FUNGAL INFECTION OF THE EAR ( OTOMYCOSIS)

Otomycosis or fungal infection can cause severe discomfort like itching, discharge and pain and can be chronic in some patients. Common in hot and humid climate,  or can be due to  prolonged  use or misuse of topical antibiotics ( ear drops), over use of buds, wick or any thing for cleaning the ear or for scratching , moisture in the ear, frequent swimming in dirty or stagnant water. Diabetes, and immunocompromised patients  and those who have  various allergies, eczema  or any injury to the canal are  also affected and various problems arise in them, if not treated properly. 

WHAT ARE THE SYMPTOMS ( complaints) 

Severe itching of the ear, greyish, green, yellow or black debris and discharge in the ear canal, pain and swelling or edema of the canal. 

Sometimes it will be a manifestation of fungal infection elsewhere in the body. Fungal elements can be seen inside the ear canal. 

TREATMENT

REMOVE the fungal ball or debris, clean the ear for  any discharge, use topical antifungals and symptomatic measures for edema( swelling) and pain. 

WHEN IT TURNS  INTO A SERIOUS CONDITION? 

Patients who have UNCONTROLLED DIABETES, IMMUNOCOMPROMISED STATES, it can  involve other soft tissues like cartilage and bone causing( destruction) necrosis and osteomyelitis( malignant otitis externa, will explain it later) 

WHY IT IS RECURRENT ( come often ) OR  NOT GOING? 

Inadequate or incomplete treatment ( sometimes  follow up is not there when patient feels symptomatically better), Moisture Retention, over use of various materials for scratching or cleaning  the ear, swimming or water sports where water is contaminated or stagnant. Also in low or impaired immunity, allergic conditions like allergic rhinitis, asthma( itching  of ears, eyes, nose will prompt the patient to use something to scratch the ear) 

ADEQUATE PENETRATION OF ANTIFUNGAL  INTO THE EAR CANAL SKIN is needed for complete cure and to prevent chronicity, for that CLEANING  the ear  ( not self cleaning) and removing all the discharge and debris is a must. 

PREVENTION

AVOID water entry into the ear( especially for immunocompromised or those with low immunity) during showering, swimming, surfing

AVOID  frequent self cleaning of the ear

AVOID Scratching the ear with wick  or other materials

AVOID Instilling EAR DROPS for each and every case of ear block and ear pain, with out knowing what is inside your ear causing those symptoms. 

PLEASE TAKE  PROPER  TREATMENT 

AND   COMPLETE THE COURSE, DON'T MISS FOLLOW UP, OR ELSE WILL END UP WITH RECURRENT OR CHRONIC INFECTION. 

PLEASE TAKE  CARE OF YOUR  EARS 👂

WHY DO MY EARS ITCH ?

Every one must have experienced itching of the ears once in your life. Itching can be due to various causes. We ( ENT) have seen persons in our OPD, who had scratched their ears( due to itching) with buds, pencil or pen tip, feather, finger nails and ended up injuring the canal skin or even injuring ear drum. 

HERE ARE SOME OF THE CAUSES FOR ITCHING

WEATHER     Dry weather  causes dryness of the skin of outer ear canal. 

WAX   Hard or impacted wax, can cause itching, which will be aggravated, especially if soap or shampoo enters the ear while bathing

INFECTION   After a bout of cold or upper respiratory infections, in swimmer's ear and in otitis externa, inflammation and infection of ear canal   causes discharge, which  gets dried up leading to severe itching. Another is fungal infection ( otomycosis). 

ALLERGIC CONDITIONS    associated with Allergic Rhinitis, Contact Dermatitis due to use of  certain soap, shampoo, topical medicine( ear drops) , hearing aid( rashes) .

Allergy to certain foods, like shell fish, nuts, gluten. 

Certain Skin conditions like psoriasis, seborrhoeic  dermatitis ( dandruff) can cause itching of the ears. 

TREATMENT DEPENDS ON THE CAUSE, DON'T  INJURE THE EAR BY SCRATCHING. IT CAN  LEAD ON TO SEVERE INFECTION  ( Uncontrolled Diabetes, or those with allergy history) 

TINNITUS.... Why My Ears Are Ringing And Should I Worry?

Tinnitus is a sensation of noises in the ear   like ringing, blowing, whistling. Severity of this condition varies from trivial to completely disabling. The way patient reacts depends on the personality trait .Some  learn to live with it, but in others ,it may lead to emotional distress, sleep disturbance, concentration problem and cognitive functioning impairment. 

