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Cholesteatoma, otitis externa and surgical advances

In the second article on ear problems, consultant otologist Professor Tony Wright answers questions from GP Dr Melanie Wynne-Jones

In the second article on ear problems, consultant otologist Professor Tony Wright answers questions from GP Dr Melanie Wynne-Jones


1. Who is at risk from cholesteatoma? What are the symptoms, how urgently should they be referred and how should they be followed up?

Cholesteatoma is defined as the abnormal presence of skin in the middle ear and mastoid air spaces. Those at risk have often had a history of childhood ear disease with retractions of the ear drum, but the condition can gradually develop in later life if there is sino-nasal disease with inadequate Eustachian tube function to maintain normal middle ear air pressures.

Occasionally, direct trauma to the ear drum (accidental or iatrogenic) can bury skin in the wrong place. As the skin continues to grow and the dead layers collect, a mass forms and continues to expand, trapped by the surrounding bone. Symptoms are few until surrounding structures are involved and then eroded.

The typical picture is of a progressive conductive hearing loss often with a foul smelling discharge because of infection of the dead skin with Pseudomonas, Proteus or Klebsiella spp with additional anaerobes. Nearby structures can get involved with a profound sensorineural hearing, tinnitus and vertigo from the inner ear, a facial palsy and even involvement of intracranial structures with a brain abscess being most likely. Pain is not common until one of the major complications is about to happen.

It is advisable to refer all patients, because cholesteatoma is nearly always more extensive than it looks.

2. Otitis externa is a difficult problem in primary care where we don't have microsuction – drops just sit on the discharge. Should we always swab at presentation?

Otitis externa is a general name for inflammation of the external ear canal. There are many causes, and a brief list includes:

• the dermatitises – eczema, psoriasis and seborrhoea

• the sensitivities – hair shampoo, perming lotion, preservatives in ear drops, aminoglycoside antibiotics

• fungal infestations

• neurodermatitis – itchy ears when stressed.

All these conditions have itching as a common symptom – and, as we all know, a good cure for an itch is a scratch. This can damage the canal skin and result in a bacterial infection. Treatment with ear drops can then frequently cause a secondary problem from a sensitivity reaction or fungal overgrowth.

There is usually lots of debris in the ear canal, which stops topical drops being effective, and this needs to be removed.

I would advise taking a swab initially, as yeasts, fungi and various bacteria can all be found apart from the usual Staphylococcus and Pseudomonas spp. I hesitate to suggest gentle syringing, but this may be appropriate if you know that the eardrum is intact.

3. When should we use oral antibiotics or antifungal drops when managing patients with otitis externa?

If the ear canal is clearly infected then antibiotic and steroid drops are indicated. The aminoglycosides can be used if there is no hole in the drum, but if there is then a quinolone (such as ciprofloxacin) is needed as this group is not ototoxic. These drugs should be accompanied by some steroid drops, as the combination is more effective than antibiotics alone.

• If there is a spreading cellulitis of the surrounding skin, oral antibiotics are needed.

• If the patient is diabetic, or immunocompromised (or both) and pain especially at night is a major feature, then they may have a necrotising (malignant) otitis externa. This is, in effect, an osteomyelitis of the skull base, and needs referral to an ENT department with this presumptive diagnosis.

4. What is a reasonable wait for microsuction? Is microsuction easy to learn, and what are the pitfalls?

Microsuction is the best form of management and is relatively simple to learn. Many ENT departments have nurse-led clinics to treat patients with otitis externa.

Be gentle all the time, make sure the speculum is centred on the ear canal and have the right equipment – a microscope with a 250mm front lens and a suction apparatus, and disposable suckers and micro tips.

5. How common is autoimmune inner ear disorder? What are the symptoms and how is it managed?

Autoimmune ear disorders are more of a concept than a reality. Although they seem like a good idea, there is little hard evidence to support their existence.

There is possibly one small, very uncommon group of younger women who do have a fluctuating, bilateral sensorineural loss without any other cause, with a raised ESR and which responds to steroids. I have not, however, seen such a patient, but my colleagues in audiological medicine very occasionally relate case histories such as this.

