ANATOMY AND PHYSIOLOGY

The external ear, namely, the auricle and the external auditory canal, is composed of skin, cartilage, and all associated appendages. The skin and cartilage of the ear are subject to the same insults as similar tissues found elsewhere in the body. Thus, many of the diseases discussed below may be found in greater detail in other Medicine articles.

The Outer Ear

PARTS OF THE OUTER EAR The outer ear consists of the pinna, or auricle, and the ear canal (external auditory meatus). Pinna the part of the "ear" that we see on each side of our heads is made of cartilage and soft tissue so that it keeps a particular shape but is also flexible. The pinna serves as a collector of sound vibrations around us and guides the vibrations into the ear canal. It helps us decide the direction and source of sound. Its function is to trap sound waves (auricle) and transmit it to the inner ear by passing down the canal and causing the eardrum to vibrate. composed of elastic cartilage covered by a thin layer of skin. The lower part known as the lobule (common name ~ ear lobe) is made up of fibrous tissue, fat and blood vessels.

The external auditory canal is a skin-lined tube that ends at a disk-like structure, which is also lined with skin, the eardrum. The skin of the canal contains highly
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specialized glands that secrete a brown wax-like substance, cerumen (earwax). This material serves as a protection for the skin. Hair follicles and sweat glands are also present.

Ear Ridges The outer margin of the ear is known as the helix and the inner elevated margin is the antihelix. The deepest depression which leads to the ear canal is known as the concha. The tragus is the small cartilaginous flap that can be pushed down to block the opening to the ear canal.
Ear Canal

The ear canal runs from the concha to the ear drum (lateral side of the tympanic membrane) and is known as the external acoustic meatus. It runs inward through the temporal bone of the skull (tympanic part) and is about 2 to 3 centimeters long, The ear canal is an S-shaped tunnel. The outer one-third is made up of cartilage lined with skin that is similar to the skin of the auricle. Sebaceous and ceruminous glands in this outer one-third produces earwax (cerumen). The inner two-thirds are bony and lined with a thinner skin.

Ear Drum

The eardrum (tympanic membrane) divides the external ear from the middle ear. It is a thin membrane that is about 1 centimeter in diameter. The lateral part of the tympanic membrane which faces the ear canal is lined with thin skin that is continuous with the skin of the inner two-thirds of the ear canal.

The best description for the eardrum is that it looks like a satellite dish. It is concave so through the ear canal it looks like the back of a satellite dish, with a central depression known as the umbo.
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The tympanic membrane moves inward and outward in response to vibration, similar to speaker. Due to the auditory ossicles, which are attached to the medial surface of the eardrum, the movement of membrane transmits force to the internal ear where it can be converted into electrical impulses and passed to the brain.

Outer Ear Disorders

Malformations of the ear, include atresia (closure) of the external auditory canal and malformed or missing auricle, cauliflower ear. These malformations may cause hearing loss. BLOCKAGES Earwax (cerumen) may block the ear canal. Even large amounts of earwax often cause no symptoms. Symptoms can range from itching to a loss of hearing. A doctor may remove the earwax by gently flushing out the ear canal with warm water (irrigation). However, if a person has had a perforated eardrum, irrigation is not used because water can enter the middle ear and may cause a middle ear infection. Similarly, irrigation is not used if there is any discharge from the ear, because the discharge may be coming from a perforated eardrum. In these situations, a doctor may remove earwax with an earwax curette, an instrument with a loop at the end, or a vacuum device. Certain solvents help soften earwax, but they usually must be followed by irrigation, because the solvent rarely dissolves all of the earwax. People should not attempt removal at home with cotton swabs, bobby pins, pencils, or any other implements. Such attempts usually just pack the earwax in more and can damage the eardrum. Soap and water on a washcloth provide adequate external ear hygiene. Other blockages can occur when people, particularly children, put foreign objects, such as beads, erasers, and beans, into the ear canal. Usually, a doctor removes such objects with a blunt hook or small vacuum device. Sometimes metal and glass beads can be flushed out by irrigation, but water causes some objects, such as beans, to swell, complicating removal. Objects that are deep in the canal are more difficult to remove because of the risk of injury to the eardrum. A general anesthetic is used when a child does not cooperate or when removal is particularly difficult. Insects, particularly cockroaches, may also block the ear canal. To kill the insect, a doctor fills the canal with mineral oil or thickened lidocaine, a numbing agent. This measure also provides immediate pain relief and enables the doctor to remove the insect.

