since the time of Hippocrates (~420
BCE).29 Ear drops containing alcohol, for its drying effect, with vinegar or lemon juice or acetic
acid to acidify, and possibly with hydrocortisone – which incidentally is effective by itself for
otitis externa30-32 – have been used for decades
to prevent and treat otitis externa.33 Acetic
acid drops with hydrocortisone (VOSOL-HC,
ACTASOL) or without hydrocortisone (VOSOL,
ACETASOL) are available in the US by prescription. While somewhat effective, don’t prescribe
these if there are tubes or a perforation in the
TM, as acetic acid might be ototoxic (it might
cause temporary or permanent deafness).34
For otitis externa (or otitis media with
drainage through tympanostomy tubes or a
perforation), prescribe ear drops instead of oral
antibiotics. 35 Prescribe oral antibiotics in addition to ear drops – don’t substitute for ear drops
– only if the patient has diabetes mellitus, local
radiation therapy for cancer, has HIV/AIDS,
or is otherwise immunocompromised. Also
prescribe oral antibiotics if the infection has
started spreading outside the ear canal; if frank
malignant otitis externa (see below), admit for
IV antibiotics.16,33 Treating otitis externa with
common antibiotics used for acute otitis media
(without eardrops) may slow healing or make
the otitis externa more likely to come back.16
Physicians commonly prescribe
CORTISPORIN drops: a combination
of the aminoglycoside neomycin (good
against pseudomonas), the polypeptide
4
antibiotic polymyxin, for additional coverage of
Pseudomonas aeruginosa, and hydrocortisone.
But neomycin causes lots of allergic reactions
– 10-15% of people are allergic to it, and with
repeated use non-allergic people tend to quickly
become allergic to it16 – so dermatologists and
ENTs hate it.36-38 Don’t prescribe it. If you see
someone whose otitis externa it getting worse
on CORTISPORIN, stop it immediately, and
switch to ear drops that combine a quinolone
and a steroid. Eczema in the lower ear canal,
or just outside it, where ear drops tend to run,
may be a clue to eardrop allergy.33 Neomycin
is an ototoxic (might cause deafnesss) aminoglycoside,39,40 another reason to avoid
CORTISPORIN, especially if there might be a
tympanic membrane perforation hidden behind
all the debris in the external ear canal.
Fluoroquinolones (“quinolones” for short)
are good for treating both gram positive and
gram negative bacterial infections, including Pseudomonas aeruginosa, and without
the ototoxicity or allergy concerns of neomycin. 41,42 Ciprofloxacin and particularly
ofloxacin are also effective against methicillinresistant Staphylococcus aureus (MRSA),43-45
and likely even against quinolone-resistant
Staphylococcus aureus.34 Quinolones seem ideal
for otitis externa. Ciprofloxacin (CIPRODEX,
CIPRO-HC) and ofloxacin ear drops (FLOXIN)
are available. They are better than prior-generation ear drops, and safe with tubes or a tympanic membrane perforation.41,46-50 Quinolone
eardrops used to be quite expensive, but in
2014, ofloxacin ear drops generally cost less
than $20.51
Antipyrine-benzocaine glycerine ear drops
(AURALGAN) are commonly prescribed for
the pain of otitis media. But, given the possibility of benzocaine allergy complicating things
and probable lack of efficacy, you probably
shouldn’t prescribe it for otitis externa.16
Patient Instructions
How you put in ear drops makes a big difference
in how they work. If the patients’ ear is full of
debris, it’s best for you to gently clear it out; a
Frazier (small ENT) suction tip may be helpful.
You can tell the patient to gently clean out the
ear a bit before putting in the ear drops. Tell the
patient to heat the drops to body temperature,
perhaps by keeping in a shirt or pants pocket
for 5-10 minutes. This prevents dizziness from
caloric stimulation (difference in temperature
causing circulation in the semicircular canal).
Tell the patient to lie on the with the bad ear
up, and put in the drops – gently pulling on the
pinna to open the ear canal a bit – and then gently press on the tragus a few times to pump the
drops deeper into the ear. Tell the patient to stay
on the side for a few minutes. A bit of a cotton
ball in the ear before standing helps keep the
drops from dribbling all over the place. This can
come out in a half-hour or so.33
Tell the patient no swimming for at least a
week, and to keep hearing aids and ear buds
(in-ear speakers) out until the ear is all better.16
Treatment Failure
With quinolone ear drops, the ear should be getting a lot better in 2-3 days; if not, the ear needs
to be rechecked. If there is still bad pain or now
fever, you might want to add an oral antibiotic
for possible acute otitis media with perforation. Also, consider malignant otitis media (see
below). You also might want to add an ear wick.
If necessary, consider intravenous analgesia or
maybe even moderate sedation before trying
to put the ear wick in; if the canal’s quite swollen, the procedure can be quite painful. Send a
culture both for bacteria and fungi. Consider
urgent ENT follow-up, as it might not be otitis
externa, but cancer.16
Prevention
Keeping the ear dry helps prevent otitis externa.
