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THE EXTERNAL ACOUSTIC MEATUS 297
DIAGNOSIS. Diagnosis is in most cases easily made by otoscopic examina-
tion, the mass or plug having a brown or yellowish colour but sometimes
it is black or greyish when mixed with desquamated epithelium. The drum-
head may be partially or totally obscured from view.
PROGNOSIS. Provided that no other cause of deafness exists in the middle
or inner ear, removal of wax should restore hearing to its previous level.
Prior to treatment patients should be asked about any previous ear disease,
and the possible presence of a perforated drumhead, or one which has
healed with a thin scar, should be kept in mind so that a warning may be
given of a possible reactivation of otitis media. In such situations it may be
decided that the wax should be removed by suitable instruments rather than
by syringeing of the ear.
TREATMENT. Wax is removed either by instrumental manipulation or by
syringeing. The former method should be reserved for special situations and
performed only by an otologist. Syringeing is advised for most cases and
may be carried out by trained personnel after the presence of wax has been
confirmed. Soft wax is easily removed by a stream of lotion directed along
the posterosuperior meatal wall. Where the wax completely occludes the
meatus, a passage for the fluid may be made by elevating the wax from the
meatal wall with the flat end of a Jobson Home probe. During syringeing
the ear should be inspected at intervals so that syringeing is not continued
after all the wax has been removed.
Hard impacted wax requires preliminary softening by the instillation of
wax solvent drops, such as sodium bicarbonate ear drops B.P.C., which
are instilled, slightly warmed, twice daily for a few days before syringeing.
Further use of drops and repeated syringeing may be necessary before com-
plete removal of wax is achieved. Very occasionally wax may resist softening
and repeated syringeing, and will require removal by instrumentation under
Syringeing, though causing discomfort, should never produce actual pain
and if such occurs syringeing should cease and the ear must be inspected.
Severe lancinating pain occurs if the drumhead is ruptured and this may
be accompanied by intense vertigo while the returning fluid is tinged with
blood. The syringeing lotion should be at body temperature. If too hot or
too cold a caloric response may be induced from the labyrinth and vertigo
experienced by the patient. After completion of the procedure the meatus
should be carefully dried and the hearing tested. Any small excoriation of
the meatal skin can be treated by the insertion of a ribbon gauze wick,
impregnated with a bland antiseptic ointment, into the meatus for 48 hours.
In this condition the meatus on one or both sides becomes blocked in its
deep portion by a mass consisting of wax, desquamated epithelium and
cholesterol. The exact cause of the formation of these hard accumulations
has not been determined but hyperaemia of the meatal skin and instability
of the epidermis are possible factors. In young adults the disease has been
found in association with bronchiectasis and with a chronic sinusitis. The
mass is closely attached to the meatal walls and pressure effects cause ab-
sorption of bone and widening of the meatus. In severe cases the facial