Tinnitus can be Subjective (  perceived by the patient only) and Objective. It is usually associated with certain ear conditions be it, external  ear canal, middle ear or inner ear like hearing loss due to ageing, noise induced hearing loss. 

Hormonal changes during pregnancy, menopause, thyroid  disorders can cause tinnitus. Certain medicines can  also be the cause. Anxiety, depression, familial inheritance also may manifest as tinnitus. 

Other causes are due to TMJ ( joint between upper and lower jaw), myoclonus of ear muscles (tensor tympani) Eustachian tube dysfunction. 

Pulsatile tinnitus ( sound like heart beat or pulse) can be due to arteriovenous malformation or certain  vascular tumours. 

WHEN YOU SHOULD WORRY? 

When tinnitus is associated with one sided hearing loss, imbalance or vertigo ,facial weakness, or pulsatile tinnitus, sudden onset of hearing loss ,one need to seek immediate medical help. Ear conditions like  otosclerosis, meniers disease, sudden SNHL( hearing loss), can cause tinnitus.

 ( wax which is a common condition can also cause tinnitus ) 

TREATMENT

Ancient times it was treated as Bewitched ear. 

Detailed history, and examination needed and treatment  done according to the CAUSE. 

Tinnitus maskers, hearing aids, sound therapy, cognitive behavioral therapy  are some of the treatment  modalities. 

COUNSELLING, and REASSURANCE  is also IMPORTANT. 

OTITIS EXTERNA ... A Cause for Earache

OTITIS EXTERNA (OE ) is a condition characterised by inflammation   and sometimes infection of the  skin of external ear canal. It causes oedema ( swelling) and erythema ( redness) of the ear canal. 

Various causes or conditions can  lead on to OE. Ear canal may be Narrow ( hereditary), or after injury or surgery, or swelling. 

Can be due to Skin problems like allergy and seborrhoeic dermatitis

Sometimes in Allergic conditions like atopy, or allergy to ear drops or any medication

Traumatic  - following swimming or bathing, water entry leading to  probing ear with buds, pin. 

Infection of the middle ear by bacterial or fungal  causes, resulting in discharge  which  affects the external canal. 

Humidity, those with decreased immunity like in  Diabetes are prone to this condition and can lead on to severe infection of cartilage and soft tissues especially in uncontrolled Diabetes. 

WHAT ARE THE FEATURES ? 

Swelling (edema), itching, ear fullness, when scratched, will lead on to injury to the skin, discharge ,edema and  if not treated can lead on to narrowing of the ear canal. Water ( contaminated) and moisture can cause bacterial  and fungal infection. 

TREATMENT & PREVENTION

Treat according to the cause

Clean the ear( not by self) 

Topical and oral medication , analgesics

Diabetes if not under control can lead on to a involvement of cartilage and other soft tissues and  cause Malignant OE which will be explained in detail later. 

DON'T SCRATCH YOUR EAR WITH NAILS, BUDS, PIN .DON'T USE EAR DROPS FOR EVERY EAR ACHE. 

Most of my patient's had OE after using ear wick and hair pin, some had infection after swimming, few cases following instillation of drops for wax, where wax was not there, few following hair treatment (chemicals accidentally entered the ear). 

POSITIONAL VERTIGO... an unpleasant condition

Vertigo ( feeling of rotation) due to head movements, often affects a person's  day to day life. It affects both young and old age group. 

Positional vertigo ( BPPV)  , patient presents with vertigo lasting seconds, with or without nausea and imbalance on lying down, sitting up from lying down position, rolling in the bed, extending(looking up) or flexing  (looking down)the neck. It can happen several times a day. 

It is due to migration of calcium carbonate crystals from organ of balance to another, resulting in stimulation of certain structures followed by vertigo and nystagmus( eyeball movement) 

Can occur in advanced age as idiopathic (without any cause ) or due to other associated conditions. After excluding other causes of vertigo, diagnosis of BPPV is made. 

Detailed history and position test done to find out which organ and side is involved. Corrective procedure  (which varies according to the canal involved and presence of neck problems) can be done to put the crystals back to where it came from. 

Medicines  are used to suppress the symptoms. 

This post  is dedicated to my 69 year old( I should say young)  patient who had severe vertigo and been taking medicine for some time. Initially she was very apprehensive, when I explained to her about position test and canal lith reposition procedure. After reassurance corrective procedure was done, and she started doing that at home. Now she is feeling better  . This procedure can be done easily in the OPD itself. 

LOOSING YOUR BALANCE? FIND OUT WHY

Some of us must have experienced imbalance or unsteadiness. It may present as, vertigo ( feeling of rotation), dizziness, vomiting, nausea, motion sickness, unsteadiness, rapid eyeball movement. 

