This transcript has been edited for clarity.
Matthew F. Watto, MD: Welcome to The Curbsiders. I'm Dr Matthew Watto, here with my great friend and America's primary care physician, Dr Paul Nelson Williams. We're about to talk about some pearls on common ear complaints from our podcast with Dr Angela Peng.
As primary care physicians, we're all very comfortable taking a history. With the ear, you want to ask about prior infections or surgeries, and whether they are sticking anything in their ear. Do they have any risk for barotrauma, like jumping in a pool, scuba diving, or flying often?
We are going to spend most of our time talking about management of common ear complaints. If someone comes in with ear pain, should I just look in their ear and we're good to go?
Paul N. Williams, MD: The ear is tricky. Looking in both ears is a great place to start for a patient with ear pain. I look at the unaffected ear first to have a basis for comparison. But the larger point is about the plumbing here. It's all very complicated, and even though the patient's pain is coming from the ear, it can be referred jaw pain from TMJ dysfunction. It could be a tongue malignancy. A great many conditions can cause pain referred to the ear. So, if you look in the ear and don't see any cause for the pain, don't stop because there are many potential causes in the head and neck. Palpate the lymph nodes and do a thorough head exam.
Watto: I look in the ear, and in the nose, with a speculum. I look in the mouth and throat as well. You don't want to miss a malignancy or something. You might throw in some allergy testing if there are a lot of sinus symptoms going on, and a CT scan, based on clinical suspicion. But that's usually not something I'm doing at a first visit.
Now let's go on to management. Sinonasal symptoms often refer to the ear. All of the ENT doctors we've talked to and all the notes I get back from ENT doctors in practice say that these patients should be doing saline irrigation with either the neti pot or the squeeze bottle, using irrigation solution or making their own formulation at home with distilled water with baking soda and salt so it doesn't burn the heck out of their nose when they use it. That works very well. Most patients with sinus symptoms should be using that. For something like an otitis media, she mentioned antibiotics, but what else did she say might be helpful in treating these patients?
Williams: She made a point about the adjunctive therapy — intranasal steroids and antihistamines to kind of clear out the plumbing and make sure that all the tubes are flowing where they're supposed to flow, in addition to the systemic, antimicrobial therapy that you'd be giving the patient. For otitis media specifically, antibiotic ear drops aren't all that helpful. With a really irritated tympanic membrane, she might use topical steroid drops. But that might be above my level of comfort. The adjunctive stuff that we have a lot of comfort with — the intranasal steroids and the antihistamines — we should be prescribing along with antimicrobial therapy.
Watto: She mentioned that sometimes she'll even use oral steroids if the patient has tried some of these other things and they are still really congested or inflamed. If you've tried the first-line therapies such as intranasal steroids and saline irrigation and the patient is not getting better, it's always reasonable to refer the patient to someone who can take a deeper look in there. Some patients are going to need a surgical procedure.
For someone with vague inner-ear discomfort that doesn't seem to be an ear infection, either otitis media or otitis externa, it could be eustachian tube dysfunction. The things we are talking about here could work for that too.
Dr Peng mentioned that you can prevent otitis externa by mixing a 1-to-1 solution of rubbing alcohol and distilled vinegar and putting a few drops in to prevent swimmer's ear. You can use that after swimming as a prophylactic measure.
Williams: It's a neat tip. But this isn't a huge ear lavage; it's just a couple of drops. You're not washing the whole thing out.
Watto: And be sure to use distilled white vinegar, not balsamic vinegar. Have you ever had the problem with the cost of fluoroquinolone dexamethasone drops? She had a tip for that.
Williams: My patients have struggled with the cost. Dr Peng made a great point that you can use the ophthalmic drops instead if they're covered by insurance. You can also separate out the ingredients. These come in a topical fluoroquinolone combined with a topical steroid. If you get them separately, it might be a little bit cheaper. Or you can use the ophthalmic drops. You can use eyedrops in your ears, but you can't use eardrops in your eyes.
Watto: The eye drops are balanced and sterile so that you can drop them in the eye and not have burning or damage. So you can put them in your ear which is a less sensitive area. She mentioned that if someone has a perforated eardrum, you wouldn't want to use over-the-counter drops in the ear. But a prescription formulation would be okay to use if indicated.
Dr Peng has a large [cotton swab] in her office that says do not use. Tell your patients not to use [cotton swabs] if they have wax in their ears. She recommends a couple of drops of mineral oil, which you can do weekly if you're trying to prevent wax buildup. If someone's got impacted cerumen, they can do this every other day and then return to the office in a week or two. It will make the cleanout much easier, and the wax might even spontaneously slide out. I thought that was pretty cool; it wasn't something that I had heard about. But what about tap water or hydrogen peroxide? I know a lot of people use those to flush out their ears.
Williams: Yeah, I was a little surprised. There is not wild enthusiasm for the cerumenolytics, which apparently just soak into the cerumen and cause it to expand. Even water can be problematic, because it can get behind the cerumen and cause otitis externa, which is not what you want. It sounds like we should not be just irrigating willy nilly, unless we're really sure what we're doing, and that we can actually get the stuff out of there. As fun as it is to do, this might be something to leave to the experts if you can't get it done with mineral oil.
Watto: So if you put a ton of water in there, make sure you get the wax and the water out. Don't send them home with water still sloshing around behind the wax.
Finally, what if somebody has really itchy ears? That actually comes up a lot in primary care.
Williams: Dr Peng mentioned that she likes to use fluocinolone oil drops, which in addition to having the anti-inflammatory benefits of the topical steroid, the oil kind of moisturizes things and keeps it nice and supple. For what is not really otitis externa but probably eczema, this can calm things down and keep people from sticking things in their ears in the first place.
Watto: Fluocinolone oil — I didn't even know that existed. I've had some success with triamcinolone ointment as well. I think it's a similar thing. When patients put it in their ears, it probably melts down a little bit and drips in there.
We heard so many great tips on this podcast, so if you want to hear the full episode, click on Common Ear Complaints With Dr Angela Peng.