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EXTERNAL OTITIS External otitis is infection of the ear canal. External otitis is caused by bacteria or, rarely, fungi. Typical symptoms are itching, pain, and discharge. A doctor looks in the ear with an otoscope (a device for viewing the canal and eardrum) for redness, swelling, and pus. Drops may help prevent swimmer's ear. Debris removal, ear drops, and pain relievers are the most common forms of treatment. External otitis may affect the entire canal, as in generalized external otitis, or just one small area, as in a boil (furuncle) or pimple. o Causes A variety of bacteria or, rarely, fungi can cause generalized external otitis. Certain people, including those who have allergies, psoriasis, eczema, or scalp dermatitis, are particularly prone to external otitis. Injuring the ear canal while cleaning it or getting water or irritants such as hair spray or hair dye in the canal often leads to external otitis. External otitis is particularly common after swimming, in which case it is sometimes called swimmer's ear. Earplugs and hearing aids make external otitis more likely, particularly if these devices are not properly cleaned. o Symptoms and Diagnosis Symptoms of generalized external otitis are itching and pain. Sometimes an unpleasantsmelling white or yellow discharge drains from the ear. The ear canal may have no swelling or slight swelling, or, in severe cases, it may be swollen completely closed. If the ear canal swells or fills with pus and debris, hearing is impaired. Usually, the canal is tender and hurts if the external ear (pinna) is pulled or if pressure is placed on the fold of skin in front of the ear canal (tragus). To a doctor looking into the ear canal through an otoscope, the skin of the canal appears red and swollen and may be littered with pus and debris. o Prevention and Treatment Swimmer's ear may be prevented by putting drops of a solution containing half rubbing alcohol and half vinegar in the ear before and after swimming. Attempting to clean the canal with cotton swabs interrupts the normal, self-cleaning mechanism and can push debris toward the eardrum, where it accumulates. Also, these actions may cause minor damage that predisposes to external otitis.

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To treat generalized external otitis from any cause, a doctor first removes the infected debris from the canal with suction or dry cotton wipes. After the ear canal is cleared, hearing often returns to normal. Usually, a person is given ear drops containing vinegar and drops containing a corticosteroid such as hydrocortisone to use several times a day for up to a week. Vinegar is helpful because bacteria do not grow as well once the normal acidity of the ear canal is restored. With moderate or severe infection, antibiotic drops also are prescribed. If the ear canal is very swollen, a doctor inserts a small wick in the canal to allow the drops to penetrate. Analgesics or codeine may help reduce pain for the first 24 to 48 hours, until the inflammation begins to subside. An infection that has spread beyond the ear canal may be treated with an antibiotic given by mouth.

MALIGNANT EXTERNAL OTITS Malignant external otitis is infection of the external ear that has spread to involve the skull bone containing part of the ear canal, the middle ear, and the inner ear (temporal bone). Malignant external otitis occurs mainly in people with weakened immune systems and in older people with diabetes. Infection of the external ear, usually caused by the bacteria Pseudomonas, spreads into the temporal bone, causing severe, life-threatening infection. o Symptoms People have severe earache, a foul-smelling discharge from the ear, and usually decreased hearing. o Diagnosis The diagnosis is based on computed tomography (CT) scan results. Often doctors need to take a small piece of tissue from the ear canal to make sure that the symptoms are not the result of cancer. o Treatment Malignant external otitis is treated with a 6-week course of antibiotics given by vein.

