The Curbsiders (00:00.302)
You know, Paul, I was milking a cow and a fly flew into its ear. So I thought that was weird. And I just kept milking. A little while later, Paul, the fly showed up in the milk bucket.

Mm -hmm. So I guess that's why they say, Paul, in one year, out the other. That's not bad. Yeah, it's not bad. The Curbsiders podcast is for entertainment, education, and information purposes only, and the topics discussed should not be used solely to diagnose, treat, cure, or prevent any diseases or conditions. Furthermore, the views and statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity aside from possibly cash -like moral hospital and affiliate outreach programs. If indeed there are any, in fact, there are none. Pretty much we are responsible if you screw up. You should always do your own homework and let us know when we're...

Welcome back to the Curbsiders. I'm Dr. Matthew Franquato here with my great friend and America's primary care physician, Dr. Paul Nelson Williams. Paul, tonight we're going to talk about common ear complaints in primary care with a great guest, Dr. Angela Pang. How are you doing? Are you excited for this show? Which we've already recorded. I really excited for this show. Yes, I am.

retroactively excited for this episode that we've already recorded just because we were talking a lot. We all just ear pain all day long. So it's nice to have a little bit more of a firm framework and feel more comfortable knowing that I'm actually going after the right thing. So I thought this was actually terrific episode. Yeah. So Paul, before you introduce our co -host, I want to tell people what is it that we do on the Curbsiders? Sure. Happy to as per usual, Matt, we are the internal medicine podcast. We use

expert interviews to bring you clinical pearls and practice changing knowledge. And as you mentioned, we have a very special co -host with us. We are joined by the effervescent and amazing primary care wizard and pimple popper of the year physician assistant, Isabelle Valdez, Curbsider Super Producer, irrigator extraordinaire. Isabelle, how are you? I'm doing great. I'm really excited about this. I can't wait to get back to clinic and just clean out ears now properly without Q -tips. I can't imagine you're using Q -tips before. Never.

The Curbsiders (02:08.366)
No. Yeah, no, but tonight we had a fantastic conversation with our guest, Dr. Angela Peng. She's an assistant professor at Baylor College of Medicine in the Department of Otolaryngology, and her practice focuses on the E in ENT, where she's having completed a lateral skull -based neuroontology fellowship at the University of Minnesota. Medical education is one of her main career passions, and just as her mentors had inspired her to pursue this pathway,

She aspires to do the same for the future of medicine where she teaches residents and other learners and us tonight. She is excited and honored to be making her debut with us here at the podcast and be part of the Curbsiders. And we got some great pearls from her. One of my favorites is like, I feel like we got a lot of DIY, like DIY cleansers, DIY sinus rinses. You can use ophthalmic medications for the ear. Just more on that. So.

Without further ado, I think we should go. We should get started. And I did want to remind the audience that this and most episodes are available for CME credit through VCU health at curbsiders .vcuhealth .org. And wanted to take a quick opportunity to thank all of our patrons on Patreon. Paul, a lot of patrons now having fun on the discord there. Any lot of good music recommendations lately from you?

Anything to say? A lot of music chit -chat, a lot of running cases past each other, sort of what would you do in this specific circumstance? And while clearly we cannot provide formal medical advice, like it's just, it's a nice open space to have conversations about stuff we run into in primary care. So it's been, yeah, it's been one of the best parts of actually starting the Patreon. Yeah. And so thank you to everyone who's joined. And if you haven't joined, please check it out. It's been a lot of fun. We do bonus episodes twice a month. We answer listener questions on those episodes and also just kind of...

in real time on the Discord. So check that out. And now let's get to the interview with Dr. Angela Pang.

The Curbsiders (04:13.77)
Angela, thank you so much for joining us. The audience has heard your bio already, but they would love to hear hobbies or interests outside of medicine that were what you're enjoying these days. I really love tennis, but one of my passions is actually cooking. I know US Open is out, so we could always talk about tennis, but I love eating, so therefore I love cooking and all different types of food.

I was born in Taiwan and my mom's a great cook. And when I left for college at Rice, I didn't know how to cook the stuff that she had cooked for me. And so I had to learn somehow, I had to survive in order to enjoy the foods I love. So yeah, cooking is one of my favorite things to do. And I'm trying to get my kids to do it too. Paul, this is becoming a theme. A lot of our guests recently are talking about cooking. Yeah, which I love. So I will ask, in terms of...

Continuing education, do you have a recent favorite cookbook or is this all just kind of self -taught stuff? Oh gosh, I love top chef too. I mean, love cooking shows, competition cooking shows. I think they always inspire me to want to cook and go out there and cook something strange, but I can't guarantee my family will eat it, but I mean, it's just at least something cool. Obviously things like sea urchin is very hard to get in my regular grocery store, but.

