Ear Injection of AM-101 May Stop Tinnitus

Phantom ringing of the ears also known as tinnitus is an extremely frustrating condition that afflicts many people. Often triggered by hearing nerve damage, there's no good treatment to fix this condition once it sets in.

Until possibly now... 

AM-101 made by Auris Medical is an experimental drug containing esketamine hydrochloride embedded within a hyaluronic acid gel formulation. It works by blocking the NMDA receptors of the cochlear inner hair cell.

Normally, when there is trauma sustained by the cochlea whether it be loud noise or viral infection, excess amount of a neurotransmitter called glutamate gets release. The problem is that too much glutamate also triggers hearing nerve death due to over-excitation via the NMDA receptor. When these hearing nerves die, it leaves the brain cells responsible for hearing in a permanently switch-on state leading to tinnitus, even if there's no sound present.

AM-101 is hypothesized to block the NMDA receptor from being over-stimulated by the glutamate neurotransmitter thereby preventing hearing nerve death.

But, does it work?

According to one small prospective, double-blind, randomized, placebo-controlled study involving 248 patients, it DOES work to a significant degree.  42% reported their tinnitus was half as quiet as before compared with 14% in the placebo group. After 90 days, 57% of those taking the active gel said their tinnitus was 'much improved' or 'very much improved'.

Of course, the trick is to administer the drug before nerve death has set in after which it would be too late. In the study, only patients with onset of ringing within 3 months were eligible to participate.

Patient also need to realize that the drug is administered by injection through the eardrum and into the middle ear space. This injection technique is commonly used in the treatment of sudden nerve hearing loss where steroids are injected. Watch video of this injection method below.

Unfortunately, AM-101 is not available except under research protocols currently and is undergoing FDA clinical trials. The preliminary results are very promising however.

Reference:
Efficacy and Safety of AM-101 in the Treatment of Acute Inner Ear Tinnitus—A Double-Blind, Randomized, Placebo-Controlled Phase II Study. Otology & Neurotology: April 2014 - Volume 35 - Issue 4 - p 589-597

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How Ears Tune In and Out Certain Sounds

Ever wonder how humans with normal hearing are able to "hear" what one person is saying in a crowded room where many people are talking? How is it that the ear is able to tune in and out of conversations going around, especially when everybody in a room is talking equally loud?

To understand this ear "tuning" ability, one needs to first understand that the ear incorporates two "aspects" that allow for good hearing: a volume knob and an antenna. Should the volume knob not work, hearing aids boost the frequencies where hearing loss is present. However, if the antenna does not work, simply increasing the volume does not necessarily make sounds/speech more understandable. This situation is analogous to an old radio where turning the volume up on a station with a lot of static does not make sounds more understandable (fiddling with the antenna to get a clear signal is better).

We have a very good understanding the volume knob of the human ear. What we do NOT have a good understanding (nor how to fix) is the antenna.

However, researchers have begun to clarify how the human ear "fiddles" the antenna to make certain sounds more understandable relative to others providing humans the ability to tune into what one person is saying in a loud restaurant.

Apparently, part of the answer is the tectorial membrane found within the cochlea (membrana tectoria in the Gray's illustration below).

Note that this membrane found inside the cochlea rests on the inner and outer hair cells which allow for hearing (the volume knob). When the ear hears a sound, "waves" are created within the cochlea stimulating the hair cells which allow us to hear. Depending on which hair cells are stimulated, a specific sound frequency is heard.

Using mutant mice, MIT researchers have determined that the viscosity of tectorial membrane depends on the size and distribution of tiny pores. This viscosity provides mechanical filtering that helps to sort out specific sounds by influencing the speed and decay of tectorial membrane waves when a sound is heard.

Although the precise way how the tectorial membrane allows for such exquisite frequency selectivity is still not fully understood, this may be the first step towards that comprehension.

Because once we firmly understand how the ear's antenna works, we hopefully can make better hearing aids that not only act as a volume knob, but can also fiddle the antenna as well.

Reference:
Porosity Controls Spread of Excitation in Tectorial Membrane Traveling Waves. Biophysical Journal, Volume 106, Issue 6, 1406-1413, 18 March 2014 doi:10.1016/j.bpj.2014.02.012

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Flushing Ears with Cold Water Can Treat Somatoparaphrenia

Somatoparaphrenia is a condition whereby a person denies that a limb or an entire side of the body belongs to them, even if provided with irrefutable proof. This condition usually is accompanied by left-sided paralysis and anosognosia (denial or lack of awareness) of the paralysis often due to a parietal stroke.