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INJURY A number of different injuries can affect the outer ear. A blunt blow to the external ear can cause bruising between the cartilage and the layer of connective tissue around it (perichondrium). When blood collects in this area, the external ear becomes swollen and purple. The collected blood (hematoma) can cut off the blood supply to the cartilage, allowing that portion of the cartilage to die, leading in time to a deformed ear. This deformity, called a cauliflower ear, is common among wrestlers, boxers, and rugby players. A doctor cuts open the hematoma and removes the blood with suction. After the hematoma is empty, the doctor applies a compression dressing, which is left on for 3 to 7 days to keep the hematoma from coming back. The dressing keeps the skin and perichondrium in their normal positions, allowing blood to reach the cartilage again. If a cut (laceration) goes all the way through the ear, the area is cleaned thoroughly, the skin is sewn back together, and a dressing is applied to protect the area and allow the cartilage to heal. The cartilage is not sewn. A forceful blow to the jaw may fracture the bones surrounding the ear canal and distort the canal's shape, often narrowing it. The shape can be corrected surgically. Note: If injury to the tympanic membrane is suspected, irrigation should not be performed. EARLOBE PIERCING Women and particularly young girls often have their earlobes pierced so that they can wear earrings without fear of losing them. However, piercing of the ears is contraindicated in persons having diabetes, skin disease,or keloids. When ear piercing is permissible, it is suggested that a physician perform the procedure. A large (18-gauge) straight needle with a sterilized and flexible and gold wire is inserted into the bevel and then inside the needle. After a little local anesthesia is applied, the needle is inserted through the back of the earlobe, then withdrawn, leaving the wire in the ear. The wire is tied loosely in placeserving as a type of primitive earringand is removd 10 days to 2 weeks later. During this time, the area is cleansed daily with soap and water or alcohol,followed by a mild antiseptic ointment, and the wire is removed from time to time to ensure patency of the opening in the earlobe. Hair should be kept away from the lobes; hair and perfume spray,bleach or dye should be avoided for 3 weeks.Swimming also should be avoided until the ears have healed.

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Some difficulties have been experienced with all types of earpiercing procedures, among them,premature closure of the puncture,hemorrhage into the earlobe, secondary infection, and keloid formation. Many individuals develop contact dermatitis and are sensitive to alloy metals. For this reason, it is recommended that only 14K gold posts be worn. Any early sign of pain,redness, swelling or tightness should be reported to the physician. PEROCHONDRITIS Perichondritis is infection of the tissue surrounding the cartilage of the earlobe (pinna), ear canal, or both. o Causes Injury, burns, insect bites, ear piercing, or a boil on the ear may cause perichondritis. The infection also tends to occur in people whose immune system is weakened and in people who have diabetes. o Symptoms The first symptoms are redness, pain, and swelling of the earlobe. The person may have a fever. Pus accumulates between the cartilage and the layer of connective tissue around it (perichondrium). Sometimes the pus cuts off the blood supply to the cartilage, destroying it and leading eventually to a deformed ear. Although destructive and long-lasting, perichondritis tends to cause only mild discomfort.

o Treatment A doctor makes an incision to drain the pus, allowing blood to reach the cartilage again. Antibiotics are given by mouth for milder infections and by vein for severe infections. The choice of antibiotic depends on how severe the infection is and which bacteria are causing it.

TUMORS Tumors of the ear may be noncancerous (benign) or cancerous (malignant). Most ear tumors are found when people see them or when a doctor looks in the ear because people notice their hearing seems decreased. Noncancerous tumors may develop in the ear canal, blocking it and causing hearing loss and a buildup of earwax. Such tumors include small sacs filled with skin secretions (sebaceous cysts), osteomas (bone tumors), and growths of excess scar tissue after an injury (keloids). The most effective treatment is surgical removal of the tumor. After treatment, hearing usually returns to normal.
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Basal cell and squamous cell cancers are common skin cancers that often develop on the external ear after repeated and prolonged exposure to the sun. When these cancers first appear, they can be successfully treated by removing them surgically or by applying radiation therapy. More advanced cancers may require surgical removal of a larger area of the external ear. Ceruminoma (cancer of the cells that produce earwax) develops in the outer third of the ear canal and can spread. Ceruminomas have nothing to do with earwax buildup. Treatment consists of removing the cancer and the surrounding tissue surgically.

PROLAPSED CANAL Associated with the ageing process, is a breakdown or sag of tissue around the canal. It causes the wall of the canal to collapse.

CANAL STENOSIS Narrowing of the external canal may develop as a result of trauma to the skin. The skin becomes inflamed and this is what causes the narrowing.The trauma may be caused by external laceration, chronic self-manipulation or chronic otitis externa. There are usually no symptoms unless there is an accumulation of wax and debris causing conductive hearing loss.In some cases the canal may be reduced to a tiny pinhole behind which keratin may be trapped. In some cases surgery may be required. - Can also be found as a consequence of otitis externa. Inflammation from the infection has also caused a narrowing of the ear canal. Can also happen where the cartilage of the ear canal has broken down and this causes the canal to collapse or even close. This commonly happens as we get older and is due to deterioration of the cartilage fibre due to ageing.