You know, I just, yeah, I just enjoy their creativity in making food taste so good. I think I could probably give up cable if it wasn't for the cooking channel. Like that's the one thing it's like the one it's like the mafia. It's the one thing that kind of drags me back in. Like I just don't know if I can get rid of that. Yeah, I'm picking up what you're putting down. I agree. Paul, I was, I was listening back to another recent episode. We were talking about.

Bush de Noel, which is something I never heard of before. We had like a 10 minute conversation about carrot cake and some other fancy desserts people were making. So it's great. My point is Paul, we're putting on a great medical podcast. Isabel, anything you wanted to ask about before we get on with to the cases? Well, Angela, you and I, I know that it might come up that you teach residents and I teach PA students. So.

The Curbsiders (06:33.358)
What is one of your favorite pearls that you like to share with your students, be it like about life or HAA residents, your trainees, like your favorite pearl that you like, like your parting words, take these words and wisdom, your words of wisdom that you like to share with them so that I could tell my students something new. Well, I, this may not be completely new, but I always tell my students and residents treat others as you would treat yourself and with respect because,

You know, everybody that you teach and you encounter in your daily life and at work or outside of work, but particularly at work, they could be your future colleagues. They could be your partners. They're going to be people who you're going to be consulting or they are going to be consulting you. And so giving that impression, being respectful of your colleagues, your future colleagues is just as important as.

being respectful of the colleagues that you encounter daily currently. So yeah, my students are going to be either going to be treating me one day or they're going to be teaching others one day and we're going to be collaborating our cases. So yeah, that's one thing that I always tell my students and residents to make sure to treat everybody with respect. Yeah, that's why I think that goes along with the lines where they say doctors who have been patients are always better doctors because...

You know, you've been in that reverse role where you have that feeling of helplessness and you're relying on someone else to give you a lot of information and take care of you, I think. It's hard to do. It's very easy to get jaded. It's hard to put yourself in that mindset of the patient. Absolutely. Well, this is a big topic. This is a great primary care topic. The stuff that you see, if you're doing a clinic all day, at least one person is going to complain about their ear.

So, uh, Isabel, why don't we go to a case from CashLac? Yeah, let's get started. So we're going to start with an inner ear case with Maurice. He is a 54 year old male with hypertension and sleep apnea. And he came to clinic with left ear discomfort since he flew back from his beach vacation about 10 days ago. And he wants you, uh, he wants you to see if he has an ear infection or another ruptured eardrum. He hopes that you can give him antibiotics and steroids because that always clears it up right away. So that's.

The Curbsiders (09:00.014)
kind of makes me cringe when they start with, I just need my antibiotics and I'm out of here. So, so help Good thing they didn't actually end the office on the phone call and asking you to prescribe them antibiotics over the phone. The MA probably told them to come in actually. Yeah, that's good. So, so yeah, so first of all, I think I could still use some some tips and tricks on how to do an exam. So could you share with us how you would approach the physical exam and

What are some of the common issues that you see your trainees do that you're like, no, no, no, you're doing this wrong? To have this approach that actually makes it a better exam and just to share some ideas. Oh, sure. I think one of the main things is to get comfortable when you're examining the patient. And so, for example, I'm a little bit on the shorter side. And so patients who are shorter or taller, they have to make sure their ear is at your eye level.

you're not bending over, it's all about ergonomics as well. But in terms of the actual exam, it's important to kind of pull the ear back just gently. And when you insert the speculum, just don't shove it in. Actually, I want you to look at your inside your ear spectrum as you're actually going into the ear canal. Some people's ear canals are very curvy, or they kind of may kind of extend more, be torturous and go superially or posteriorly. So when you insert it in,

straight on, you can bump it into your ear canal and they're just going to jump back right away and somebody who has an ear infection potentially, they're just not going to let you look in that ear again, you know, or they don't want you to touch that ear again. So that's actually one of the main things that I usually tell my students to make sure you do is look as you get into the ear canal. And of course, you know, look at the the ear canal and the quality of the ear canal. Is there redness? Is there fluid?

Is there bone that's exposed in that area? And looking at the ear drum, is there an ear drum even there? Or is there, how big is the hole? Do you see any hearing bones? And so the ossicles are typically located in the back superior quadrant. And so you can look, that's where you kind of can look for the presence of the ossicles there. And then also look at the status of the middle ear.

The Curbsiders (11:20.526)
Is there a fluid in the middle ear? Is there a mucus? Is there a growth? Is there a big red pulsating mask inside the ear? It could be something like a glomus or something like that. Or cholestia thoma. So yeah, those are the things to kind of look out for. But as I tell my residents and students and even my residents sometimes, it's only in their PGY three years after three years of training when they actually start feeling comfortable looking at ears.