What is interesting is that flushing the left ear with cold water (caloric vestibular stimulation) can temporarily treat/resolve somatoparaphrenia. Specifically, the protocol is flushing into the left ear canal 60cc of cold water (20 degrees Celsius) for one minute. During the stimulation, the patient is laid down and head tilted forward 30 degrees. If properly done, clear horizontal nystagmus with leftward slow phase can be seen for about 3 minutes.

Normally, flushing the ear in this manner is routinely performed as part of balance testing (ENG) to determine whether a person's dizziness is due to an inner ear problem or not.

In any case, how does vestibular stimulation help with somatoparaphrenia? I don't quite understand it myself, but according to one reference:

"vestibular input takes part in building up and updating the representation of egocentric space." [link]

Whatever that means...

References:
Can vestibular caloric stimulation be used to treat apotemnophilia? Med Hypotheses. 2007;69(2):250-2. Epub 2007 Feb 9.

Partial Remission of Hemiplegia and Somatoparaphrenia Through Vestibular Stimulation in a Case of Unilateral Neglect. Cortex Volume 28, Issue 2, June 1992, Pages 203–208

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Acupuncture Helps with Ear Surgery Pain

Researchers at Boston Children's Hospital has found that acupuncture may be effective in diminishing both pain and post-anesthesia agitation in children after ear tube placement determined thru a prospective randomized controlled trial.

Typically, children are placed under general anesthesia in order to have this procedure performed and upon waking, are often tearful and agitated. In this study, acupuncture needles were placed at LI-4 and HT-7 immediately after anesthesia, but prior to ear tube placement.

A blinded assessor than determined that pain and agitation were significantly lower in the acupuncture group compared with controls during the 30 minutes after surgery. Furthermore, the number of patients who required analgesia was considerably lower in the acupuncture group than that in the control group.

Although promising, in order to be fully convinced of the effectiveness of acupuncture, further research by other groups in larger number of kids need to be performed.

BUT... because the risks and side effects are so nominal, it can't hurt to give it a try for those patients and families interested in doing so.

For full disclosure, I personally have no experience in providing acupuncture and I would suggest taking these research findings to a reputable and licensed acupuncturist to get this done in those who are interested.

Reference:
Acupuncture management of pain and emergence agitation in children after bilateral myringotomy and tympanostomy tube insertion. Pediatric Anesthesia. Volume 19, Issue 11, pages 1096–1101, November 2009

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Does Removing the Adenoids Decrease Risk of Ear Infections? Yes...

A recent meta-analysis has determined that risk of recurrent ear infections is significantly reduced if adenoidectomy is performed in combination with ear tube placement as opposed to ear tube placement alone. When stratified by age, removing the adenoids was found particularly helpful in children older than 4 years of age.

Combining results from over 15 studies containing over 71,000 children, the estimated rate of repeat ear tube placement for recurrent ear infections in children who also had adenoidectomy was only 17.2% vs 31.8% for children undergoing ear tubes alone. However this significance faded under the age of 4 years.

Why would adenoid removal influence ear infections?

First a little anatomy lesson...

In the back of the nose, there is an opening called the eustachian tube that goes up into the ear. That's why one is able to pop the ears when blowing into a pinched nose.

Image by Chittka and Brockmann from Wikipedia

The adenoids are located in the back of the nose immediately behind the eustachian tube opening. The adenoids can potentially lead to ear problems via two mechanisms. First, the adenoids could be very enlarged causing physical obstruction of the eustachian tube which can make it impossible to pop the ears. Second, the adenoids could be a reservoir of germs which can lead to ear infections given proximity to the eustachian tube.

As such, removal of the adenoids would allow the eustachian tube to function better as well as eliminate a potential reservoir of infection.

However, recommendation for adenoid removal typically occurs if a child requires a 2nd set of tubes which usually occurs around age 4. Adenoidectomy may be recommended with the initial set of ear tubes (after taking into consideration age) if other symptoms are present including nasal obstruction and a snotty nose.


Reference:
Adenoidectomy as an Adjuvant to Primary Tympanostomy Tube Placement: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2013 Nov 28. doi: 10.1001/jamaoto.2013.5842. [Epub ahead of print]

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ENT Doctor iPhone App Games

This was bound to happen sooner or later… thanks to @hobsonent who brought this to my attention.

This Nose Doctor iPhone app game basically is to try and remove nasal hair as well as boogers from different characters' noses using different instruments.

Another iPhone app game is Ear Doctor which deals more with ear problems (obviously).

Although these iPhone apps makes a game out of it, do ENT doctors actually professionally remove boogers, earwax, and nasal hair? We do… Regularly… For real… We are indeed professional ear and nose-pickers.

