pertaining to hearing and the organs responsible for hearing.
the outer portion of the ear; also known as the pinna.
a state of balance referring to the orientation of the body relative to gravity, allowing an individual to maintain coordination and position in space.
tube within the middle ear that connects to the pharynx or upper respiratory system.
damage to the hearing or balance functions of the ear by drugs or chemicals.
ringing sound in the ears.
After completing this chapter, you should be able to
Review the anatomy of the ear.
Describe various ear disorders, including signs and symptoms.
Identify medications used in the ear to treat cerumen buildup, water-clogged ears, contact dermatitis, and otitis media.
List medications that can cause ototoxicity.
Describe how to properly administer eardrops.
Ear complaints are common and account for more than 1.5% of all doctor visits each year.1 They can affect people of all ages, but occur more often in pediatric and geriatric patients. The ear is part of the auditory system (which is responsible for hearing and balance), equilibrium, and many communication skills. In order to understand patients’ complaints, it is important to understand the anatomy of the ear.
A 60-year-old male comes into the pharmacy reporting gradual hearing loss over the past couple of weeks. He reports some pain in the ear that is preventing him from wearing his hearing aid earpiece and from talking on the phone. His ear is also red, swollen, and itchy. Mr. Green states that he has had this problem before and was able to fix it himself using a bobby pin to remove some earwax. He tried the bobby pin trick yesterday but was not successful.
Anatomy of the Ear
The external ear is made up of the auricle, external auditory canal, and tympanic membrane. The auricle has a thin layer of skin, which covers cartilage, whereas the ear lobe has more fatty tissue. The external auditory canal is lubricated with cerumen. The job of the cerumen is to protect the middle ear from infections by trapping dust and other materials, and by providing a waxy, waterproof barrier to defend against pathogens. Cerumen has an acidic pH, which helps to prevent infections from developing. As cerumen collects debris, it is moved outward by jaw movements like talking and chewing. Cerumen darkens as it is exposed to air and may appear light gray, orange, or brown. Its consistency also varies and may be dry and flaky or oily and paste-like.
Not all earwax has to be removed. Excessive attempts to remove cerumen may damage the external auditory canal. Only cerumen that has moved to the outermost part of the external auditory canal should be removed.
Is Mr. Green at risk for having a bacterial or fungal infection, and if so, why?
The external auditory canal is susceptible to collecting moisture, making it a great environment for bacteria and fungus to collect and grow. The defense system for the ear includes the skin, cerumen, acidic pH, and hairs, which line the outer part of the canal. A normal, healthy ear will not allow bacteria and fungus to grow. Breaking or scratching the skin of the auditory canal with objects like fingernails, cotton-tipped applicators (e.g., Q-tips®), or bobby pins creates a door for bacteria and fungus to enter. Ear piercing, sports injuries, and poorly fitted or poorly cleaned hearing aids can also impact the defense system of the ear. Finally, upper respiratory infections and viral infections can break down the defense system of the ear.
The external auditory canal is closed by the tympanic membrane or eardrum, which separates the external ear from the middle ear. This forms a blind cul-de-sac, which can collect moisture. In children, the external auditory canal is shorter, straighter, and flatter. The tympanic membrane is concave and oval, smooth, pearl gray in color, and clear (transparent). It acts as a barrier for the middle ear and is the part of the ear responsible for hearing by transmitting sound waves. When a sound is produced, the tympanic membrane vibrates, causing the three tiny bones (the malleus—hammer, stapes—stirrup, and incus—anvil) within the middle ear to vibrate. The vibration is then transferred to the cochlea, a channel of the inner ear, which is lined with tiny hairs that trigger nerve signals to the brain to register the sound.
The stapes is considered the smallest bone in the body.
The eustachian tube is also within the middle ear and connects to the pharynx or upper respiratory system. The eustachian tube helps equalize the pressure within the middle ear and allow fluid to drain from the middle ear. When patients experience a cold or viral infection in the nasal cavity, bacteria and viruses can travel through the eustachian tube and contribute to an infection within the ear. Additionally, the eustachian tube tissues can swell, trapping fluid in the middle ear, which can lead to a middle ear infection. Children are more prone than adults to experience a middle ear infection because their eustachian tubes are shorter. The eustachian tube lengthens downward in adults, which helps to promote drainage.