But when occupations require wet ears – competitive swimming or diving, for example – prevention is harder. Though 95% isopropyl alcohol
drops are widely marketed for drying ears after
swimming, there is some significant anecdotal
evidence in the literature that a half-and-half
mixture of isopropyl alcohol and vinegar is
likely more effective.52 Back in the 1960s and
1970s, the U.S. Navy’s experimental diving unit
had major problems with otitis externa, and
performed controlled studies of a variety of
ear drops for prevention, and found that
half-and-half rubbing (isopropyl) alcohol
and vinegar (acetic acid) ear drops were
only mildly helpful. However, a 1974
Navy study53 of saturation diving, which
is in many ways a worst-case scenario
for developing otitis externa, found
that acetic acid and aluminum acetate
ear drops (e.g., DOMEBORO OTIC, STAROTIC, BOROFAIR) were much more effective.
However, they also followed a rigid protocol,
allowing the drops to stay in the ear for 5 minutes by the clock.
Furuncles
A furuncle, which is an infected (abscessed)
hair follicle, may appear in the outer third of
the external ear canal – that’s the part that has
hair follicles. As with any abscess, you may see
purulent drainage or overlying cellulitis. Some
people call this focal otitis externa, but it’s really
very different from otitis externa. Treatment
is the same as for any abscess: local heat, and
if you think appropriate, incise and drain. If
there is significant overlying cellulitis, prescribe
oral antibiotics that cover MRSA, such as sulfamethoxazole-trimethoprim (BACTRIM) or
clindamycin.16
External Ear Anatomy
Entire visible external portion
referred to as pinna or auricle
1 – Helix
2 – Scapha
3 – Fossa Triangularis
4 – Anti-Helix
5 – Concha
6 – Tragus
7 – Anti-Tragus
8 – Lobule
Malignant Otitis Externa
Think of malignant otitis externa as
nasty, nasty otitis externa: infection that spreads
beyond the lining of the ear canal, into soft tissues and bone, and maybe even into the brain.
Fifty years ago or more, before antibiotics, half
the people with malignant otitis externa would
die from it. Now, the mortality is much, much
lower, about 0-15%. Pseudomonas aeruginosa is
by far the most common bacterium that causes
malignant otitis externa. It may invade tissues
and cause septic thrombophlebitis (infected
blood clots in vessels).54
It’s mostly a problem for those with immunosuppression, such as diabetes mellitus or
HIV/AIDS. Cerumen in diabetic ears has an
alkaline pH rather than a normal acidic pH.
This helps explain why malignant otitis externa
is most common in diabetics (65-90% of cases).
Elderly diabetics also tend to have endarteritis,
microangiopathy, and small-artery obliteration,
which also contributes.55 So if you see a bad
otitis externa, investigate to see if the patient
might have diabetes or HIV, even if previously
unrecognized.
5
Physician Quality
Reporting
System (PQRS)
The PQRS is a practitioner
reporting program. There are
currently financial incentives
for reporting specific
measures. Eventually, it
will become a “pay for
performance” system.
In 2014, practitioners
who report these
measures get a bonus for
taking care of Medicare
patients. Beginning in
2015, practitioners who
don’t report these quality
measures will have their
Medicare payments cut.
For 2014, two of these
quality measures are
about otitis externa.
Measure #91: Acute Otitis
Externa (AOE): Topical
Therapy: Percentage of
patients aged 2 years and
older with a diagnosis of
AOE who were prescribed
topical preparations.
Measure #93: Acute Otitis
Externa (AOE): Systemic
Antimicrobial Therapy –
Avoidance of Inappropriate
Use: Percentage of patients
aged 2 years and older with a
diagnosis of AOE who were
not prescribed systemic
antimicrobial therapy.
Bottom line: Big
Brother is watching!
6
If you look in the ear with an otoscope and
you see granulation tissue or exposed bone,
most commonly in the lower portion of the
canal, you’ve made the diagnosis. Even if the
ear exam isn’t that impressive, one of the key
findings in malignant otitis externa, as with
mesenteric ischemia, is pain out of proportion to your exam findings. If you send labs, an
elevated ESR in the face of normal temperature
and white blood cell count tends to support
the diagnosis. To confirm the diagnosis, MRI
is superior to CT, and may show enhancement
of the dura (covering of the brain) near the ear
and involvement of medullary bone spaces.
However, a technetium or gallium scan is best,
though it will be positive in other local inflammatory conditions, including cancer.
Send a culture of the exudate before you
start IV antibiotics. If you’re admitting to a
service other than ENT, consult an ENT for
a biopsy, because carcinoma may present
similarly.24 Treatment consists of several weeks
of intravenous antibiotics, and in children,
fluoroquinolones are used only if the benefits
outweigh the risks of joint damage. Given the
increasing resistance of Pseudomonas aeruginosa to fluoroquinolones, antipseudomonal
penicillins and cephalosporins are now generally the treatment of choice, combined with an
antibiotic appropriate for methicillin-resistant
Staphylococcus aureus, until cultures are
available.16,24
Fungi such as Aspergillus are uncommon as a
cause of malignant otitis externa except in HIV
patients with CD4 counts less than 50 cells/
mm3.54 Rare cases of malignant otitis externa
due to the fungus Aspergillus are treated with
intravenous antifungals.56
Malignant otitis externa can lead to damage
to the facial nerve, necrosis of the tympanic
membrane, stenosis of the external ear canal,
deformity of the external ear, and sensorineural
and conductive hearing loss and maybe even
brain infection.