6. What is the role of lasers in middle ear surgery?

Lasers are slowly becoming used on a more regular basis in middle ear surgery. The KTP and argon laser beams can travel along a flexible light cable and so can be used fairly easily. The CO2 laser (which is theoretically better but cannot go along a light cable) requires extremely expensive apparatus to use with the operating microscope, so is rarely used in the UK.

The beauty of the laser is that it is a no touch technique – although it is quite noisy. The main use is probably in performing stapedectomies, where the arch of the stapes can be lasered through, instead of manually fracturing it; the hole through the stapes footplate can then be created with the laser, again with minimal trauma.

The laser is also excellent for dividing adhesions and scars in revision surgery, and is probably a requirement nowadays for revision stapedectomy. It is also used for removing cholesteatoma, which is adherent to underlying structures.

7. What technological advances are on the horizon?

One great technological advance has been the development of Hopkins rods (small rigid endoscopes with angled front lenses) that allow the surgeon to look round corners. There are plenty of inaccessible corners in the middle ear with the sinus tympani, which is the recess deep to the descending portion of the facial nerve in the mastoid, being the most important. With these and specially developed instruments by Thomassin, ENT surgeons are able to be much more certain of clearing disease.

High-resolution spiral CT scanning has made pre-operative diagnosis of middle ear lesions more reliable, as it is now possible to determine accurately whether otosclerosis is present or if some other process is causing a conductive hearing loss.

Implant technology for reconstructing the ossicles has improved with titanium prostheses becoming fashionable, although this has not been tested over the long term. The search is still on, however, for a truly implantable hearing aid – although this may be a surgical false dream, as conventional acoustic hearing aids are becoming more compact.

8. How easy and reliable would it be for GPs to carry out audiometry and tympanometry in the surgery to avoid referral? What should we look for and avoid in the equipment?

Undertaking pure tone audiometry and tympanometry should not be a significant challenge apart from the time involved in learning the techniques and then performing the tests.

Testing needs a quite environment and the less the background noise the more reliable are the low tone results.

Air conduction with headphones tests the whole system – outer, middle and inner ears and auditory brain. Bone conduction, using a calibrated vibrator on the mastoid, bypasses the outer and middle ears and tests inner ear and auditory brain pathways.

Unfortunately for testing purposes, bone is a very good transmitter of sound and with the vibrator on one mastoid, the test tone will be heard in the better hearing ear. If this happens to be the other ear a false result will be recorded. Masking the non-test ear is therefore important and this is a technique that probably has to be learned under instruction and with real patients. Once this has been mastered then your audiometry tests should be reliable.

Tympanometry is an altogether simpler task with few pitfalls other than not being able to obtain a seal.

As with both techniques there is no need to buy a research machine and there are plenty of quality low-end machines available.

It is important to remember that the machines need calibrating each year.

If you are going to test hearing then you could extend the range by testing otoacoustic emissions. These are small echoes of sound introduced into the ear and are only found in normal ears. This means that you can easily test babies' hearing and a positive response indicates normal hearing, which is often a huge relief for parents and the GP alike. Small screeners are available, which can be used in general practice.

Professor Tony Wright is a consultant otologist at the Royal National Nose Throat and Ear Hospital, London, and professor of otolaryngology at the University College London Ear Institute

Competing interests None declared

Take-home points

• In cholesteatoma, symptoms are few until surrounding structures are involved and then eroded. The typical picture is of a progressive conductive hearing loss often with a foul-smelling discharge.

• The main use of lasers is probably in performing stapedectomies. They are also excellent for dividing adhesions and scars in revision surgery, and are probably a requirement nowadays for revision stapedectomy.

• Lasers are also used for removing cholesteatoma that is adherent to underlying structures.

• High-resolution spiral CT scanning has made pre-operative diagnosis of middle ear lesions more reliable.

• Implant technology for reconstructing the ossicles has improved with titanium prostheses.

What I will do now

Dr Wynne-Jones responds to the answers to her questions

In practice, I will certainly:

• Take swabs more frequently in patients with otitis externa

• Remember to consider allergy and stress as possible causes of itchy ears or otitis externa

• Use quinolone drops when I cannot exclude a possible perforation in a discharging ear

• Audit our referrals for microsuction and hearing tests to see whether investing in equipment (perhaps as part of practice-based commissioning) would be worthwhile

Dr Melanie Wynne-Jones is a GP and GP trainer in Marple, Cheshire

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