The inner ear is made up of a series of fluid-filled tubes called the bony labyrinth. The bony labyrinth has three sections: the cochlea, vestibule, and semicircular canals. The cochlea helps with the hearing functions of the ear, is snail shaped, and is lined with tiny hairs (see Figure 35-1). The vestibule connects the cochlea to the semicircular canals and helps with the balance function of the ear. The semicircular canals also help with the balance functions of the ear. Finally, within the inner ear, the vestibulocochlear nerve (cranial nerve VIII) transmits hearing and balance information to the brain. Several conditions, including cerumen buildup, water-clogged ears, contact dermatitis, otitis media, and deafness can impact the hearing or balance functions of the ear or both. Medications can also contribute to hearing loss, both temporarily and permanently. Each condition is described in further detail below.
Excessive or impacted cerumen affects up to 10% of children, 5% of adults, and more than 30% of older (aged ≥65 years) adults. It is the most common cause of hearing loss at all ages. Narrow or oddly shaped external auditory canals, hearing aids or earplugs, and excessive hair growth in the ear canal make it difficult for people to cycle newly formed cerumen with the older debris-filled cerumen. Additionally, patients may have overactive ceruminous glands, causing excess cerumen production. In older adults, cerumen has less moisture, making it harder to remove. In these situations, the cerumen can become impacted, causing a problem for patients.
When there is excessive or impacted cerumen, patients will complain of fullness or pressure in the ear, possible hearing loss, dull pain or discomfort, dizziness, itching, and/or tinnitus. Efforts to remove the wax with cotton-tipped applicators, bobby pins, fingernails, toothpicks, etc., can actually force the wax further into the ear. Instead, a wet, wrung-out washcloth around a finger may be used to remove the excess cerumen. This method is ineffective once the cerumen is impacted.
The goal of treatment is to soften the cerumen so that it can be removed and prevent any adverse events. Removing the cerumen should correct temporary hearing loss and alleviate any pain the patient may be experiencing. Patients who show signs of infection, have an ear discharge, bleeding, ruptured tympanic membrane, recent ear surgery, tympanostomy tubes (to prevent middle ear fluid accumulation), or are under 12 years of age should be referred to a healthcare practitioner (HCP) first. If the washcloth method does not remove the cerumen buildup, the most effective treatment is often an ear drop like one listed in Medication Table 35-1 (Medication Tables are located at the end of the chapter). Carbamide peroxide 6.5% in anhydrous glycerin is the only nonprescription ear wax softening agent approved by the US Food and Drug Administration (FDA). Carbamide peroxide helps to break down and loosen the cerumen, while glycerin helps to soften the cerumen. This product is available over the counter (OTC) in a variety of brands and packages and is safe for use in adults and children 12 years of age and older. Carbamide drops should stay in the ear canal for several minutes (no longer than 15 minutes) and can be used twice daily for up to 4 days.1 Common side effects include pain, rash, irritation, tenderness, redness, discharge, and dizziness. Patients developing side effects or whose problem does not resolve within 4 days should be referred to an HCP. Some patients may express a desire to use a rubber otic bulb syringe to remove any remaining cerumen. Specific earwax removal syringes are also widely available, with some claiming to be a safer alternative than a bulb ear syringe. Patients should use these products cautiously so that they insert the syringe tip correctly. Incorrect placement of the syringe tip may lead to otitis media, perforated tympanic membrane, vertigo, otitis media, or tinnitus.
Other treatment options are not recognized by the FDA as approved agents for the removal of earwax and should not be recommended over carbamide peroxide for self-treatment, but some are utilized or prescribed by HCPs when excess cerumen prompts an office visit.
Docusate is an emollient that can soften cerumen; however, it is more commonly used orally as a stool softener. It is more expensive than carbamide and is not available as an OTC product for earwax removal. Patients must cut open the gel cap and insert the liquid contents into the ear according to their HCP’s directions. Glycerin, olive oil, and mineral oil are also emollients. They are commonly found in combination with other agents for excessive cerumen. Olive oil has also been used to treat itching and pain in the ear canal, but this is not recommended as self-treatment. Patients experiencing ear pain should be referred to their HCP. Either a 1:1 solution of hydrogen peroxide 3% and warm water or just plain hydrogen peroxide 3% is sometimes recommended or prescribed by HCPs to flush the ear canal to soften or remove excessive cerumen. Overuse of hydrogen peroxide may break down the tissue of the ear canal and lead to infection.