It's because they do it over and over again. And you have to see the normal. Just don't look at people with ear complaints, but actually look at everybody with any other complaint and look at normal ears so that when you actually look at an abnormal ear, actually you can recognize it's like, oh, this is not what I usually would see and go from there. One of those lines, I like I think I was always trained to go to the unaffected ear first. So if someone comes in with a unilateral hearing concern.

Go to the ear that's not bothering them first just to have an idea of what their normal looks like so you have some sort of basis for comparison too. Absolutely. A lot of patients have called me out, it's like, that's not my problem here. I'm like, no, no, no, I always want to get a baseline and see what your good year looks like first. Absolutely. Can I ask a follow up about the fluid? So when I'm looking at the tympanic membrane, oftentimes I'll see a clear tympanic membrane and I can see the bones.

And but it looks like maybe there's some clear fluid there, but I'm not I'm not seeing like an air fluid necessarily, but it just looks like it's a little plump and there's some clear fluid behind it. How do you like, what do you look for that's telling you that it's an abnormal fluid that shouldn't be there? I don't I don't think I remember this from like years and years ago when I was learning this for the first time.

So color is a big thing for me. And then also the light reflex is somewhat helpful, although you can still get light reflex even if there's fluid inside the middle ear, especially if it's a very bright otoscope. I am lucky because as a practicing neurotologist, I usually have a microscope in my clinic room. So I get to cheat a little bit and get to see and...

The Curbsiders (13:29.07)
have like 10x mag in order to really see the eardrum. So, you know, that's the little caveat there in my exam. But normally, you would kind of look for color. And so even if it's dull, but it looks clear, one of the things that would be concerning is CSF fluid could present actually as clear fluid and it can be dull at the same time. So that's also.

the cancer concern exam, but then you have to look at patient's history, etc. But in terms of, I think the color is like the first and foremost thing I kind of look for is, is it more, you know, serious, which is yellow, kind of straw colored? Or is it kind of red, kind of more bulgy kind of looking thing? Or, or is it just like a pus on the eardrum and there's, you know, nothing behind it?

Gosh, it's so hard to see it when some people who have a lot of infections before, their eardrums are so scarred and they have just kind of that thickened eardrum and it's kind of white, opaque kind of look. So then, and you're like, gosh, what am I seeing? And sometimes you just can't see because it's calcification plaques on the eardrum and you just can't see through it. So long story short, I think that's the easiest way of looking at the eardrum.

That's one thing I'm confident I see a lot of the time. I was saying this before you had joined that when I'm looking at the eardrum, sometimes it's just the clear normal and you get the light reflects and everything. And other times you see scattered opacities and I'm just like, is that? I think that's just scarring probably from prior things, but you know, I never know. I'm assuming it's not like candida on the eardrum in most situations.

No fuzzy, no white fuzzy things, yes. Okay, well that's very helpful. Is there any resource you point your learners to, like a picture, like a resource that has good pictures of the eardrum other than just like an up -to -date or something like that? I do, yes, up -to -date is great. I actually collect my own photos, so I use that too from, you know, previous patient exams I actually save.

The Curbsiders (15:48.59)
and that's my library to kind of go through it. I don't have, unfortunately, a particular kind of library that I can direct it at YouTube, but I think some of the internet ones with good reputable clinics, they have great pictures sometimes. Yeah. Okay. Thank you. And Angela, critical question here. Yes. When you hold the otoscope, where's the handle? Because I feel like I've seen students taught in a way that is like, they're just like, they're in contortions because they're supposed to be protecting you. So is the handle...

Six o 'clock, are we at three o 'clock, are we, I favor actually 12 o 'clock. So what's your personal technique just to validate me or make me feel ashamed? So for the right ear, for somebody's right ear, you should be holding the otoscope with your right hand. Okay? So your hand should be resting on the cheek and you're holding your otoscope, your handle of your otoscope, probably grabbing it like this, but using your pinky to kind of hold this. So when the patient moves, you move with them.

Same thing. So it's going to some people who are not left, left -handers and they're right, righties. It's better actually to switch the handle to your left hand and then, um, and look in the left ear with a left hand as well. And then use the other hand to grab and kind of stabilize the head and ear at the same time. That's very helpful. Thank you. Sure. Paul, have we satisfied your physical exam? Uh, you know, the physical exam nerd inside of you.

Sure, yeah, we can skip insufflation for now, I guess. Well, I don't know, can we? How practical is that for... It wasn't something I was ever taught. That bulb came with the otoscope that I have, but I have to confess that I haven't used it much. So, everybody's ear canal is very different. So, unless you have the proper, the speculum size...

at the pneumatic otoscopy, you can lose air around your smaller speculum and then you don't get a really great exam. So you have to make sure the speculum is snug. Again, getting an audiogram actually is very helpful because they do tympanograms for you. And the tympanograms actually will show you what the eardrum is doing. Is it kind of retracted? Does it move?