Cholesteatoma
Cholesteatomas are epidermal inclusion
cysts of the middle ear or mastoid. Early investigators thought these “pearly tumors” contained
cholesterol crystals,57 but we now know that they
are filled with desquamated keratinaceous material, similar to the “sebaceous” epidermal cysts
found on the skin. As with epidermal cysts of
the skin, they may become infected, causing
drainage. Cholesteatomas may also, by either
direct extension or becoming infected, result
in bone destruction or even intracranial infection. Frequently they may become infected
with anaerobic bacteria, resulting in otorrhea
with a characteristic and almost feculent odor.58
Cholesteatomas may also present with a variety
of symptoms, depending on the location and
extent: vertigo, hearing loss, facial nerve paralysis, or intracranial infection. The classic location
for a cholesteatoma is adjacent to the posterosuperior portion of the tympanic membrane, but
they may appear in other portions of the external ear canal, or perforating through the tympanic membrane.59
If infected, cholesteatomas should be treated
with appropriate antibiotic ear drops. If suspicious of osteomyelitis, CT or MR imaging
would be appropriate; as with any suspected
infection or tumor, IV contrast will improve
the diagnostic quality of both CT and MR.
Patients with cholesteatomas should generally
be referred to an ENT for ongoing care.
Perichondritis
Infectious perichondritis of the ear is a lot
more common these days than it was decades
ago. That’s because piercing of the upper ear is
now a lot more common. Piercing through the
less-infection-resistant cartilage carries a high
risk of serious infections. People who perform
or get such piercings don’t seem to have a clue
about this. Your goal in treating this is healing
without permanent deformity. Pseudomonas
aeruginosa and staphylococcus aureus are common pathogens, so ciprofloxacin would be a
good choice; it covers both and it penetrates well
into cartilage.60 Sometimes there is an abscess
that you need to incise and drain.
Cerumen Impaction
A 2008 clinical practice guideline61 from
the American Academy of Otolaryngology–
Head and Neck Surgery Foundation is currently
the definitive reference for managing cerumen
(earwax) impactions. The following represents a
distillation of the portions of this guideline relevant to the practice of emergency medicine.
Cerumen impaction – defined by the 2008
clinical guideline as either complete or partial
occlusion of the external ear canal with excess
cerumen – is found in 1 of every 10 children, 1
of every 20 adults, and in a third of the elderly
and in a third of those with developmental
delay.
If there are no symptoms, earwax need not
be removed. However, cerumen impaction may
diminish cognitive function in the elderly, and
may interfere with visualization of the tympanic
membrane during otoscopy. Cerumen impaction may also cause hearing loss, tinnitus, vertigo, fullness, itching, otalgia, discharge, odor,
or cough; however, these may be a symptom of
some other problem and the cerumen impaction may be incidental. Removing earwax may
help you diagnose a complaint, either by relieving the symptoms or by allowing you to see the
external ear canal and TM.
The ENTs say that those with dermatologic diseases of the ear canal, recurrent otitis
externa, keratosis obturans, prior radiation
therapy affecting the ear, previous tympanoplasty/myringoplasty or canal wall down
mastoidectomy should have their cerumen
impactions managed by an ENT. I think most
emergency physicians, even if they aren’t quite
sure what all of those listed diseases are, would
agree.
Cerumen removal has risks as well as benefits; it may result in external ear canal pain,
abrasions or lacerations, vertigo, syncope or otitis externa. TM perforation and hearing loss are
rare complications. However, one study showed
a 0.2% chance of TM perforation from irrigation, as well as a similar 0.2% chance of vertigo.
In addition to that above list of “refer to ENT
for wax removal” conditions, you should also
consider co-existing conditions that might
change your choice of how to remove the wax.
For example:
·· nonintact tympanic membrane (perforation
or tympanostomy tube);
·· ear canal stenosis (narrowing of the canal);
·· exostoses (bony prominences sticking out
into the canal);
·· diabetes mellitus;
·· other immunocompromised states (e.g.,
HIV); and
·· anticoagulant therapy.
There are three main methods to remove ear
wax: 1) cerumenolytic agents, 2) irrigation, and
3) manually, using ear curettes, probes, hooks,
forceps, or microsuction. There is no evidence
as to which of these, or which combination of
them, is best.
There is some evidence that cerumenolytic agents may help remove ear wax, but no
evidence that any one is superior to the others.
Cerumenolytic agents should not be used in
patients with otitis externa, as otitis externa is
an exclusion for studies of such agents. There
are also concerns about a reported 1% skin
allergy incidence to 10% triethanolamine polypeptide oleate (CERUMENEX) drops. There is
some evidence that if you put in a cerumenolytic agent before irrigation, it will be easier to
get out the wax. Even water or normal saline
drops 15 minutes prior to irrigation makes irrigation work better.
