Otoscopic findings provide new information for patients, putting hearing healthcare providers in a unique position. Patients need to be counseled carefully and referred if needed. Blood, foul-smelling drainage, or an inflamed ear canal or eardrum call for referral.
It is more difficult to detect a tiny perforation, clear fluid behind the eardrum, or a small retraction pocket in the eardrum, and the need to refer may not be so obvious. Make a diagnosis by considering the patient's and his family's history, not just one piece of information.
A 47-year-old man came to my office complaining of ear pain, tenderness around the ear, and hearing loss. I could see gooey debris and white structures with an otoscope. He reported “a lot of pain,” which is a red flag that something is wrong. His pain level is characteristic of the type of problem in this case.
The absence of pain does not necessarily mean there is no danger to the patient. Several months ago, I reported on a patient with middle ear fluid and nasopharyngeal carcinoma. (See FastLinks.) The patient did not report pain, but it was urgent he see the appropriate specialist.
The presence of pain suggests disease, and the degree of pain requires a referral. Consider a case of purulent otitis media: the pressure on the eardrum is extreme if the middle ear is infected and the tissues are generating exudates. The patient experiences debilitating pain because the eardrum is in danger of a traumatic perforation.
The patient in this case needs to see an ENT who can best treat the disease and alleviate the patient's suffering. What is your diagnosis?
This patient has an ear infection caused by the fungus Aspergillus, which is a genus of fungi from the class Ascomycetes. Aspergillus contains many species with black, brown, or green spores. A few species are pathogenic, some are innocuous, and others, like those in Figure 1, invade body tissues and cause significant harm.
The distinguishing feature of Aspergillus is its shape: a multitude of tall stalks, each with a round spore pod on top, similar to a Tootsie Pop. Many of the round white spore pods are visible in Figure 1. Aspergillus is usually long and thin and comes in many different colors and configurations, giving it an almost aesthetic appearance. I might call them beautiful if they were not so pathogenic. (Figure 2.)
Aspergillus ear infections tend to be painful. The root grows like Bermuda grass, with a multitude of rhizome tendrils pointed in different directions. The tendrils grow into the tissue, resulting in marked pain.
Aspergillus, like other fungi and molds, prospers in regions with high humidity. This patient had small ear canals that tend to trap water and do not ventilate naturally. I gave him alcohol and vinegar drops (equal parts of rubbing alcohol and white vinegar) to prophylactically treat this condition when his ears are back to normal.
A couple steps are involved when I treat patients with Aspergillus. I clean the ear meticulously under a microscope to remove the fungus, and then I put medication in the ear. No specific antifungal medications exist for Aspergillus, but I use Domeboro Astringent Solution, an over-the-counter, saturated suspension of aluminum acetate. The fungus may regrow rapidly, so the patient should come back for a follow-up after two or three days to repeat the cleaning. I then powder the patient's ear with a combination of sulfanilamide, chloromycetin, Fungizone, and hydrocortisone to help keep the ear dry for several days. The patient uses alcohol and vinegar drops when the fungus is gone to prevent regrowth.
The patient should remove his hearing aid during the initial stages of treatment, and carefully disinfect them with alcohol to prevent reinfection. Immunocompromised patients have a higher incidence of Aspergillus infections and prophylactic treatment is sometimes recommended.
* See Dr. Rensink's article on middle ear fluid at http://bit.ly/OtoscopeMidEar.
* Read Dr. Rensink's past columns in a special collection at http://bit.ly/HJ-Archive.
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