The Curbsiders (18:09.614)
But yes, the office exam, the pneumatic otoscopy is helpful, but it can be difficult to do, like Paul said. I have to say, and I know Matt's signing a past physical exam, but if I am in an office where I have a working otoscope that has a light that turns on and specula, it's like the best day of my life. Like the idea of like I should be able to do it's a patient too. Like that's, then I would just immediately ascend into heaven. So I can't imagine having that kind of capacity. Angela, in residency, Paul carried around a

a very nice mini pocket otoscope that was like, it was maybe like a little bit bigger than this thing here that I'm holding. And people would like hunt him down for it because there was no working otoscopes anywhere. And so I much respect to Paul Williams. He's the real deal. That's why he's America's primary care physician for that reason.

And you remembered insufflation bulbs, because I completely forgot about them all. Completely forgot. I'm impressed too. I did a pizza rotation 27 ,000 years ago. All right. Isabelle, I think you need to pull us forward or we're just going to spend our whole time here. Talking about insufflation bulbs. Now we know how to hold the autoscope. So now what's the approach to Maurice with this ear pain since he came back from vacation, because he's concerned about another eardrum rupture. So.

How would you approach a patient with this concern and taper the expectation of like, I want antibiotics now, so. Sure. I think the key thing is they're here to see you for an ear complaint. So you have to do a good examination of the ear. In the ear canal, middle ear, and external ear to make sure there's no lesions. There's nothing out on the outer part of the ear that could be causing the ear pain as well besides potential middle ear pathology.

you know, like even herpetic lesions can occur in the outer ear. And that could actually result in Bell's Palsy. It's called something called Ramsey -Hunt syndrome. And so they're, you know, they, but they present initially with ear pain. So there are different things that you can look at the ear, but then if that examination looks pretty normal, and you're not really suspect of a, you know, otologic etiology, then you kind of go outside of the ear a little bit and.

The Curbsiders (20:27.042)
the surrounding structures like your TMJ, the muscles of mastication. So you have your temporalis muscle up there and your masseter muscle right here. So you can actually, instead of just having TMJ kind of arthritic pain or joint pain, you can actually have myofascia pain. And one of the my...

the dental friends or my friends, he always kind of gripes on me saying, gosh, you guys diagnosed with it. You tell you got the TMJ. Well, like everybody has a TMJ, you know, but it's actually the, you know, my, the pain that's associated with the muscles attached to the TMJ that causes a lot of the pain. And so it's more like myofascia pain. That's really their true diagnosis. And so those are the things that you kind of have to look for.

If everything in the surrounding area looks great, there's no sinus issues, then I look in the throat as well. So some people who have tonsillitis, throat pain, they could actually get referred pain in the ear as well. So even throat cancer, people who have base of tongue cancer, laryngeal cancer, sometimes their initial presenting complaint is actually that unilateral ear pain. And then the ear exam looks great.

So we have to look for other etiologies from, you know, inside out, different entities that could cause it, your pain. Yeah. So that would be like your older patient who history of smoking, uh, heavy alcohol use, that sort of thing. Like you'd be more keyed into that. Could be. of, uh, possibility. And even younger patients, I feel like younger and younger patients, um, are developing, you know, even, you know, throat cancer, basal tongue cancer, you know, head and neck cancers.

Um, that don't meet the usual criteria, but yes. Um, especially if you don't, uh, see any obvious ear problems, you know, for, for, for their, why they're coming to see us, then I would consider looking elsewhere as well. Yeah. Like HPV you're thinking about medical. And you say looking in the throat. I mean, generally if, if I can't figure out what's causing the ear pain, I'm often sending to.

The Curbsiders (22:41.452)
ENT and they're doing the nasolaryngoscopy where they can kind of look in the area. Is that that's what you mean? Because when I try to look at people's throat, if they're like malanpotty three or four, which I think is like the majority of my patients, I'm like maybe seeing the top of their tonsils if I'm lucky. And I'm not confident that I would see, you know, anything bad that's going on back there. Yeah, I absolutely would be happy to help. That's what that's that's our that's what we're here for. Yeah. Okay. And then.

Other things, I mean, I know like the, I mean, I'd be very proud of myself if I figured this out, but like somebody with cardiac or like GI issues from the vagus nerve that's presenting with inner ear pain, is that something that's like, you know, commonly happening, do you think, or is that just sort of like a fun theoretical thing to add anxiety to me when I'm working up ear pain? I think you could put that in the more kind of zebra rare categories.

I just do common things, being more common, I would go through that route. But sometimes I do that my examination, everything is normal. Even the scope, I do imaging after that. And I check to see with a CT neck with contrast to take a peek at exactly what you said, any neck tumors or masses that could be causing referred issues.