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Ear Tube Placement in Kids WITHOUT Sedation (Starting at 12 Months of Age)

A recent report describes how using a relatively old technology, ear tube placement can now be performed in children starting at 12 months of age with chronic ear infections or hearing loss due to fluid buildup without the need for sedation of any kind nor aggressive restraints (ie papoose). Historically, ear tube placement in the office without sedation is typically performed starting at around 12 years of age using standard local anesthesia techniques. Any younger, a child could not be trusted to stay still during the procedure due to presence of some discomfort.

In any case, a Texan ear group reports how they accomplished this simple procedure at such young ages.

First, the ear canal is cleaned as much as possible of all earwax and debris. The ear canal is than filled with an anesthetic liquid (concoction of lidocaine, epinephrine, and sodium bicarbonate). Over 10 minutes, iontophoresis was than used to induce profound local anesthesia to the ear canal and eardrum. The liquid was than suctioned out and ear tube placement was performed with a reported 90% success rate (78 of 86 ears; 17 subjects were 3 years old or younger; 8 were 12 months old).

The key to success required 3 "new" elements.

• Iontophoresis device made by Acclarent. There are other iontophoresis devices in the market (Medtronic and Otomed), but none adapted for simultaneous bilateral ear canal usage that works within 10 minutes. Iontophoresis works by applying a gentle electric current in order to actively move charged drug molecules into the skin. In this particular case, positively charged lidocaine and epinephrine.
• Optimal anesthetic solution for iontophoresis. Dubbed "EMGIM", it contains 1:12,000 epinephrine with 3.3% lidocaine hydrochloride and 0.7% sodium bicarbonate. The solution is prepared fresh prior to use by combining 10 mL of 4% lidocaine hydrochloride with 1 mL of 1:1,000 epinephrine. After mixing the lidocaine and epinephrine, 1 mL of 8.4% sodium bicarbonate is added.
• Ear tube delivery device and placement system. Typically, a competent ENT can place an ear tube in about 10-20 seconds. However, when dealing with kids who may potentially move unexpectedly and operating within a very small ear canal space, a faster and more reliable way of placing a tube was required. Hence, this new device. [link]

Of course, during the actual procedure, age-appropriate distraction was needed to minimize movement, especially given aggressive restraint was not used.

Sounds great as sedation is something to be avoided if at all possible. However, there is one problem... the Acclarent iontophoresis device is NOT yet FDA approved contrary to what the report states (direct communication with Acclarent executives October 1, 2013). Hopefully in 2014. As such, beyond a research setting, this in-office technique is not yet available for use in the United States.

As an aside, there are FDA-approved iontophoresis devices for use in pediatric head and neck surgical procedures mainly for sub-cutaneous mass excisions and abscess incision and drainage. Check out Phoresor for such applications using lidocaine infused electrodes. It's even sold on Amazon.


References:
Otologic Iontophoresis: A No-Papoose Technique. Annals of Otology. Rhinology & Laryngology 122(8):487-491. Aug 2013.

In-Office Tympanostomy Tube Placement Under Local Anesthesia Using a Novel Tube Delivery Device. Triological Meeting Poster. Dec 2012.

Iontophoresis: a needle-free, electrical system of local anesthesia delivery for pediatric surgical office procedures. J Pediatr Surg. 1999 Jun;34(6):946-9.

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Swimming Pools, Poop, and Ear Infections

So here's an interesting statistic... The average person has 0.14 grams of feces on their rear end. If a person does not shower prior to swimming, that 0.14 grams of stool gets washed off into the swimming pool. Kids tend to have a bit more stool on their rear end (up to 10 grams). [statistic taken from CDC as reported by NBC News]

That means if 100 individuals enter the swimming pool in any given day without showering beforehand, anywhere from 14 grams to 1 kilogram of stool enter the swimming pool water (0.03 - 2.2 pounds).

Although sunlight, chlorine, and filtration helps clean the water, it takes time (and is why a swimming pool is shut down the rest of the day when an obvious code brown occurs).

The stool issue is worse in lakes and oceans where you can add animals using such bodies of water as a toilet.

It may be one reason among many why swimming leads to increased risk of ear infections. Otitis externa (aka swimmer's ear) if the infection involves the ear canal skin or otitis media when an ear tube or a hole in the eardrum is present. It's also one reason why some ENTs recommend wearing ear plugs.