When the tympanic membrane is not intact
(perfed TM or tube), you can try mechanical
removal in the ED. Don’t irrigate: there are worries that irrigation may cause pain, infection,
caloric vertigo (dizziness from temperature
differentials in the ear causing flow in the inner
ear’s semicircular canals) or ototoxic hearing
loss.
Atrophy (thinning) of the tympanic membrane from prior surgery, including tympanostomy tubes, is a risk for tympanic membrane
rupture. So don’t irrigate.
If your patient is immunocompromised,
as with diabetes mellitus or HIV/AIDS, you
should worry about the dampness from irrigation causing malignant otitis externa. So if you
need to irrigate such immunocompromised
ears, great care is taken to avoid abrasions, and
one considers prescribing acidifying ear drops
such as 2% acetic acid (VOSOL, ACETASOL) 2
drops in each ear BID, or recommending overthe-counter drops such as aluminum acetate
(Burow’s solution, DOMEBORO).
Mechanical removal of cerumen may be
7
Key Points
A great variety of conditions,
including some distant
from the ear itself,
may cause earache.
Don’t treat traumatic
TM perforations: no oral
antibiotics, no ear drops.
Simply tell the patient to
keep it scrupulously dry,
and refer to an ENT.
Treat otitis externa,
not with allergenic and
ototoxic antibiotics such
as the neomycin found in
Cortisporin, but a quinolone
antibiotic drop such as
ofloxacin or ciprofloxacin;
do this even in the
setting of tympanostomy
tubes or a ruptured
tympanic membrane.
Those with otitis externa
and immunosuppression
(including diabetes
mellitus) are at risk for both
fungal otitis externa and
malignant otitis externa
(necrotizing otitis externa).
Diagnose malignant
otitis externa in
immunosuppressed patients
with external ear erosions
with visible bone, with pain
out of proportion to the
physical exam, or with an
elevated ESR or WBC. You
may confirm with MRI.
Perichondritis (infection
of the external ear
cartilage) is increasingly
common due to upper ear
piercing, and may require
incision and drainage;
cover with antibiotics for
Pseudomonas and MRSA.
8
faster than irrigation, allows you a direct view
of the external ear canal, and does not make
the external ear canal wet, which is thought to
be a risk for otitis externa. For patients with a
non-intact tympanic membrane (perfed TM
or tube) or the potential for it (possible otitis
media with ruptured TM), or prior ear surgery,
mechanical removal is better than irrigation or
cerumenolytic agents. Manual removal, with or
without cerumenolytic agents, is preferred over
irrigation for those with immunosuppression
due to conditions such as diabetes mellitus or
HIV/AIDS, or who may be immunosuppressed
due to systemic illness, and who are likely to get
otitis externa from a wet external ear canal. Few
EDs have ENT-type operating microscopes. The
best alternative is to use the combination of a
curette or plastic ear scoop, a headlight, and an
otoscope speculum.
If your patient is taking an anticoagulant, use
a curette only with the greatest care. A cerumenolytic and irrigation may be a better option.
In some cases, you might decide you can’t
safely remove the wax in the ED. If so, make
decisions as best you can without seeing the
TM. Refer the patient to an ENT, who can
remove the wax using a binocular microscope
and micro-instrumentation.
The consensus is that some methods of home
removal are bad. Oral jet irrigators may cause
ear trauma. Q-tips and similar cotton-tip swabs
may also cause ear trauma, including a ruptured tympanic membrane. There is even a case
report of a fatal brain abscess from retained
cotton in the ear.
You can counsel people who get earwax
impactions as follows:
·· Don’t use bobby pins or cotton swabs to try
to remove wax; this may damage the ear
and tends to pack cerumen up against the
eardrum.
·· Use a few drops of a topical ear emollient (such
as baby oil, olive oil, or Cerudel Lipolotion)
weekly. It may significantly (61% vs 23%)
decrease future earwax impactions.
Foreign Bodies in Ears
People commonly show up at primary care
offices, Emergency Departments, and urgent
care centers with foreign bodies (FBs) in their
ears. It would be nice to know which is the
most effective way to get them out, and which
is least likely to result in complications such as
tympanic membrane perforation or external
ear canal laceration. Unfortunately, there are no
controlled studies to tell you the best way to get
ear FBs out. There are at least some case series
and expert opinions, so let’s look at them.
One retrospective case review focused solely
on those patients referred to ENTs, so it doesn’t
likely reflect your practice. 62 It found that about
half of those cases referred to an ENT after
attempted removal by an emergency physician
or primary care physician had lacerations of
the external canal. Oops. However we have no
information on the corresponding number of
foreign bodies that were successfully removed
by an emergency physician or primary care
physician; seems to me from ~30 years of
emergency medicine practice that referral to
an ENT is pretty rare. The article also notes
that ENTs tend to use a microscope to remove
foreign bodies (91% of the time). The most common foreign body in this study was a cockroach
(43/98) followed by beads (15/98). The study
recommends lidocaine instillation (provided
the tympanic membrane is intact) which, in
their series, rather than paralyzing the cockroaches, caused them to quickly back out. The
recommendations from this case series are:
·· Preremoval hearing assessment for patients in
whom damage to the hearing is suspected.