Yeah. So basically, to summarize what you said so far, first thing is like you key in on the ear. Is there anything going on with the outer ear, the ear canal, the middle ear that looks like it's causing this? If not, you're looking at sinuses and the throat. The throat might involve us sending them to you to do the nasal laryngoscopy, but if that's not showing anything, then it's going to be potentially CAT scan to look at everything and see if there's anything serious going on. Correct.

Okay. So Isabel, what's next for our patient here? What? Yeah. So actually as we're starting to think about the differential for this patient, like what are, actually how, what are the key questions that you hone in on? So the questions I typically ask, you know, do they have any pain, drainage? How long has this been going on? Is it intermittent? Sometimes they talk about how it just comes and goes, especially if they eat or it comes and goes at certain times of the day or when they open their mouth and.

The Curbsiders (25:09.294)
you think more of TMJ issues, but if they have a history of prior chronic infections, if they have any remote history or recent history of having otologic surgery like ear tubes, I like to go from the inside out model. So again, focusing on the ear stuff, but then looking for other things that could contribute to ear problems like spinal, nasal type of sources. So do they have allergies? I feel like a lot of people here in Houston have.

some sort of allergies. And so they always have some sniffles or some congestion. And then of course, you know, chronic sinus issues as well that could cause some eustachian tube problems and therefore ear problems as well. Other people that you can think about are more probably more prone to this are, you know, people who fly and that there's change in altitudes when they descend, they have problems with flying.

and clearing their ears. And so those people also tend to have more oologic kind of eustachian tube and probably effusion issues. Yeah, I'm glad you mentioned eustachian tube because that's, I feel like I have to like really explain that to patients sometimes. Like I really do think it's an eustachian tube dysfunction. They're like, no, no, no, it's an infection. Like, no, no, no. Believe me, there's this little tube there. I cannot see it, but that's the problem. Well, if you cannot see it, how do you know it's that one? Faith.

So besides that, which I tend to blame, you know, we have with Titus Media. So I know it's less common of an infection with adults, but they can happen. Absolutely. We actually do see it more than people think. You know, people talk about ear tubes in adults. We actually do that quite a bit. You know, I mean, sure, if they tend to be patients who have had ear issues even as a child, but you can develop.

you know, sinusal issues as an adult and cause ear problems too. It seemed like when I was reading just this is all stuff like dusting off cobwebs, but the eustachian tube is more horizontal in kids and then in adults it becomes more, I guess, angled so that maybe it drains better. Is that the idea of why both infections and eustachian tube dysfunction are more common in kids than adults? Correct. Yep. And then they talk about

The Curbsiders (27:33.14)
People have talked about having, you know, when you feed your children, you kind of want them at a sort of an angled position so that any feed don't reflex inside into the ear. Yeah. Yeah. Understood. So I would love to hear how you explain eustachian tube dysfunction to an adult because I'm still not sure that I understand, like that I understand it that well.

that I could explain it to somebody in a coherent way. I often like to use a picture of an ear anatomy. So kind of a cross section of an ear. So we have the ear canal and the eardrum at the end of the tunnel. And behind the eardrum, you have three bones, your hammer, anvil, and your stirrup. And the eardrum vibrates those bones into the nerve of the inner ear, and that sends a signal to the brain. Now, within the space behind the ear, there's actually, it's connected.

to the back of your nose, there's something called eustachian tube. And it's all about plumbing here. So if that plumbing gets plugged up, things get backed up and things can get backed up into the ear if you have a lot of sinus congestion, or if you had a cold, things get in there, that pipe closes off and obstructs, and then you get buildup behind the ear. But when that tube opens up, as it should be, it's a should for most people, it actually drains into the back of the nose.

So I like to use piping as analogy. Everybody knows how pipes work in their house plumbing. So that's what I like to use for a comparison. That's kind of genius. The pipes should be unblocked. This is the thing where when you're up in a plane or you're just going up to high heights where if you're chewing gum or something, it tends to help. That's working on the eustachian tube.

Correct, yep. You're opening the muscles that when you chew and swallow, they're muscles that are attached to the openings of the eustachian tube. And so when you swallow and chew and open, and you know, as you're trying to stretch your mouth and you actually open up those stretches muscles and open up the eustachian tube. Now that we know how to explain it to patients, I mean, how do you identify that? I mean, otitis media, I think we're used to, you look in the ear, you see a red eardrum.

The Curbsiders (29:58.414)
But eustachian tube dysfunction, how do you confidently make that diagnosis? And I guess the next question will be, what do we do about it for primary care? Well, when you look in the eardrum, you tend to see probably a little bit more of pacification because they probably have had an infection in the past because of quote, poor plumbing issues, right? And so having a fluid behind the ears, sometimes that causes a lot of scarring on the eardrum.