Which product might the pharmacist recommend for Mr. Green, and how long should he use the product?
Ear candles are hollow candles made of a fabric tube soaked in beeswax or paraffin or a combination of both. One end is burned while the other is inserted into the ear canal. The FDA has warned patients not to use ear candles because they can cause serious injuries, including burns, broken eardrums, and blockage of the ear canal.2 Yerba santa and chamomile are two natural products or folk remedies used to treat excessive cerumen. However, there is no published safety and efficacy information on these products. Thus, they are not recommended for use in self-treatment.
Various ear cleaning tools are also available OTC for patients to purchase. Examples include Ototek Loop and Clinere® ear cleaners. Both products are inserted into the outer ear and external auditory canal and bear the risk of injury to the ear canal or tympanic membrane.
Water-clogged ears result from excessive moisture in the ear canal, which becomes trapped and cannot escape. Humid climates, sweating, bathing, or incorrect use of solutions to cleanse the ear can result in water-clogged ears. Cerumen can also swell, trapping water in the canal. Some patients are more prone to water-clogged ears because of the shape of their ear canals or excessive cerumen. Often, simple attempts like shaking the head in one direction are not enough to remove the water.
The use of cotton-tipped applicators on a daily basis after showering can cause abrasions and lead to infections in the ear and is not recommended. Patients should let their ears dry naturally or use a washcloth draped over a finger to dry out the ear.
Mr. Green reports that he tried to flush his ear with warm water 1 week ago and was not successful. The next day, he said his ear started itching. Is Mr. Green likely to have water-clogged ears, and if so, what product might the pharmacist recommend?
Patients sometimes complain of a sense of wetness or fullness in the ear and possibly, hearing loss. They may also report pain and itching in the ear canal. The goals of treatment are to remove the water and to prevent recurrences. If patients show signs of infection, ear discharge, bleeding, ruptured tympanic membrane, or have had recent ear surgery, tympanostomy tubes, or are under 12 years of age, they should automatically be referred to their HCP. All patients should also be referred to their HCP prior to any treatment to ensure that their tympanic membrane is not ruptured or a tympanostomy tube is not in place.
Patients wishing to try self-treatment after seeing their HCP should be directed by the pharmacist to tilt the affected ear downward and manipulate the auricle to help remove the excessive water. This can also be done after swimming and bathing to prevent water-clogged ears. A blow dryer may also be used to help dry the ear but should be on the lowest setting and pointed away from the ear. Otherwise, the only FDA-approved treatment is isopropyl alcohol 95% in anhydrous glycerin 5%. Alcohol mixes well with water and acts as a drying agent. Glycerin helps to coat the canal to aid in removal of the water and prevents over-drying from the alcohol. Various OTC products, listed in Medication Table 35-2, containing alcohol, acetic acid, or glycerin are available. A home remedy of 50:50 mixture of household white vinegar and isopropyl alcohol 95% creates an acetic acid solution that has also been used to help dry water-clogged ears, but presents a risk of over-drying the ear.
It is important that patients considering the use of home remedies be warned to use white vinegar and not cider or wine vinegar. Cider and wine vinegars are produced from fruit and contain impurities that could promote bacterial growth.
Patients may also try to prevent water-clogged ears. Options include the use of ear plugs or bathing caps. AquaEars, BioEars, and ClearEars are products that either protect the ears from exposure to water or are intended to absorb water that enters the ear. Lastly, patients may use “waterproofed” cotton balls prior to water exposure to block the ear canal. Cotton balls are “waterproofed” using petroleum jelly.
Water-clogged ears are a separate issue from swimmer’s ear. Swimmer’s ear is an infection of the outer ear (external otitis), which develops from swimming in polluted water. Although it results from water becoming trapped, as in water-clogged ears, in swimmer’s ear, the tissue of the ear begins to break down and eventually leads to an outer ear infection. Prescription medications used to treat external otitis include corticosteroid and antibiotic ear drops. Corticosteroid drops decrease inflammation and help to relieve any pain or itching. Antibiotic drops treat bacterial infection present in the ear. Treatments for otitis are detailed in Medication Table 35-3.