·· Removal under direct vision, using a microscope if appropriate. (Most EDs don’t have
an ENT microscope, but they usually do
have headlights, head-worn magnifiers and
ear speculums, which is better than doing it
blind.)
·· Patients with objects not readily removed by
the primary-care physician may require referral to an ENT (duh).
·· Mineral oil or lidocaine in the ear may help
your remove a live cockroach.
A prospective review from an ENT service in
Brazil found that beans were the most common
foreign body in the ear. Maybe that just means
that kids in Brazil play with beans a lot.63
A different retrospective review of 141 cases
presenting to primary care offices and the
Emergency Department of an eye and ear
hospital found cockroaches to be less common
than that first study (“insects” only 21/141).64
Beads (31/141), plastic toys (29/141) and pebbles
(21/141) were the most common. This study
mentioned common instruments available for
removal:
·· Frazier tip suctions,
·· alligator forceps,
·· Hartman forceps (more commonly called
“alligator forceps”),
·· cerumen loops, and
·· right-angle ball hooks (right-angle rod tip,
with a slight ball at the end).
Right-angle ball hooks have a thin (fewmillimeter) rod that makes a right angle at the
end, with a blunted end, sufficient to slip into
the central hole of a bead, though this sounds
easier than it is in practice. My favorite such
probe, which I use fairly often, is a Miltex Gross
Ear Hook and Spoon - 19-228 (~$50). You
can improvise one by straightening and then
bending the very tip of a paper clip; this has
the disadvantage that it is not smooth at the tip,
which makes it harder to slip into the hole in
the bead, and makes it more likely to lacerate the ear canal. Fashioning a paper clip into
a U loop with a bit of a bend at the end, and
never getting the sharp ends in the ear, seems
a safer technique. The paper also mentions the
Schuknecht foreign body remover, a 22 gauge
angled suction catheter with a funnel-shaped
tip. My online research in early 2014 shows it is
no longer commercially-available, but there are
a variety of commercial competitors, including
the Vacutract (a $160-for-5 suction tip with a
soft tip), and the Vacutip ($140-for-20 soft tips
that fit on a 7 French ENT suction catheter).
This study makes a recommendation to
avoid any attempts at irrigation if the foreign
body could be a small button battery, due to the
possibility of damage from short-circuiting the
battery with resultant burns to the ear. It goes
on to make specific recommendations for referral to an ENT:
·· Lack of proper instrumentation
·· Lack of staff to adequately restrain uncooperative child (although I would add, lack of
capability for moderate sedation of a child)
·· Failure to remove foreign body on initial
attempt(s)
·· Existent injury to the external auditory canal
or tympanic membrane
·· Object wedged in the medial external auditory canal or up against tympanic membrane
·· Glass or other sharp-edged foreign body
·· Special circumstances such as insects, putty,
and disc batteries
One retrospective pediatric Emergency
Department study found only 4/58 ear foreign
bodies were successfully removed in their
Australian Emergency Department.65 Another
pediatric Emergency Department study, a retrospective chart review of 36 cases over a one-year
period, found a better success ratio (53%; maybe
doctors in New England are better at this than
those in Australia?) but found a higher complication rate in rounded objects that were hard to
grasp, and concluded: … certain foreign bodies
(graspable type) of the EAC in pediatric patients
can be successfully managed by skilled emergency
department personnel with low complication
rates, whereas other foreign bodies (nongraspable
types) may be better managed by early referral to
an otolaryngologist.66
A literature review from 2000 notes that the
literature frequently recommends restraining
children prior to attempts at removal, but that
modern emergency medicine capability makes
moderate sedation a more humane option. It
also notes that irrigation is contraindicated if
there is a tympanostomy tube or ruptured tympanic membrane, or if there is vegetable matter
that may swell.67
A variety of methods have been reported
successful in isolated case reports to remove
foreign bodies from the ear. This list might
make you more likely to find a method appropriate for a particular foreign body:
·· Killing an insect with vinegar then removing
with a probe (recommendation from the era
of the Roman Empire)67
·· Binding the patient to a table with the affected
ear down and then pounding on the table
(another Roman Empire recommendation)67
·· Cyanoacrylate glue on the end of an instrument to remove a bead.68
·· A Jobson Horne probe (a steel probe with a
circle of steel on the end, used sometimes for
removing cerumen) or steel wire loop67
·· Impression materials: pouring a fast-setting
flexible material into the ear canal, and then
removing the resulting plug including the foreign body69
·· A paper clip bent into an appropriatelyshaped loop69,70
·· Tiny magnets71
·· Using ethyl chloride to dissolve styrofoam
beads72
Finally: ear candles. Sticking a hollow candle
Key Points
Remove ear wax
impactions with ear drops,
curette, irrigation, or a
combination. Don’t use a
curette if anticoagulated.