And then also you can see that there's some negative pressure that kind of pulls the eardrum in. And sometimes it's so severe that the eardrum is actually plastered on the hearing bones, like Saran Wrap, that's kind of wrapped the structures of the inner ear. And you basically, it's like, I see the eardrum, but it doesn't look like it's in the right position. And it's because it's kind of just adhesed to different structures in the middle ear, or even the promontory, which is the cochlea.

And then once those pockets and things like that form, then you could get other pathologies like Cholestiotoma. But then besides just that examination, then I always ask about, like I said, the sinus issues, allergy problems. And I would start treating them with just Flonase and antihistamine or Fluticathone and some type of antihistamine, nasal steroids. Any of the counter ones are great.

It's not one bed, honestly, better than others. And then if, especially if you can do some allergy testing as well, formal allergy testing, and if they do test positive, they can consider allergy shots. Or even before they start on allergy shots, you can give them antihistamine nasal sprays in addition to steroid nasal sprays. The combination of two works synergistically and actually have been shown to help.

a lot with people with allergies and their sinuses. Oh, that's fantastic. So Azelastine is the antihistamine one that I'm familiar with. I'm not sure if there's another available and then you give it with a fluticasone or another nasal steroid. Correct. Correct. Okay. And of course I have to give a plug on saline irrigations. I love saline irrigations. That's like the cheapest and the best thing out there. My now nine -year -old has been

The Curbsiders (32:24.078)
as does it, he's been doing it for the last three years of his life. He doesn't like it, but it makes a big difference. He even says, mom, I can, I notice a difference when I don't do my irrigations. And so, so it's messy. And to the expression we're talking high volume neti pod. Yes, it's the, it's the squeezer body, squeezer bottle. I like a lot, correct. Yeah, that's great. I have a question though. So I don't like it. It hurts.

is what I get. So I've been using, I've been recommending there's an aerosolized version, just the mist. I heard that it has the same effect. And my follow -up is, I thought I saw this once upon a time in a label in one of those devices. Like if you have sinus pain or ear pain or sinus or ear pressure, you shouldn't use it. So I feel like I make doctors turn in their graves when I say don't use it right now because you have ear pain. But what are your thoughts on that?

It can, because if you irrigate around the eustachian too, some people, especially when you're trying to blow your nose after you irrigate, there's sometimes that reflexes into the ear. So yes, you have to be careful about doing your irrigations. So here are some tricks about using your irrigations. Warm that water that's sailing up in the microwave for like 10 to 15 seconds.

Um, so it becomes room temperature or, um, a little bit more, a little bit lukewarm. Um, no one likes to be waterboarded, uh, that stuff when it's like room temperature, like room temperature, like cold or it's just not pleasant. And so, um, warming it up, I think makes a big difference. Um, and you can actually make your own sailing irrigations. I know it's the, it's an, this is an ear talk, but this is a sinus recipe, but you can use, uh,

a teaspoon of like regular salt, kosher salt or sea salt with a half quarter teaspoon of baking soda and mix it in two cups of water, like distilled water. And you can make a batch of it and anytime you're ready to use it, you can microwave it before you irrigate your sinuses. And Isabel and Angela, I think we have, I think the great Dr. Beth Garbatelli may have made a...

The Curbsiders (34:47.64)
some sort of a graphic that we have from like a previous episode where we talked about sinus. So we, I think it has the formula in there as well. Right. You don't have to link it. Yeah. So, okay. So for eustachian tube dysfunction, is, are patients going to surgery for this? And like, I don't know that I've necessarily seen it, but I'm sure you have. So is that something that we should tell them might be necessary if this like, you know, if we,

go after the sinuses and they're still miserable. If they have failed kind of conservative measures, we can look at doing an ear tube to basically help mentalate the middle ear, prevents the eardrum from retracting further, prevent fluid from building up. Of course, there are some side effects of doing ear tubes because you could potentially get more infections if you don't take care of your ear, getting water into the ear, which then gets through the ear tube and it'll cause more ear pain.

and infections. So there's potential sequelae for going the ear tube route. There's something new that has come up in the last, say, 10 years or so, where we have started doing eustachian tube dilations, where you put a balloon in the eustachian tube to dilate and try to stent that open a little bit. Studies have tried to use stents and other things to try to open up the eustachian tube. But...

It's promising. The balloon dilations are promising, but it's not for everybody. It's for select patients who would benefit from the eustachian tube. That's something that the ENT has to kind of do a pretty thorough evaluation to make sure that that person's a good candidate. So it's not offered to everybody. Yeah. That sounds very specialized. Paul, you do that in your office, right? Sure. Yeah. Yeah. After the installation.