PERFORATIONS(Trauma to the Tymapanic Membrane) Ruptures are holes in the eardrum. They are caused by infection, a foreign object, a bone fracture, a nearby explosion, or a blow on the ear with the palm of the hand. Small holes often heal in a few weeks. Larger perforations require a surgical technique, tympanoplasty or myringoplasty to patch the hole.
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Management-most accidental perforations of the drum membrane heal spontaneously. Some persist because of the growth of scar tissue over the edges of the perforation, thus preventing extension of the epithelial areas across the margins and final healing. o In suspected traumatic perforations, warn the patient against irrigating the ear.cleanse the outer ear carefully with sterile cotton but leave the ear canal alone until an otologist can aspirate blood and inspect the drum for evidence of perforation. o If the patient has sustained a head injury, he is kept under observation to detect any evidence of cerebrospinal otorrhea, such as clear watery drainage. Such fluid can be checked in the laboratory to determine whether its source is the cerebrospinal canal. Myringoplasty- is a plastic surgical procedure designed to close perforations of the tympanic membrane. The operation has a dual purpose: 1. To create a closed middle ear cavity by graft over the perforation and 2.to improve hearing. The most important advantage of the closed tympanic membrane is the avoidance of the risk of contamination of the middle ear during bathing,swimming or diving.The reactivation of a chronic otitis media and/or mastoiditis thus may be prevented. Contraindications: Medical or surgical closure of perforations of the drum in the presence of an active infection usually is contraindicated. In chronic disease of the middle ear with malfunction of the Eustachian tube, and therefore inadequate drainage from the middle ear(the only avenues for egress odf discharges),surgery is contraindicated.Involvement of the nasopharynx because of chronic infections discharge from sinusitis or allergy, plus a history of acute exacerbations of otitis media, is an obvious contraindication. ECZEMA or DERMATITIS Makes the external ear itchy and painful. The skin of the external auditory canal becomes red and swollen. This condition will not cause a hearing loss unless the swelling blocks the canal.

Fungal Ear Infection (Otomycosis)

The typical presentation is with inflammation, pruritus, scaling and severe discomfort. The mycosis results in superficial epithelial exfoliation, masses of debris containing hyphae and suppuration.4 Pruritus is more marked than with other forms of ear infections and discharge is often a marked feature. The initial presentation is similar to bacterial otitis externa but otomycosis is characterised by many long, white, filamentous hyphae growing from the skin surface. Suspicion of fungal infection may arise only when the condition fails to respond to antibiotics. Even if bacteria have been grown, there may be more than one aetiological agent. It is also possible that topical antibiotics have predisposed to the fungal infection. 9|Page

Treatment Otomycosis is a chronic recurring mycosis. The ear canal should be cleared of debris and discharge as this lowers the pH and reduces the activity of aminoglycoside ear drops (see separate article Otitis Externa and Painful, Discharging Ears). Suction can be used if available. Cleaning may be required several times a week. Analgesia is required. If there is an irritant or allergen it must be removed. Keep the ear dry and avoid scratching it with cotton wool buds. Avoid cotton wool plugs in the ear unless discharge is so profuse that it is required for cosmetic reasons. If used, keep them loose and change often. Burrow's solution or 5% aluminum acetate solution should be used to reduce the swelling and remove the debris. An aqueous solution of 1% thymol in metacresyl acetate, or iodochlorhydroxyquin should be considered if drying the ear does not work satisfactorily. Antifungal ear drops are of value. There is no consensus on treatment but evidence supports the use of topical ketoconazole. Clotrimazole and econazole drops are very effective but may be needed for 1 to 3 weeks. Clioquinol is both antibacterial and antifungal and may be used as ear drops with hydrocortisone in the formulation of Locorten-Vioform. Cleaning of the ear can represent a problem in the presence of a perforated eardrum and a specialist may need to be involved.