Detailed history of the problems, patient is facing, has to be noted, along with provocating factors like sound, visual stimuli, movement. 

Whether problem started suddenly, or gradually or presence of associated symptoms( problem) like ringing sensation in the ear, hearing loss, ear fullness as in Meniers Disease ,  displacement of calcium carbonate crystals to  one part of the inner ear to another as in BPPV , after an infection as in  labyrinthitis or vestibular neuronitis  ,vesicles ( varicella  and herpes Zoster lesions) in the ear canal, double vision, numbness of the face, swallowing and speech problem, fits, loss of consciousness,  head ache or blindness. Vestibular  migraine  another cause for vertigo .Above  mentioned symptoms points towards any involvement of ear and higher centres (brain) 

Other causes for  giddiness are hormonal problems, hypoglycemia ( low sugar levels), heart problems, hypotension( low blood pressure) anaemia, anxiety, phobia, panic attacks to name a few. 

Hope you got some idea of balance problems. 

SWIMMERS EAR ...What you should know

Some of you must have experienced this problem once in your life. If you have any history of diabetes or allergy, then it will be troublesome. 

Swimmers ear is actually an inflammation (body reaction) and then infection of external ear canal after swimming( water and moisture helps inflammation.) 

Patient may give history of swimming. Ear canal will be edematous(swollen), with pain, itching, earblock. On  scratching ,the canal skin will be injured, ulceration and secondary bacterial infection sets in. This causes  ear discharge ,which can be colorless, yellow or greenish.  Once it involves,the  perichondrium and cartilage It becomes serious  .It  can also  lead on to narrowing of the ear canal, perchondritis ,if not treated promptly. 

Treatment depends on severity ,associated comorbidities. Need ear cleaning, topical and or oral medication. 

Those who are prone, should keep a Vaseline smeared cotton plug while taking shower, or use ear moulds while swimming. Sometimes AVOIDANCE is the best prevention, in prone patients. 

BLUE EAR DRUM......After recurrent cold or upper respiratory infection

Tympanic membrane( ear drum) appears blue, instead of its normal colour due to various causes. 

HEMOTYMPANUM is a condition where blood collects behind the  ear drum due to fracture or head injury or any blood disorders. 

Other common cases   are due to  1)INFECTION ( rhinosinusitis, ie affecting nose and sinuses) 

2) NASAL ALLERGY  which lead on to Eustachian tube block( which connects nose and ear) 

3) EUSTACHIAN TUBE BLOCK ( in children due to adenoiditis or other lesions) 

4) BAROTRAUMA

The features of fluid in the middle ear( behind tympanic membrane) are ear fullness, hearing loss, ringing sound, and sometimes imbalance. Ear drum appears dull, retracted and fluid may be there sometimes and it appears blue. 

Treated  by certain manoeuvres ,medically, and if it's a chronic problem causing hearing loss, has to be treated surgically. 

EPISTAXIS( NOSE BLEED) IN ELDERLY

Nose bleeding in an elderly patient can be due to various causes, some times it can occur without any reason too. A slight male preponderance seen with in  an age group of 60's.

Bleeding can be minor or major, some times from anterior ( front) and posterior ( back) of the nose. 

Weather( autumn and winter) cases are more. Uses of analgesics( NSAID) like aspirin can lead to nose bleed, along with alcohol ,bleeding will be more. High blood pressure has been noticed during bleeding in some cases. 

DNS( deviation of nasal septum )with spur  is another cause. Nose picking also can be a factor. Secondary causes can be liver disorder, blood disorders, sinusitis, angiomas, abnormalities of artery and veins, certain other noncancerous and cancerous tumours. 

When bleeding occurs don't panic, if it is mild oozing from the front part of the nose, pinch your nose for sometime( few seconds)  If it's not stopping, visit a doctor immediately .MAJOR BLEEDING warrants IMMEDIATE  HOSPITAL  VISIT. Patient can go in for shock or can aspirate the blood. 

Don't forcefully blow the nose, inform the doctor the amount of blood lost, in terms of tissues or towels used, duration of bleeding, any precipitating factor. Always inform  the doctor, what all medicines you are taking. History of heart  ailment should be informed. 

Frequently asked question, what should I do? swallow the blood or spit it out? 

ALWAYS SPIT THE BLOOD OUT, DON'T SWALLOW IT, AS IT CAN CAUSE IRRITATION OF STOMACH AND VOMITING. 