Consider not irrigating if:
·· diabetic or HIV (wet ears
get infected easily),
·· perfed TM or tube
in the TM, or
·· TM atrophy from prior
tubes or big perf.
If irrigating diabetic/
HIV ears, prescribe an
antimicrobial ear drop
after. If needed, refer to
an ENT to get the wax out
with an ENT microscope.
You can try to remove
a foreign body from the
ear canal in the ED (see
text for methods). But,
the complication rate is
high. If the ear canal is
already damaged, or if the
foreign body is rounded
and likely hard to grab,
you should probably refer
to an ENT who can get it
out with a microscope.
The only medicallyapproved use of
ear candles is on
birthday cakes.
9
Illustration Credits
Page 1, Severe Otitis
Externa: James Heilman,
MD, Widimedia Commons
Page 2, Anatomy of
the Ear:: BruceBlaus,
Wikimedia Commons
Page 5, External Ear
Anatomy: Henry Gray
(1825–1861). Anatomy of
the Human Body. 1918
This work is licensed under the
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10
in your ear and lighting it is a traditional
“holistic” remedy for a variety of ear conditions, including impacted cerumen. It does
not remove cerumen, and causes many
complications, including occlusions of the
external ear canal with candle wax, perfed TM,
otitis externa and burns. The only appropriate
use of an ear candle is on a birthday cake.61,73,74
References
1. Teele DW, Klein JO, Rosner B.
Epidemiology of otitis media during
the first seven years of life in children
in greater Boston: a prospective, cohort
study. J Infect Dis 1989;160:83-94.
2. Schappert SM. Office visits for
otitis media: United States, 1975-90.
Advance data 1992:1-19.
3. Stool SE, Field MJ. The impact
of otitis media. Pediatr Infect Dis J
1989;8:S11-4.
4. Fisher EW, Parikh AA, Harcourt
JP, Wright A. The burden of screening
for acoustic neuroma: asymmetric
otological symptoms in the ENT clinic.
Clinical otolaryngology and allied
sciences 1994;19:19-21.
5. Wiener SL. Differential diagnosis of acute pain : by body region.
International ed. New York: McGrawHill; 1993.
6. Leonetti JP, Li J, Smith PG.
Otalgia. An isolated symptom of
malignant infratemporal tumors.
The American journal of otology
1998;19:496-8.
7. Ely JW, Hansen MR, Clark
EC. Diagnosis of ear pain. Am Fam
Physician 2008;77:621-8.
8. Lou ZC, Lou ZH, Zhang QP.
Traumatic tympanic membrane perforations: a study of etiology and factors
affecting outcome. Am J Otolaryngol
2012;33:549-55.
9. Griffin WL, Jr. A retrospective study of traumatic tympanic
membrane perforations in a clinical
practice. Laryngoscope 1979;89:261-82.
10. Kristensen S. Spontaneous healing
of traumatic tympanic membrane
perforations in man: a century of
experience. The Journal of laryngology
and otology 1992;106:1037-50.
11. Ritenour AE, Wickley A, Ritenour
JS, et al. Tympanic membrane
perforation and hearing loss from blast
overpressure in Operation Enduring
Freedom and Operation Iraqi Freedom
wounded. J Trauma 2008;64:S174-8;
discussion S8.
12. Pahor AL. The ENT problems
following the Birmingham bombings.
The Journal of laryngology and otology
1981;95:399-406.
13. Orji FT, Agu CC. Determinants
of spontaneous healing in traumatic
perforations of the tympanic membrane. Clinical otolaryngology : official
journal of ENT-UK ; official journal of
Netherlands Society for Oto-RhinoLaryngology & Cervico-Facial Surgery
2008;33:420-6.
14. Ireland PE. Traumatic perforations
of tympanic membrane due to blast
injury. Can Med Assoc J 1946;54:256-8.
15. Amadasun JE. An observational
study of the management of traumatic
tympanic membrane perforations. The
Journal of laryngology and otology
2002;116:181-4.
16. Rosenfeld RM, Brown L, Cannon
CR, et al. Clinical practice guideline:
acute otitis externa. Otolaryngol Head
Neck Surg 2006;134:S4-23.
17. Alter SJ, Vidwan NK, Sobande
PO, Omoloja A, Bennett JS. Common
childhood bacterial infections. Current
problems in pediatric and adolescent
health care 2011;41:256-83.
18. Roland PS, Stroman DW.
Microbiology of acute otitis externa.
Laryngoscope 2002;112:1166-77.
19. Beers SL, Abramo TJ. Otitis
externa review. Pediatr Emerg Care
2004;20:250-6.
20. Martinez Devesa P, Willis CM,
Capper JW. External auditory canal
pH in chronic otitis externa. Clinical
otolaryngology and allied sciences
2003;28:320-4.
21. Stone M, Fulghum RS.
Bactericidal activity of wet cerumen. Ann Otol Rhinol Laryngol
1984;93:183-6.