Now that's all very interesting... but perhaps the biggest question is HOW in the world did the CDC determine how many grams of residual stool on average is present on people's rear ends (kids and adults)??? Anyone know the answer to this? I would love to know the reference... I imagine that perhaps a bunch of GI docs who were performing colonoscopies scraped as much residual feces around people's bungholio prior to the colonoscopy and some poor technician had the unenviable task of weighing the scraped material.

Source:
No. 1 swimming pool problem? It's number two!. NBC News 5/16/13

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Maggots in the Ear After Trip to Peru

Image from Wikipedia

Adventurous international travelers have to worry about malaria and safe drinking water, but for one 27 years old British woman, she also had to contend with a maggot infestation in the ear after a trip to Peru.

It was not quite the 57 maggots found in one Illinois woman, but apparently this traveler recalled walking thru a fly swarm in Peru and that one fly did briefly enter her ear canal. However, it was enough for the fly (New World Screwworm fly) to lay its eggs causing maggots to hatch and slowly eat away her ear canal causing severe pain and scratching sounds within her head.

Surgery was required to remove the maggots. Less aggressive attempts to remove would only cause the maggots to burrow even deeper into her ear/head. Potential damage from the maggots include permanent hearing loss for obvious reasons, but also facial paralysis and taste changes given the facial nerve and chorda tympani (taste nerve) pass through the ear as well.

Fortunately, all maggots were successfully removed without any permanent damage.

Source:

British Woman Discovers Flesh-Eating Maggots Inside Her Ear. Medical Daily 7/16/13.

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New Movie Trailer for Fauquier ENT YouTube

It has been an amazing experience with how successful our videos have been on YouTube. We now have 60+ different videos of ENT procedures that has been viewed over 247 million times since 2007. We also now have over 12,300 subscribers to our video channel.

To celebrate, a movie trailer of sorts has been created to introduce new viewers to the sort of videos they will see and will continue to see from us.

Check it out! And... if you haven't yet subscribed to our video channel, please do so!

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Woman Drinks Beer Through Her Ear

Now I am not sure if this woman is actually drinking beer through her right ear at a Czech beer festival as reported by Huffington Post, but is it anatomically even possible?

Well the answer is that it IS theoretically possible though highly improbable.

In order for this to occur, there must first be a hole in the eardrum. Given an eardrum hole, beer can be sucked up into the ear canal (1), through the hole in the eardrum (2), into the middle ear space (3), through the eustachian tube (4), and down into the throat.

Now why would it be highly unlikely that the women is drinking beer through her ear?

1) The eustachian tube opening is VERY small (< 2mm). Trying to suck beer through the eustachian tube would be even harder than trying to suck beer into the mouth through a coffee stirrer.

2) The video would have been more believable if she pinched her nose up when drinking beer into the ear.  The fact that she is not makes it unlikely adequate negative pressure can build up in the back of the nose to the point that it would suck beer up into the ear. Not pinching the nose is equivalent to trying to drink something up into the mouth WITHOUT making a tight lip seal around the straw.

Even if you could drink beer through the ear, you really shouldn't because...

1) Beer contains alcohol and if this touches the middle ear region which is very sensitive, there would be quite a bit of pain akin to alcohol touching an open skin wound.

2) Alcohol can also potentially lead to permanent hearing loss if drawn into the middle ear. It's the same reason why earwax removal drops specifically caution against using it whenever there's a hole in the eardrum.

3) Beer in the ear could lead to an ear infection.

4) Lastly, if the beer is not at body temperature, it could lead to severe dizziness due to a phenomenon known as caloric vestibular stimulation.

So... don't do it... even if you could!

Source:
Woman Drinks Beer Though Her Ear? Czech Clip Appears To Show Crazy, Dangerous Stunt (VIDEO). Huffington Post 5/14/13

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When Your Child Has a Draining Ear

Guest Blog Post by Dr. Julie Wei, MD, FAAP

One of the most common and simple procedures that Otolaryngologists (ear, nose, and throat specialists) perform is that of putting “tubes” in children’s ears. General and pediatric otolaryngologists alike perform thousands of these simple and quick procedures every year, often several times in a single hour! Most children who need and get “tubes” in their ears are toddlers and those in preschool age. What continues to surprise me is how often parents and caretakers are not explained to clearly about what to do once a child has ear tubes in and then develop a wet or draining ear. Yes, I am talking about yellow, green, white, brown, stinky (the smell can fill up a room!), sticky, nasty stuff that not only runs out your child’s ear canal, but then crusts around their ears and worse, perhaps down their cute cheeks!