There are no FDA-approved OTC medications for preventing or treating swimmer’s ear. In the past, manufacturers may have stated that removing the excess water would prevent breakdown of the ear tissue; however, the FDA no longer allows manufacturers to make statements that their products can prevent swimmer’s ear.
Contact dermatitis or allergic reactions of the external ear can be associated with topical antibacterial ointments, nickel in earrings, poison ivy, and chemicals used to clean hearing aid ear molds. Allergic reactions in the ear are not usually caused by soaps or detergents, which require extended contact to produce an allergic reaction. Most patients will present with itching and redness in the ear. The itching may be so severe that patients will want to stick things in their ears to relieve the pain. Burow’s solution (1:40 aluminum acetate) is used to treat contact dermatitis of the ear. It is applied as a wick inserted into the ear canal, kept moist for 24 hours, and then removed.
Eye drops can be used in the ear but ear drops cannot be used in the eye. The tissue in the eye is more sensitive than the ear. Thus, eye drops are gentler than ear drops. The Institute for Safe Medication Practices (ISMP) recommends to “double-check the label on the product—if it says otic, it’s for the ear, and if it says ophthalmic, it’s for the eye.”3
A mother comes into the pharmacy stating that her 11-month-old daughter, Isabella, has been very fussy for the past 24 hours, not sleeping well, and has been tugging at her ear throughout the day. Isabella normally goes to daycare; however, her mother has stayed home with her today. When they come into the pharmacy, Isabella is sucking on a pacifier and has red puffy eyes from crying, but her mother reports that she has not had a fever. The mother is concerned and is looking for advice.
Otitis media is inflammation of the middle ear and is very common in children, especially between the ages of 6 and 18 months. It is the most common reason antibiotic prescriptions are written for children. Otitis media occurs more frequently in the winter months and usually presents after an infection in the nose. An infection of the nasal passageways can result in pressure and buildup into the eustachian tubes, causing them to swell. Swelling of the eustachian tubes can trap bacteria, leading to otitis media. Children have shorter and more horizontal eustachian tubes than adults, making it more difficult for fluid to drain out. Risk factors for otitis media include age less than 2 years, viral respiratory tract infection and the winter season, daycare attendance, young age at first diagnosis, siblings, tobacco smoke exposure, anatomic defects such as cleft palate, pacifier use, lack of breastfeeding, immunodeficiency, and gastroesophageal reflux.
Is Mr. Green likely to have otitis media? Is Isabella likely to have otitis media? What risk factors, if any, does each of these patients have?
Patients with otitis media will present with fever, ear pain, irritability, ear fullness, and possibly even tugging at the ear and hearing loss. Patients may also report poor sleep, lack of appetite, vomiting, and diarrhea. The goals of treatment are to eliminate the pain and infection in the ear, prevent future infections, and minimize antibiotic use. Treatment is oral (not locally applied in the ear), usually with high-dose amoxicillin for 10 days. Other drugs given include amoxicillin-clavulanate (Augmentin), cefuroxime, cefpodoxime, and cefdinir. These antibiotics are discussed in detail in Chapter 27. For infections with a fever or for pain control, acetaminophen (Tylenol) and ibuprofen (Advil) can be given to help lower the fever and relieve any pain. Topical anesthetic agents such as benzocaine may also be given, especially in older children. Patients should expect to see an improvement within 72 hours of therapy; however, symptoms may seem worse during the first 24 hours of antibiotics. Some patients may benefit from the application of heat or cold agents, such as a washcloth soaked in very warm water, wrung out, and placed on the external ear for 15 minutes. Finally, in children with recurrent infections, tympanostomy tubes may be placed in the ear. The tubes help to extend the eustachian tubes and promote drainage.
What recommendations for treatment would the pharmacist make to Isabella’s mother?
Hearing impairment or deafness is a condition in which an individual cannot hear things that other people can hear. Hearing impairment is categorized by the type (conductive, sensorineural, or both), severity, and age of onset. Conductive hearing impairment results from dysfunction in the outer ear, tympanic membrane, or bones of the middle ear, whereas sensorineural hearing impairment results from dysfunction in the inner ear. Most sensorineural impairment result from abnormalities in the hair cells in the cochlea. The severity of hearing impairment is classified by how loud a sound must be before it is detected and can be mild, moderate, severe, or profound.
Mr. Green’s current medications include lisinopril 20 mg daily for high blood pressure, metformin 500 mg twice daily for diabetes, and simvastatin 40 mg daily for high cholesterol. Is he currently at risk for developing ototoxicity from any of his medications?