BULLOUS MYRINGITIS Bullous myringitis is a painful condition characterized by middle ear inflammation and oozing blisters on the eardrum. It typically arises as a secondary complication of a bacterial or viral infection. A person who has bullous myringitis is likely to experience radiating pain and some degree of hearing loss over the course of about two days as a blister develops. It is important to seek medical care at an emergency room or otolaryngologist's office at the first signs of ear pain to receive the appropriate treatment. The eardrum, or tympanic membrane, forms a barrier between the middle and outer ear. It helps to relay sound waves to the brain and prevent foreign particles from irritating the middle ear. When a bacterium or virus pervades the eardrum, it causes an inflammatory response that leads to swelling, itching, and burning sensations in the ear. The most common causes of bullous myringitis are the bacteria Mycoplasma pneumoniae, Streptococcus pneumoniae, and Staphylococcus aureus, though several other bacteria and viruses can potentially cause ear infections. Bullous myringitis occurs when middle ear inflammation leads to the development of a small pus-filled blister on the tympanic membrane. As a blister grows, an individual is likely to experience constant, sharp pain that disrupts hearing. The sore may ooze yellow or white pus that drains from the ear. Painful sensations and drainage typically persist for the life of a blister, usually one to two days. The infection responsible for bullous myringitis may continue to cause symptoms after the ear pain sto 10 | P a g e

Treatment Treatment for bullous myringitis usually includes a course of anti-inflammatory drugs and antibiotics. A patient may also be prescribed ear drops that help to cleanse the eardrum and soothe painful burning. In most cases, symptoms are quickly relieved with medical treatment. Since ear infections can be contagious, patients are generally instructed to wash their hands frequently and avoid close contact with others until symptoms resolve. Surgery is rarely needed to treat an ear infection, but a simple operation may be required if the eardrum tears. A surgeon can perform a procedure called a myringoplasty to mend a perforated eardrum and remove dirt, bacteria, and other irritating agents from deep within the ear. The procedure has a high success rate, and most patients start feeling better within about a week.

EXOSTOSIS Exostosis is a benign bony outgrowth. It can occur anywhere in the body, and may be caused by a number of different things, ranging from environmental stresses to genetics. When someone develops an exostosis, the outgrowth may become painful or aesthetically displeasing, in which case surgery is a treatment option. In other cases, the growth may be allowed to remain, with a doctor keeping an eye on it to identify any early signs of complications which may emerge. One common reason for exostoses to occur is environmental stress. A classic example known as surfer's ear happens when bone grows into the ear canal, apparently in response to frequent flooding with cold water. The patient starts to experience difficulty hearing and may have pain in the ears caused by the bony growth. A surgeon can remove the bone to restore hearing and patient comfort. Another form, buccal exostosis, involves the jawbone, with the lower jaw being more prone than the upper jaw. o Causes Damage to joints can also cause exostosis. In this case, strain on the joint results in the development of a small deposit of bone on or near the joint. A closely related condition, osteocartilaginous exostosis, involves a growth of bone and cartilage. This condition is also known as osteochondroma, and it tends to appear at the ends of the long bones. This benign bone tumor may be left in place or removed, depending on whether or not it interferes with the patient's quality of life. ` Exostosis can also occur spontaneously, with no clear environmental cause. Some patients have a form known as hereditary multiple exostosis (HME), in which exostoses occur randomly across the body due to an inherited condition. In a family with a history of this condition, people may monitor children as they develop so that they can detect signs of bony growths early.

DIAGNOSTIC EXAMS

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OTOSCOPY How the Test Is Performed -The health care provider may dim the lights in the room. -A young child will be asked to lie on his or her back with the head turned to the side, or the child's head may rest against an adult's chest. -Older children and adults may sit with the head tilted toward the shoulder opposite the ear being examined. -The health care provider will gently pull up, back, or forward on the ear to straighten the ear canal. Then, -the tip of the otoscope will be placed gently into your ear. A light beam shines through the otoscope into the ear canal. The health care provider will carefully move the scope in different directions to see the inside of the ear and eardrum. Sometimes, this view may be blocked by earwax. -The otoscope may have a plastic bulb on it, which delivers a tiny puff of air into the outer ear canal when pressed. This is done to see how the eardrum moves. Decreased movement can mean that there is fluid in the middle ear.

How to Prepare for the Test No preparation is needed for this test. How the Test Will Feel If there is an ear infection, there may be some discomfort or pain. The health care provider will stop the test if the pain gets worse. Why the Test Is Performed An ear exam may be done if you have an earache, ear infection,hearing loss, or other ear symptoms. Examining the ear also helps the health care provider see if treatment for a certain ear problem is working.

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Normal Results Everyone's ear canal differs in size, shape, and color. Normally, the canal is skin-colored and has small hairs. Yellowish-brown earwax may be present. The eardrum is a light-gray color or a shiny pearly-white. Light should reflect off the eardrum surface.