I have believed it is critical that every ENT surgeon take the time to explain to parents why and how tubes decrease “ear infection”, which is when there is buildup of pus in the middle ear space, pushing on the eardrum from the “inside”. Every time I recommend ear tubes, I make sure that parents understand the simple “plumbing” logic that is involved once there is a small opening created in the eardrum so that oxygen and air can go from the world into that tiny space behind the eardrum (middle ear space), and of course, when there is “infection” or pus which develops from that space now it can drain out through the tube directly out of the ear canal and be seen by parents. The whole point of tubes is that parents and caretakers can tell when a child actually has an ear “infection”. Instead of pain from pus trapped and pushing on eardrum and fever that results from trapped pus, there should be no pain or fever... just nasty stuff coming out the ear. I realized early in my career that unless I explain in detail how a wet ear should be treated once a tube has been placed and is working, parents go first to an urgent care, or their primary doctor’s office, and then are usually prescribed oral antibiotics (almost always unnecessary as well as ineffective), instead of using antibiotics in the form of ear drops which primary and ENT doctors should prescribe.

You see, the beauty of the ear tubes is that now just as air can go through that tiny 1.2 mm round ‘hole” in your child’s ear drum, so can ear drop which contain antibiotics (and steroid, an important component of ear drop therapy in my experience). The strength of the antibiotics in those few drops from that expensive bottle is likely 300 times stronger than what the human body can safely eat. Since the drops are getting absorbed into our blood stream and system which is what happens when we eat/drink it, it works by simply making contact with the infected surfaces of the middle ear space, the mucosal lining with living cells which produce the pus or mucus in the first place (when it is inflamed by viral and bacterial infection along with the irritation that goes with every infection).

A nasty draining ear is easily treatable – the junk is all removed from the canal, tube is checked to ensure it is still in the eardrum and “working” (hole is open), and then topical ear antibiotic and steroid drops are prescribed. I emphasize the importance of aural toileting, that means taking toilet paper or KleenexTM, twirling it into tiny 1-2 cm “wicks”, and putting that gently into the canal for a few seconds so that the nasty drainage is absorbed onto the tissue. Twirl another area of tissue and repeat, and repeat, until not much nasty wet stuff is coming out. THEN, and ONLY THEN, do they start putting the few ear drops into the ear canal. It is also critical to perform the “tragal pump”, meaning to gently push on the little “nubbin” just in front of the opening of the ear canal to make sure that trapped air bubbles come out and drops make it all the way deep into the canal to where the tube and “hole” is to have a chance to get into the middle ear space where the infection is.

Of course, there may be other problems. Sometimes the child is having this issue because it’s been 2 or 3 years since the tubes were put it, but not one knows if it’s still in the ear drum or has “fallen out”. Often the tube is no longer in the drum, the hole has healed itself, but the tube is “stuck” on the drum or ear canal which is lined by skin. The body gets irritated with this “foreign body” that is stuck there and then angry tissue called granulation tissue forms. This angry reddish mass is full of blood vessels and is most likely cause of blood coming out of any child’s ear if that child has had tubes placed. Thankfully, the treatment is the same. As I tell parents every clinic day, it doesn’t matter what is coming out of the ear canal, using the antibiotic and steroid ear drops is the way to go. The steroid component will calm the anger, reduce inflammation, shrink the angry tissue, stop the drainage and pain associated with this, and then the tube can be removed from the canal in the office most likely.

If families are informed of how tubes work, and techniques for good aural toileting, as well as immediate use of ear drops whenever there is draining ear in a child with tubes, then they can be empowered to stop going to urgent care, their primary physicians, save time from work and school missed, save money on oral antibiotics, and most importantly, spare their child from yet another course of oral antibiotics.

I must mention that while perhaps 95% of draining ears should respond to a solid week of using ear drops containing antibiotics and steroid, currently we do have another cause of persistent draining ears in healthy kids. That is the issue of methicillin-resistant staphylococcus aureus (MRSA) infection, even in the ear. I find that many daycare aged toddlers will show up in the office, after using drops as I have intensely preached, and in these children often the culture will prove they have MRSA as the bacteria causing this problem. Thank goodness MRSA in this setting is almost universally susceptible to a class of antibiotics that are “sulfa” based, like “Bactrim” (trimethoprim/sulfamethoxazole), because we the medical professions have not used this drug much in the past decade or two since we have many “newer” antibiotics, it is actually useful to fight MRSA. If your child’s ears are still draining after a week of the antibiotic and steroid ear drops, you should call the surgeon who put the tubes in, ask to be seen, for a culture to be done of the nasty drainage, and if it is MRSA positive, then the best treatment is to switch to a “sulfa” based drop , 10% sulfacetamide, used 3 times daily for next 7 days, as well as put mupirocin ointment in the child’s nostrils twice a day for 10 days, and finally your child should also be given oral Bactrim for 10 days. The idea is to try to eradicate the MRSA living in their nasopharynx which is connected to the middle ear space through the Eustachian tube – details worthy of a separate blog.