22. Pata YS, Ozturk C, Akbas Y,
Gorur K, Unal M, Ozcan C. Has
cerumen a protective role in recurrent
external otitis? Am J Otolaryngol
2003;24:209-12.
23. Nussinovitch M, Rimon A,
Volovitz B, Raveh E, Prais D, Amir
J. Cotton-tip applicators as a leading
cause of otitis externa. International
journal of pediatric otorhinolaryngology 2004;68:433-5.
24. Carfrae MJ, Kesser BW. Malignant
otitis externa. Otolaryngologic clinics
of North America 2008;41:537-49,
viii-ix.
25. Ruben RJ. Efficacy of ofloxacin
and other otic preparations for
otitis externa. Pediatr Infect Dis J
2001;20:108-10; discussion 20-2.
26. Rosenfeld RM, Singer M,
Wasserman JM, Stinnett SS. Systematic
review of topical antimicrobial therapy
for acute otitis externa. Otolaryngol
Head Neck Surg 2006;134:S24-48.
27. Myer CM, 3rd. The evolution
of ototopical therapy: from cumin
to quinolones. Ear Nose Throat J
2004;83:9-11.
28. Myer CM, 3rd. Historical perspective on the use of otic antimicrobial
agents. Pediatr Infect Dis J 2001;20:98101; discussion 20-2.
29. Johnston CS, Gaas CA. Vinegar:
medicinal uses and antiglycemic effect.
MedGenMed : Medscape general
medicine 2006;8:61.
30. Emgard P, Hellstrom S. A
topical steroid without an antibiotic
cures external otitis efficiently: a
study in an animal model. Eur Arch
Otorhinolaryngol 2001;258:287-91.
31. Emgard P, Hellstrom S, Holm S.
External otitis caused by infection with
Pseudomonas aeruginosa or Candida
albicans cured by use of a topical group
III steroid, without any antibiotics.
Acta Otolaryngol 2005;125:346-52.
32. Tsikoudas A, Jasser P, England RJ.
Are topical antibiotics necessary in the
management of otitis externa? Clinical
otolaryngology and allied sciences
2002;27:260-2.
33. Osguthorpe JD, Nielsen DR. Otitis
externa: Review and clinical update.
Am Fam Physician 2006;74:1510-6.
34. Dohar JE. Evolution of management approaches for otitis externa.
Pediatr Infect Dis J 2003;22:299-305;
quiz 6-8.
35. Hannley MT, Denneny JC,
3rd, Holzer SS. Use of ototopical
antibiotics in treating 3 common ear
diseases. Otolaryngol Head Neck Surg
2000;122:934-40.
36. Epstein E. Allergy to dermatologic
agents. Jama 1966;198:517-20.
37. Gette MT, Marks JG, Jr., Maloney
ME. Frequency of postoperative allergic contact dermatitis to topical antibiotics. Arch Dermatol 1992;128:365-7.
38. Dickel H, Taylor JS, Evey P, Merk
HF. Delayed readings of a standard
screening patch test tray: frequency
of “lost,” “found,” and “persistent”
reactions. American journal of contact
dermatitis : official journal of the
American Contact Dermatitis Society
2000;11:213-7.
39. Wright CG, Halama AR,
Meyerhoff WL. Ototoxicity of an
ototopical preparation in a primate.
The American journal of otology
1987;8:56-60.
40. Wright CG, Meyerhoff WL.
Ototoxicity of otic drops applied to
the middle ear in the chinchilla. Am J
Otolaryngol 1984;5:166-76.
41. Gates GA. Safety of ofloxacin otic
and other ototopical treatments in
animal models and in humans. Pediatr
Infect Dis J 2001;20:104-7; discussion
20-2.
42. Wall GM, Stroman DW, Roland
PS, Dohar J. Ciprofloxacin 0.3%/dexamethasone 0.1% sterile otic suspension
for the topical treatment of ear infections: a review of the literature. Pediatr
Infect Dis J 2009;28:141-4.
43. Mraovic M, Canic-Radojlovic M.
The activity of ofloxacin against methicillin-resistant Staphylococcus aureus.
Infection 1986;14 Suppl 4:S231-2.
44. Peterson LR, Cooper I, Willard
KE, et al. Activity of twenty-one
antimicrobial agents including
l-ofloxacin against quinolone-sensitive
and -resistant, and methicillin-sensitive
and -resistant Staphylococcus aureus.
Chemotherapy 1994;40:21-5.
45. Kang SL, Rybak MJ,
McGrath BJ, Kaatz GW, Seo SM.
Pharmacodynamics of levofloxacin,
ofloxacin, and ciprofloxacin, alone and
in combination with rifampin, against
methicillin-susceptible and -resistant
Staphylococcus aureus in an in vitro
infection model. Antimicrob Agents
Chemother 1994;38:2702-9.
46. Dohar JE, Garner ET, Nielsen
RW, Biel MA, Seidlin M. Topical
ofloxacin treatment of otorrhea in
children with tympanostomy tubes.
Arch Otolaryngol Head Neck Surg
1999;125:537-45.