It's just the balloon gets actually, you know, passes right next to the carotid artery. So, yeah, this is always a risk. Yipes. So, office, everything just may not. Yeah, exactly. There you go. So, where, Isabel, where are we going next with this? So, we've talked about eustachian tube dysfunction, anything, any.

The Curbsiders (37:07.79)
points that we need to hit on with otitis media in adults? We started to talk about what could it not be when it's not that. So I think you started to talk about the, I always mispronounce this, the cholestatoma. Cholestatoma. Thank you. So when should we start thinking that could it be that versus a chronic issue of mastoiditis or autosclerosis also is something that I've seen before.

What would lead us go like, okay, it's eustachian tube, fix this, can take symptoms persist? Thoughts on that? So for otosclerosis, you don't see people with infections as much. They kind of develop kind of middle of life and feel like they're starting to get some hearing loss and not necessarily like ear pain, ear infections, those types of symptoms. And then they tend to usually have start with like a conductive hearing loss.

So not too similar to having some fluid in the eardrum, but there's no fluid or anything like that in there. But people who have chronic otitis media and people who have pretty severe eustachian tube dysfunction makes you more predisposed to developing cholestia, thoma and chronic mastoiditis. And so if patients come in to see you and you have tried, you know, all these measures, antibiotics after antibiotics,

and antihistamines and all the nasal regimen and nothing has proven to be any better. So yes, your tube would be probably the next thing to consider with an ENT. And then an exam, if you see basically this pimple, when you squeeze a pimple and you see that white cheesy stuff that comes out of the pimple, keratin debris. And basically that's the kind of same debris that you would see in

and cholestia thoma, we call it keratin pearls. So they have their white skin that is basically cholestia thoma. And then you find it in that usually that top posterior superior quadrant corner around the bone, because that's the weakest part of your eardrum. And we usually see that most often in adults where the cholestia comes from. And then that actually is the tip of the Ivesburg and potentially there's more cholestia thoma.

The Curbsiders (39:34.222)
deeper in the middle ear and in the mastoid. So it doesn't always have to protrude out through the eardrum, but a little bit of debris on top of it actually may be like a red herring for like something else going on. So out of these diagnoses for this patient that we gave you presenting, Maurice, the 54 year old guy, he was on vacation. And I was in my head, I was thinking he was at the beach, so he was probably swimming.

But what is like, when a patient like that comes to you with ear discomfort, on the top of your differential, what do you think we should, because I know we could list like a hundred diagnoses for you, but what do you think are the most common ones that we would probably be seeing in primary care that we should think about? So number one, otitis externa, foreign body, impaction. If they use Q -tips or they try to clean their own ears, they have some retained object inside the ear canal.

otitis media, acute or chronic otitis media. So infectious process to begin with, and then secondarily, then you have the middle ear pathologies with the fluid or tumors of the inner, of the middle ear. And then, and less likely of the inner ear, but it's more so in the middle ear for patients with pain and, you know, questions of, of, of infections.

And then of course we can go back to the TMJ route to look at things that, you know, that could cause ear discomfort and pain or even parotitis. You know, people who have infections of the parotid gland that could also cause pain in the ear because it's so close to each other. Yeah. Okay. And, and Barrow, I know, I know Isabel, you had brought up the possibility of Barrow trauma. I don't know that I've seen that Angela or.

If I'm missing it, who's the patient that makes you think that there might be barotrauma? So people who actually say it was summertime and they jumped into the pool and their ear lands in the water just the wrong way, that actually could cause barotrauma. And they have ear pain after that. So it could be barotrauma. If they go diving, scuba diving, that could cause barotrauma. Or if they're flying and they had a URI,

The Curbsiders (41:57.806)
Um, and they're very congested. They incidentally may have had just a little bit of serious fluid in that middle ear. And then that descent from the airplane could cause, um, some trauma. Okay. Very helpful. So I know we, we were going to try to move on, um, to an outer ear case in a minute, but Isabel, what else, anything else you wanted to get to in this topic before we go forward? We're going to have to cure our patient too, but. Oh, well, how do I cure him?

I mean, how? Because this is the point where I was thinking, do we use the steroids? We've talked about already a fluticasone nasal steroids and whatnot. Let's say he does have otitis. He's a patient with chronic otitis and he's in an acute or chronic issue. What, I mean, do I do drops, which I never have for something like this, or maybe I should? What, I guess, oral antibiotics, what's the approach that I should start with there? So for patients with otitis media,

you know, topical drops are not as effective. If their eardrum is really erythematous and irritated, sometimes I do give them dexamethasone drops, necessarily antibiotic drop for symptomatic relief for the edema and swelling of the drum. But most importantly, you know, the appropriate antibiotics, a good coverage to make sure the otitis media is addressed. And then I do also give flutigazone as well. And that helps.

hopefully open up the eustachian tube and antihistamine. For pretty severe patients who have like sinus, nasal issues at the same time as serotitis, I actually give them a course of oral steroids, like a medrodose pack as well to really help decrease inflammation in their sinuses. Hopefully their cough, they probably usually are having a cough at the same time. And then their ear pain as well. Yeah. Antibiotics, is it amoxicillin, amoxicillin clavulonic acid?