If the MRSA drainage does not clear up, I will make the tough but proactive and effective decision to take those tubes out and let the ear drum heal. Thankfully, these children do not necessarily go back to having a bunch of ear infections or trap fluid causing mild hearing loss. Thanks to time, sunshine, love, and nourishment, little heads and bodies grow and they often do well without the tubes.

Sometimes I joke with parents that I am just a glorified plumber. There is a great deal of truth in that. If the plumbing is blocked, much goes wrong in the house. You would certainly contact the plumber, and as such, do contact your child’s ENT sooner rather than later if a draining ear does not stop, AFTER you’ve done what I have described. May you and all parents out there whose children have tubes save money and time live better lives as promised by your child’s ENT.

By the way, stop plugging your child’s ears from bath and swimming, unless they complain of pain every time water gets in. Ten years of a handful of studies show that children whose ears are plugged from water are no better than those who plug and there is no difference….but everyone is much happier without those plugs. Yes, even if your child is swimming in a lake (again, another blog worthy topic). I am a mother first, and believe that your child deserves more than opinions, but information based on science.

by Dr. Julie Wei, MD, FAAP

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Why Do Culture Results Take So Long? [video]

One of the most common questions I get after obtaining a culture of pus whether from the ear or the nose is how long it takes before the culture results are back... especially when MRSA is a concern.

Does it take a few hours? 24 hours? Days?

Disappointingly, it can take up to 5+ days if not longer.

You want to know why?

Well, rather than explaining, watch a 6-minute video that explains the numerous steps that goes into providing a diagnosis after a culture has been obtained... in this particular case, ear drainage though the same steps apply to any culture obtained from anywhere else in the body.

Special thanks to Robin Earl who spent hours hanging out in the microbiology lab video-taping all the relevant video clips as well as Fauquier Health for allowing this video to be made!

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Negative Ear Pressure Causing Inability to Pop a Clogged Ear

Have you ever closed the lid on an air-tight container containing a left-over hot meal and stuck it in the refrigerator? And than when you try to open the lid the next day once that hot meal cools down, it is REALLY hard to open the lid because of the accumulated negative pressure? In essence, the negative pressure has "locked" the lid down.

Well, something similar can also potentially happen inside the ear with eustachian tube dysfunction, especially with negative pressure (rather than positive pressure).

Eustachian tube dysfunction is a phenomenon whereby a person is unable to pop their ears to relieve symptoms of ear pressure, clogging, or fullness. It is much akin to the ear pressure a person experiences when flying, but at ground level. Traditionally, treatment of this condition involved medications like steroid nasal sprays and prednisone along with active valsalva (watch video below). Once medical treatment has failed, ear tube placement has been the step of last resort.

The question some patients have is WHY does it become so hard to get an ear to pop open with eustachian tube dysfunction...

It may be that the mucosal lining of the eustachian tube has swelled to the point that there is no opening present.

There may also be a physical obstruction blocking the eustachian tube due to large adenoids, nasal polyps, or some other nasal mass.

However, a lesser known phenomenon is due to the negative pressure itself creating a suction effect on the lining of the eustachian tube analagous to the stuck container lid mentioned in the first paragraph. The middle ear negative pressure itself may be literally "sucking" the lining of the eustachian tube closed. If the negative pressure is great enough, it may be very hard to get it open.

When this happens, the eustachian tube becomes "locked".

One can "mimic" this effect even in a healthy individual (not that anybody would want to try). When a swimmer dives deep into the water, some ear pain will start to develop due to the negative pressure building up in the middle ear. If the swimmer does not ear pop and continues to go deeper into the water, at around 3.9 feet, it may start to get very difficult to get the ear to pop open even with effort. At around 5 feet of water depth, it will become impossible to pop the ear open. Normally, swimmers and SCUBA divers continuously ear pop when diving at depth to prevent any ear discomfort.

As such, in situations where negative ear pressure is present and medications fail to resolve the ear clogging, a hole can be surgically made in the eardrum WITHOUT tube placement which will often resolve the symptoms fairly quickly. The hole "releases" the negative pressure to allow the eustachian tube to function normally. The analogy would be that once you release the negative pressure within an air-tight container, it becomes very easy to remove the lid thereafter.