Major causes of hearing loss include noise, genetic factors, disease, medications, exposure to ototoxic chemicals, and trauma. Noise-induced hearing loss typically affects higher and lower frequencies. Common causes include car stereos, transportation (e.g., airports or freeways), lawn maintenance equipment, gun use, and power tools. The degree of severity depends upon the length of time exposed and the loudness of the sound. Diseases that can result in hearing loss or damage include measles, meningitis, mumps, HIV, AIDS, and otosclerosis, hardening of the stapes (one of the tiniest bones within the inner ear).
Infants born of mothers with chlamydia or syphilis, born prematurely, or born with fetal alcohol syndrome may also experience hearing loss. In addition to medications that cause hearing loss, which are described below, exposure to heavy metals (eg, lead, mercury), solvents (eg, toluene), asphyxiants (eg, carbon monoxide), and pesticides can lead to hearing loss. Often, ototoxic chemical exposure is coupled with noise-induced hearing loss.
Treatment for hearing loss can include the use of sign language, hearing aids, and cochlear implants. Additionally, individuals must also make lifestyle adaptations, such as telecommunications relay services, hearing dogs, and special light devices.
Medications That Cause Ototoxicity
Many drugs can cause ototoxicity or damage to the hearing or balance functions of the ear. The degree of toxicity depends on several factors, including the drug, dose, and location of the damage. Damage can occur in the cochlear and vestibular parts of the inner ear. Cochlear damage will present as hearing loss, whereas with vestibular damage, patients may have hearing loss but also difficulty walking, especially in the dark, and oscillopsia, a sensation that objects are moving or bouncing, seen especially when walking. Patients may experience a full recovery after the drug causing the ototoxicity is stopped but not always. In other cases, the damage may be limited or too small to be noticed. For example, a patient may have high-frequency hearing loss. In extreme situations, the ototoxicity may be permanent.
Medications that cause or contribute to ototoxicity include aminoglycosides (streptomycin, neomycin, kanamycin, amikacin, gentamicin, tobramycin, vancomycin), platinum chemotherapeutic agents (cisplatin, carboplatin), loop diuretics (ethacrynic acid, furosemide), salicylate analgesics (aspirin), and quinine. Cancer chemotherapy drugs, especially those containing platinum, can cause tinnitus and hearing loss, which can present immediately or up to several months after finishing treatment. Typically, the hearing loss with platinum chemotherapeutic drugs affects both ears and is permanent. Loop diuretics (such as furosemide) are more likely to cause permanent hearing loss in patients with decreased kidney function and those receiving aminoglycosides. Aspirin in high doses (more than twelve 325-mg tablets daily) can cause tinnitus and temporary hearing loss. Finally, quinine can cause temporary hearing loss. If possible, ototoxic drugs should be avoided in pregnancy, older adults, and individuals with existing hearing loss. If an ototoxic drug must be used, the lowest effective dose should be given and levels should be closely monitored.
Mr. Green’s primary care provider would like to start him on furosemide 20 mg daily for his high blood pressure in addition to lisinopril. What, if anything, should be done before he starts the new medication and during the time he receives the new medication?
Proper Method of Administering Eardrops
To properly administer eardrops, the head should be tilted toward the opposite shoulder. The auricle should be pulled so that the canal is open and visible. Drops should be administered into the canal with the dropper as far into the canal as possible without touching the canal. Patients should lie on their sides for 20 minutes or place a cotton ball blocking the ear canal to maximize drug exposure.4
If the dropper for ear drops touches the ear canal, it can become contaminated and allow the patient to get reinfected every time the solution is administered.
Ear complaints are common, and patients need to understand how easily the external auditory canal can be injured. Patients should be reminded not to use external objects to remove excessive cerumen or water, or alleviate itching. If patient symptoms worsen after 4 days, the patient should be referred to a healthcare provider.
Don’t get burned: Stay away from ear candles. https://www.fda.gov/consumers/consumer-updates/dont-get-burned-stay-away-ear-candles. Accessed January 16, 2020.3. Institute for Safe Medication Practices. “And the ‘EYES’ have it”: Eardrops, that is. . . https://www.ismp.org/resources/and-eyes-have-it-eardrops. Accessed January 16, 2020.