POSTERIOR BLEEDING MORE SERIOUS ( as source of bleeding may not be visible). 

When to Suspect SINONASAL MALIGNANCY(CANCER)

Sinonasal( nose and sinus) malignancy or cancer can occur even though they are rare. Maxillary sinus ( sinus behind the cheek) are more commonly involved. Age groups between 45 and 85  are affected mainly. 

Males are of increased risk,  occupational exposure to wood dust, textile, leather, nickel, smoking, HPV( a viral infection) are some of the risk factors. Tumour can easily spread to the orbit ( eye) as  it is closer to the nose and sinuses. 

Tumours of the NASAL CAVITY causes unilateral congestion or blockage of the nose which is progressive. Can cause bleeding through the nose or blood stained discharge. Later nose shape will be distorted or deformed. 

SINUS cancers  manifests only after bone destruction or involvement. MAXILLARY sinus present as facial pain , bleeding from nose ,tearing from the eyes, difficulty in mouth opening, pain over the face.Tumor may present over the roof of the mouth or bulging, loosening of the teeth, bulging of eyeballs and double vision, cheek swelling in advanced cases. 

ETHMOID sinus cancer  causes unilateral ( single side) nasal block, eye watering, orbital swelling and diplopia( double vision) 

Other sinus involvement are rare. 

Any of the above symptoms symptoms you need to visit an ENT  specialist. 

NOT ALL BLEEDING THRU NOSE ARE CANCEROUS, CAN HAPPEN IN NONCANCEROUS CONDITIONS ALSO. 

Hope I cleared the doubt (who asked me to write) 

Ear block.... due to not so common condition

Whenever ear is blocked, some people start using wax solvents, thinking of wax. There are numerous cases for  ear block, can be due to  external canal  swelling, wax, fungal ball, furuncle, middle ear causes. Keratosis obturans( KO) is one cause. 

KO is characterized by accumulation of large plug of desquamated (shedded) keratin in the ear canal, causing widening of the canal. Two types are there, silent  KO and  other one following a viral infection. 

Some of my patients had involvement of both ears with associated seborrhoeic dermatitis and dandruff ( younger age groups). Another patient  was  in his 60's with diabetes and ear was infected. 

KO presents with ear ache and decreased hearing, sometimes granulations and bone erosion .Some cases, association with sinusitis and lung conditions are documented. 

Keratosis Obturans  need to be diagnosed early and proper treatment should be given to prevent complications. Sometimes there will be associated fungal infection also as shown in the picture (  with patient's  permission) 

Tonsillitis in children

Tonsillitis is a condition where tonsils are congested or swollen, usually after an episode of upper respiratory infections( bacterial or viral) 

Tonsils are composed of lymphoid tissue, which provides both cell mediated and humoral immunity. They produce antibodies, on exposure to a pathogen or allergens. 

Tonsillitis can be acute, chronic or recurrent. Acute, presenting as sudden onset with sore throat, fever and painful swallowing. Tonsils will be enlarged and red in colour. 

Viral tonsillitis  resolve  with analgesics and hydration. Bacterial tonsillitis if not improving within  2 to 3 days, antibiotics has to be started, along with supportive care. 

Sometimes complications like  abscess (pus) may form  and spread to other adjacent areas. This is a serious  condition, pus has to be drained and antibiotics and analgesics to be given. 

Indication for tonsillectomy are recurrent sore throat which prevent normal function, previous history of tonsillar abscess, in obstructive sleep apnea  or ear problems . 

Tonsillitis can be managed medically with supportive care, only certain cases need surgery

Nasal Allergy

Nose is the first portal of entry of airborne allergens. Nasal allergy is characterized by inflammatory changes in the nasal mucosa. It can cause sneezing episode, runny nose, itching of nose, throat and eyes. 

Family history ie  hereditary factor, plays an important role. 

Children with allergic rhinitis if not treated can lead on to asthma, manifested as wheeze or night time cough. 

Airborne allergens are indoor and outdoor. 

Indoor allergens are house dust mite, cockroaches, furry pets, moulds

Outdoor allergens are airborne pollens of grass, weeds, mould  spores. 

Main plant allergens in South India is parthenium and castor plant. 

PREVENTION

No smoking( pregnant and lactating period) 

Breast feeding 

Decrease allergen exposure

Pollen avoidance ( mask, sunglass,) 

Eradicate cockroaches from  houses

Mould allergen avoidance( use dehumidifier in case of excess humidity) 

Change curtains, bedsheets frequently

Reduce carpets, floor mats. 

SEEK HELP IF INTERFERING WITH DAILY ROUTINE