The eardrum hole typically heals closed in a few weeks and the clogged ear sensation will often not come back. If it does, the myringotomy (surgically creating a eardrum hole) can be repeated and if necessary, a tube can be placed to prevent the body from healing the hole closed anytime soon.



Some things that have helped some people to pop their ears:

 

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UFC Boss Dana White Underwent Surgery for Meniere's Disease

Balance is very important in martial arts... So imagine have a condition like Meniere's Disease and being the boss of the Ultimate Fighting Championship organization.

Dana White who is the president of the UFC organization apparently has Meniere's Disease since 2011 causing  symptoms of ringing, ear fullness, fluctuating hearing loss, and spinning attacks that last for hours to days at a time. Usually, one ear is the culprit though it can occur on both sides as well.

Presumably, he already tried conservative measures without improvement and therefore underwent surgery for this condition on January 15, 2013. [link]

What is Meniere's Disease?

It is simplistically hypothesized that Meniere's Disease, also known as endolymphatic hydrops, is due to a fluid overload within the inner ear residing inside the skull (DIFFERENT location from fluid that occurs with ear infections).

When too much fluid accumulates in the inner ear, symptoms of tinnitus, ear fullness, and hearing loss occurs followed by the spinning attack. The spinning vertigo lasts until the fluid overload dissipates.

Treatment

Treatment occurs as follows (there are variations, but these are the steps overall):

Step 1: Diet Changes

Avoid all salt, caffeine, and alcohol. Salt avoidance typically means less than 1000mg of sodium per day. Caffeine avoidance is not just coffee, but also decaffeinated coffee, coke, pepsi, tea, chocolate, etc. Alcohol avoidance is pretty self explanatory.

By avoidance of these substances, it seems to substantially minimize the amount of fluid retention that occurs in the inner preventing fluid overload and the symptoms that go with it.

If symptoms persist with dietary restrictions, than...

Step 2: Diuretic Medications

In addition to dietary avoidance of salt, caffiene, and alcohol, a prescription water pill (diuretic) is added. I typically prescribe maxzide though any diuretic will do. Diuretics force the kidneys to produce more urine to be expelled from the body. If you can believe it, the inner ear also behaves like the kidney and does the same thing preventing fluid overload within the inner ear.

If step 1 and 2 do not work, than...

Step 3: Surgery

Surgical drainage of the inner ear is called endolymphatic shunt decompression (ELS surgery). This operation is what Dana White underwent. Essentially, the mastoid bone located behind the ear is completely removed and once the inner ear structure called the endolymphatic sac is reached, it is opened and a plastic-like tubing (the shunt) is placed. Risks of surgery include permanent hearing loss and facial paralysis.

Essentially, the surgery is trying to physically drain the fluid out of the inner ear rather than medications or diet adjustments which attempts to prevent fluid from building up in the first place.

Step 4: More Surgery

There are other surgical procedures that may be tried beyond step 3, but these are considered destructive procedures and have a high risk of permanent hearing loss (consider it likely to happen) as well as the possibility of making the dizziness worse. In essence, the balance system of the ear is permanently destroyed whether thru injection of a neuro-toxic drug like gentamycin into the ear itself or surgically cutting the balance nerve completely from the brain.

Source:

UFC's White hopes surgery relieves debilitating disease. USA Today 1/14/13

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Pencil Drawings of the Aging Ear, Nose, and Mouth

Came across these beautiful pencil drawings of a collection of 60 ears, noses, and mouths arranged chronologically from ages 16 to 90.

Drawn by Shawn Feeney, you can purchase your own 15" x 9" copy from his website.

Check it out!

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Screwdriver into the Ear of Tennis Star Rafael Nadal

On a more humorous note, take a look at this picture from Sports Illustrated...

As per the caption in SI, it is EXACTLY what it looks like except,

A worker at Madame Tussaud’s puts the finishing touches to a model of Rafael Nadal in London last May. (Kirsty Wigglesworth/AP Photo)

I did want to point out that though a screwdriver inserted into the ear canal may be OK for a wax model, it is not OK for a breathing, living human being.

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Do Ear Candles Actually Remove Earwax? [video]

About once a week, I have a patient who presents to my clinic with a history of ear candling for earwax removal due to clogged ear sensation.

About once a month, I have a patient with ear canal and/or eardrum damage due to using an ear candle in an attempt to remove earwax.

I even have on occasion patients who I thoroughly remove earwax under the microscope, who than go home, perform an ear candle, and inform me of all the "earwax" that I missed.

Well... I've decided to make a video (see below) illustrating how ineffective ear candling is in removing earwax as well as how it could be even harmful. The other aspect of this educational video is to show how misleading ear candling is when it comes to earwax.