What Abnormal Results Mean Ear infections are a common problem, especially with small children. Middle ear infections may be present if the light reflex is dull or absent. The eardrum may be red and bulging. Amber liquid or bubbles behind the eardrum are often seen if fluids collect in the middle ear. An external ear infection may be present if the ear canal is red, tender, swollen, painful when wiggling or pulling on the outer ear, or if the canal is filled with yellowish-green pus. Additional conditions under which the test may be performed:

Cholesteatoma External ear infection - chronic Ruptured or perforated eardrum Risks If the instrument used to look inside the ear is not cleaned properly, an infection can be spread from one ear to the other. Considerations Not all ear problems can be detected by looking through an otoscope. Additional ear and hearing tests may be needed. Otoscopes sold for at-home use are lower quality than the ones used at the doctor's office. Parents may not be able to recognize some of the subtle signs of an ear problem. If there are symptoms of severe ear pain, hearing loss, dizziness, fever, ringing in the ears, or ear discharge or bleeding, see a health care provider. Pneumatic otoscope An instrument called a pneumatic otoscope is often the only specialized tool that a doctor needs to make a diagnosis of an ear infection. This instrument enables the doctor to look in the ear and judge how much fluid may be behind the eardrum. With the pneumatic otoscope, the doctor gently puffs air against the eardrum. Normally, this puff of air would

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cause the eardrum to move. If the middle ear is filled with fluid, your doctor will observe little to no movement of the eardrum. Additional tests Your doctor may perform other diagnostic tests if there is any doubt about a diagnosis, if the condition hasn't responded to previous treatments, or if there are other persistent or serious problems.

Tympanometry. This test measures the movement of the eardrum. The device, which seals off the ear canal, adjusts air pressure in the canal, thereby causing the eardrum to move. The device quantifies how well the eardrum moves and provides an indirect measure of pressure within the middle ear. Acoustic reflectometry. This test measures how much sound emitted from a device is reflected back from the eardrum an indirect measure of fluids in the middle ear. Normally, the eardrum absorbs most of the sound. However, the more pressure there is from fluid in the middle ear, the more sound the eardrum will reflect. Tympanocentesis. Rarely, a doctor may use a tiny tube that pierces the eardrum to drain fluid from the middle ear a procedure called tympanocentesis. Tests to determine the infectious agent in the fluid may be beneficial if an infection hasn't responded well to previous treatments.

Other tests. If your child has had persistent ear infections or persistent fluid buildup in the middle ear, your doctor may refer you to a hearing specialist (audiologist), speech therapist or developmental therapist for tests of hearing, speech skills, language comprehension or developmental abilities.

What a diagnosis means

Acute otitis media. The diagnosis of "ear infection" is generally shorthand for acute otitis media. Your doctor likely makes this diagnosis if he or she observes signs of fluid in the middle ear, if there are signs or symptoms of an infection, and if the onset of symptoms was relatively sudden.
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Otitis media with effusion. If the diagnosis is otitis media with effusion, the doctor has found evidence of fluid in the middle ear, but there are presently no signs or symptoms of infection.

Chronic suppurative otitis media. If the doctor makes a diagnosis of chronic suppurative otitis media, he or she has found that a persistent ear infection has resulted in tearing or perforation of the eardrum.

NOTE: Research at many universities shows that exposure to noise of 90 decibels or more can cause the skin to flush, the stomach muscles to constrict, and tempers to be short. Among those who take an important part in the diagnosis of auditory disorders are otologist, otolaryngologist, audiologist. OTOLOGIST-is a physician who specializes in the diagnosis and treatment of problems of the ear. OTOLARYNGOLOGIST- is a physician who specializes in problems relating to the ear,nose and throat. AUDIOLOGIST- is a person who specializes in nonmedical evaluation and rehabilitation of hearing disorders; educational preparation usually includes an M.A or Ph.D. degree. The signs of significant ear disease which require referral to an otolaryngologist have been identified by the National Hearing Aid Society (NHAS). 1. Visible congenital or traumatic deformity of the ear. 2. Active drainage from the ear within the previous 90 days. 3. Sudden or rapidly progressive hearing loss. 4. Acute or chronic dizziness or tinnitus. 5. Unilateral hearing loss of sudden or recent onset. 6. Significant air-borne gap(which can be recognized only from hearing tests). 7. Visible evidence of cerumen accumulation or a foreign body in the ear canal. 8. Pain or discomfort in the ear.

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