47. Jones RN, Milazzo J, Seidlin M.
Ofloxacin otic solution for treatment
of otitis externa in children and adults.
Arch Otolaryngol Head Neck Surg
1997;123:1193-200.
48. Drehobl M, Guerrero JL, Lacarte
PR, Goldstein G, Mata FS, Luber S.
Comparison of efficacy and safety
of ciprofloxacin otic solution 0.2%
versus polymyxin B-neomycinhydrocortisone in the treatment of
acute diffuse otitis externa*. Curr Med
Res Opin 2008;24:3531-42.
49. Rahman A, Rizwan S, Waycaster
C, Wall GM. Pooled analysis of two
clinical trials comparing the clinical
outcomes of topical ciprofloxacin/
dexamethasone otic suspension and
polymyxin B/neomycin/hydrocortisone otic suspension for the treatment
of acute otitis externa in adults
and children. Clinical therapeutics
2007;29:1950-6.
50. Pistorius B, Westberry K,
Drehobl M. Prospective, randomized,
comparative trial of ciprofloxacin otic
drops, with or without hydrocortisone, vs. polymyxin B-neomycinhydrocortisone otic suspension in the
treatment of otitis externa. Infect Dis
Clin Pract 1999 8:387–95.
51. Rosenfeld RM, Schwartz SR,
Cannon CR, et al. Clinical practice
guideline: acute otitis externa executive
summary. Otolaryngol Head Neck Surg
2014;150:161-8.
52. Jones EH. Prevention of “swimming pool ear”. The Laryngoscope
1971;81:731-3.
53. Thalmann ED. A prophylactic program for the prevention
of otitis externa in saturation
divers. Washington, DC: U.S. Navy
Experimental Diving Unit; 1974.
54. Hern JD, Almeyda J, Thomas
DM, Main J, Patel KS. Malignant
otitis externa in HIV and AIDS. The
Journal of laryngology and otology
1996;110:770-5.
55. Chandler JR. Malignant external
otitis. Laryngoscope 1968;78:1257-94.
56. Gordon G, Giddings NA. Invasive
otitis externa due to Aspergillus species: case report and review. Clin Infect
Dis 1994;19:866-70.
57. Cruveilhier J. Anatomie
Pathologique du Corps Humain, Vol. 1,
Book 2, Plate 6. Paris: Bailliere; 1829.
58. Harker LA, Koontz FP.
Bacteriology of cholesteatoma: clinical
significance. Transactions Section on
Otolaryngology American Academy of
Ophthalmology and Otolaryngology
1977;84:ORL-683-6.
59. Holt JJ. Ear canal cholesteatoma.
Laryngoscope 1992;102:608-13.
60. Hanif J, Frosh A, Marnane C,
Ghufoor K, Rivron R, Sandhu G.
Lesson of the week: “High” ear piercing
and the rising incidence of perichondritis of the pinna. BMJ 2001;322:906-7.
61. Roland PS, Smith TL, Schwartz
SR, et al. Clinical practice guideline:
cerumen impaction. Otolaryngol Head
Neck Surg 2008;139:S1-S21.
62. Bressler K, Shelton C. Ear
foreign-body removal: a review of
98 consecutive cases. Laryngoscope
1993;103:367-70.
63. Balbani AP, Sanchez TG, Butugan
O, et al. Ear and nose foreign body
removal in children. International
journal of pediatric otorhinolaryngology 1998;46:37-42.
64. Ansley JF, Cunningham MJ.
Treatment of aural foreign bodies in
children. Pediatrics 1998;101:638-41.
65. Mackle T, Conlon B. Foreign
bodies of the nose and ears in children.
Should these be managed in the
accident and emergency setting?
International journal of pediatric
otorhinolaryngology 2006;70:425-8.
66. DiMuzio J, Jr., Deschler DG.
Emergency department management
of foreign bodies of the external ear
canal in children. Otol Neurotol
2002;23:473-5.
67. Davies PH, Benger JR. Foreign
bodies in the nose and ear: a review of
techniques for removal in the emergency department. J Accid Emerg Med
2000;17:91-4.
68. Hanson RM, Stephens M.
Cyanoacrylate-assisted foreign body
removal from the ear and nose in
children. J Paediatr Child Health
1994;30:77-8.
69. Raz S, Stassen R, Hilding D.
Impression materials for removal of
aural foreign bodies. Ann Otol Rhinol
Laryngol 1977;86:396-9.
70. Wavde V. Removal of foreign body
from nose or ear. Aust Fam Physician
1988;17:904.
71. Stool SE, McConnel CS, Jr. Foreign
bodies in pediatric otolaryngology.
Some diagnostic and therapeutic pointers. Clin Pediatr (Phila) 1973;12:113-6.
72. Brunskill AJ, Satterthwaite K.
Foreign bodies. Ann Emerg Med
1994;24:757.
73. Ernst E. Ear candles: a triumph of
ignorance over science. The Journal of
laryngology and otology 2004;118:1-2.
74. Seely DR, Quigley SM, Langman
AW. Ear candles--efficacy and safety.
Laryngoscope 1996;106:1226-9.
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