Please note that we are aware that the  "official" way to use an ear candling is small end down into the ear, but for this video, we have elected to use it the way most "lay" public would (small end up).

[SPOILER ALERT!!! A burning ear candle actually creates debris that looks like earwax. As such, an ear candle "works" whether it is in the ear or not.]

References:
Ear candles: Efficacy and safety. Laryngoscope 106 (10): 1226–9.

Ear candling: Should general practitioners recommend it? Can Fam Physician 53 (12): 2121–2. PMC 2231549. PMID 18077749.

Ear candles can be purchased on Amazon.com for you to "experiment" with.

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Does WaxVac or EarVac Actually Remove Earwax?

The EarVac or WaxVac is a device that purportedly suctions out earwax. Shaped like a miniature hair dryer, one simply needs to hold it up to your ear canal in order to suction out the earwax. Recently, they have been marketing this device heavily, especially through TV commercials.

Now, does it actually work???

Not really... In fact, British researchers tested it out against the humble ear curette (Jobson-Home Probe). With their test population, the WaxVac worked in exactly ZERO percent of patients. The ear curette worked 100% of the time to restore eardrum visibility and 88% for subjective hearing improvement for the patient.

Why would the WaxVac work so poorly?

Think of a handheld vacuum cleaner. Even for a regular vacuum cleaner, it will only suck up debris only when it is right on top of it. One can't "vacuum" out a bedroom simply by holding the vacuum cleaner at the bedroom door entrance or hovering it around in the bedroom. The vacuum needs to be placed DIRECTLY over debris in order to suction it out.

Well, the same goes for the WaxVac.

Even when the ear canal is professionally vacuumed by an ENT under the microscope, it only works with some earwax types... and doesn't work at all for other earwax types.

I also wanted to point out the danger of using an WaxVac which has the potential to create high negative pressures when sealed up against the ear canal entrance which could lead to eardrum perforation as well as permanent hearing loss (similarly to kissing ear syndrome).

As such, I personally do not recommend this product. However, should you decide to purchase it, I would strongly urge people to do their homework before buying this unproven device. Even if it did work, beware that the company seems to make their money by scamming people with shipping charges [link]. 

Reference:

A non-randomized comparison of earwax removal with a 'do-it-yourself' ear vacuum kit and a Jobson-Horne probe. Clin Otolaryngol. 2005 Aug;30(4):320-3.


Watch how earwax is cleaned at an ENT office video.

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57 Maggots Removed from Woman's Ear

92 years old woman with Alzheimer's was found to have 57 maggots in her ear sparking a lawsuit. Read more from media reports.

Beyond the gross factor and questions regarding how this was allowed to happen, this story does bring up some interesting teaching points and the medicinal properties of "maggot therapy".

Media reported the patient suffered from earwax build-up and had "an enlarged ear canal from surgery performed decades earlier."

This  surgery was most likely a canal-wall-down tympanomastoidectomy often performed for a benign ear tumor called cholesteatoma or a severe chronic draining ear. This surgery essentially removes all the bone from behind the ear (mastoid) and ear canal back wall. Depending on how aggressive the surgery, the eardrum and middle ear bones (malleus, stapes, and incus) may also be removed.

With such surgery, the ear canal now 2-3 times larger than before, is prone to developing earwax impaction and requires surgical debridement or removal every 4-6 months for the rest of the patient's life.

If surgical debridement is not performed regularly in such patients, infection may set in.

With such infection, ear drops can be used as described in the story, but such treatment is bound to fail until ear canal debridement of all earwax is first performed.

What I suspect is that this poor patient did not get her ear cleaned out regularly resulting in infected earwax. A fly noting the foul cesspool located in a dark, humid environment of this enlarged ear canal probably thought this the perfect place to lay eggs and allow a maggot infestation to occur.

Gross, horrid, and astounding I know...

However, medicinal maggot therapy is actually used in hospitals... Why?

Because maggots are apparently WAY better than a surgeon in certain situations at removing dead infected tissue with or without antibiotics.

It is entirely possible that given time, the maggots might have cleaned and removed the infection that was probably present in this patient's ear. However, unlike medical-grade maggots which are "sterilized" prior to use, "natural"maggots probably harbor other microbes that could cause a secondary infection.

Such medicinal maggots can be purchased for wound control with a prescription. Monarch Labs is the exclusive USA supplier of medicinal maggots which the FDA considers a "medical device."

Here is a video produced by National Geographic on maggot therapy.

Source:
92-year-old has 57 maggots removed from ear, family sues nursing home. CBS News 11/30/12

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