Through the Otoscope
Michael J. Rensink, MD, is a member of ENT Associates of San Diego and has been a practicing ENT specialist for more than 35 years.
Some hearing-impaired patients have problematic ears—severe contact dermatitis, psoriasis, eczema, or another medical problem in their external ear and ear canal. And what's worse, the patient's hearing aids aggravate the health of the ear.
Most of these patients have seen their family doctor and tried different medications—usually drops—none of which is highly successful. These patients have what I call notorious ears. They are difficult, challenging, and demand a lot of devotion and care. Ears like these also require the patient to cooperate fully with his doctor and the recommended care schedule. In fact, this condition can be fatal if not recognized and treated vigorously and properly.
“Sandra” is a patient of mine with a long complex ear history. When I first saw her several months ago, her external ears were severely swollen and the right ear canal was closed. Her primary concern was that she could no longer wear her hearing aids because the edema in her external ears changed their shape and her earmolds no longer fit. The canals were plugged with exudate and keratin.
I started Sandra on a continuous cleaning program: Clean ears heal faster than ones full of debris. The epidural layer of normal skin is replaced about every four months, and when this tissue becomes “sick,” the skin cells die quickly and the cycle is much faster than normal, sometimes as often as once a month. This accumulation of dead tissue creates a breeding ground for bacteria, fungus, and other pathogens.
After an initial cleaning, I discussed various treatment modalities with Sandra: creams, salves, drops, powders, pills, antibiotics, steroids, and anti-inflammatories, and started her on some medications. She returned weekly for further cleaning and debridement of dead skin. The cleanings allowed the drops and creams to reach the involved skin in the ear and canal.
Sandra's right external ear was in bad shape when I first met her. A huge improvement could be seen just a few weeks after her initial visit (Figure 1), and now a couple of months later, her ear looks better still (Figure 2). Sandra says it also feels better than it has in years. While she desperately wanted to wear a hearing aid on that ear, hearing aid use is still problematic. I advised her against wearing her existing earmolds because they are too tight and aggravate the inflammation in her ears. New molds were made, which fit a lot better and caused less irritation to the ears. When an ear disease is out of control, prolonged hearing aid use is contraindicated.
Sandra will require close follow-up and frequent cleaning of the pinna and canals to prevent a recurrence and allow her to wear her hearing aids. She will also have to continue to use her drops and creams. If not followed and treated properly, this condition may lead to necrotizing otitis externa, particularly in diabetics.
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