The latter, yeah. A macosomal and a copy of exit. Okay. So I guess as you were saying that, I realized like chronic otitis media, does that look different? Like acute otitis media is like the red, you know, red painful eardrum, right? And the other symptoms would be used to a chronic otitis media. What does that present like? Or is that just the person with recurrent or who has acute and just doesn't get better? Yes. The secondary. Yeah. It's just. Okay.

The Curbsiders (44:22.574)
they just cannot clear, it might develop into serous otitis and then they get infected again, it becomes acute on chronic, it really becomes chronic otitis media. Understood. Okay. So, and actually at that point, with that chronicity, that's when we should be already referring them to you, right? Correct. Is there like a criteria, I know that for like, it's out of the scope, like for strep, you have X amount of infections equals tonsillectomy, not that we're going to...

do like an earectomy on these patients, but if we have so many infections, so many otitis medias, at what point should we start sending them to you? Like to a year, to a month, or is there a criteria that we should be following? So the AAO, American Academy of Otolaryngology, actually has a great clinical guidelines, practice guidelines. If you look on their website, they actually have various kind of

ear, not only ear stuff, but ENT, like usual things that we kind of ask questions about, like otitis media, otitis externa. And so they actually have great information for practitioners and even patients. So I would kind of, I would recommend looking at that as well. But I, you know, for me, I would consider patients who are at risk of, you know, severe hearing loss, or people who have

you know, potential for complications from having chronic otitis media, you know, patients who are potentially immunocompromised and, you know, complications of otitis media isn't very mild. You have meningitis, you know, thrombosis of your venous system in the brain. So a lot of intracranial issues because of...

complications of otitis media. So, you know, I wouldn't wait a whole year before you refer them. But yeah, if they are showing signs of having, you know, chronic otitis recurrent infections, it may be time to refer to see an ENT. Probably after the first course of antibiotics didn't work. If I don't like what I'm seeing in there, I'm probably sending them back to you. I'm sending them to you pretty quickly.

The Curbsiders (46:50.382)
Paul, I imagine that's your practice here. Yeah, I just, I will immediately devolve to assuming I don't know what I'm doing and have them see an expert. Yeah, that's exactly right. Let me do a little bit of a recap because we talked about a ton of stuff. So we, because we started this most recent section with the histories, we were asking about like how often they're having symptoms, is there drainage, prior infections, have they had prior surgeries? You talked about approaching things from the inside out. So,

thinking like if we don't, if we didn't see anything obvious with the ear when we're examining it, you know, thinking about sinuses, you asked, you said you also ask about flying and if they're flying frequently, the changes in altitude can cause problems for, for the eustachian tube and the, and the ear with the eustachian tube dysfunction, which was one that I hadn't really heard about. You talk, you talked about explaining it like a tunnel and how you, the treatment that you like to try is sinus.

really sinus treatment initially. So fluticasone, antihistamines, any of the over -the -counter ones, and maybe even doing allergy testing and sending for allergy shots if they seem like there's somebody who has a lot of allergies. You talked about azolastene can be added to fluticasone as like a complementary therapy. That's a topical antihistamine. And then saline irrigation, the high volume, the neti pot or the squeeze bottle.

that and that we're warming it in the microwave for 10 to 15 seconds to make sure it's more comfortable for the patient. But ear tubes or even balloon dilatation, which apparently comes near the carotids, is, might be necessary. You told us barotrauma could be the person that was jumping into a pool and hits their ear wrong. And then we sort of ended talking about with this patient.

which antibiotics we might give and that was the cocktail that we might give for this person with recurrent like chronic otitis media was antibiotics, fluticasone and antihistamines, might even give some oral steroids and I think that was sort of where we were. Then we were saying the guidelines from the AAO are really a nice place to start. Anything I'm missing from that recap?

The Curbsiders (49:16.398)
No, you summed it up perfectly. Probably not perfectly, but I think listening back to these, I feel like it helps because we go through it so fast to just like sort of solidify things and make sure that we understood because sometimes it uncovers that I didn't understand the way I thought I did. No, that's great. So now, Isabel, let's do the outer ear case. So now that we fixed the...

inner ear, let's see if we can help some with an outer ear issue. And this is Lauren. We have Lauren is a 38 -year -old female with diabetes. And she came in a clinic with this left -sided earache and itchiness and some decreased hearing that started, just started yesterday. She denied sinus congestion, cough, sore throat, but she felt a little feverish. And the over -the -counter ear drops that she's been using for pain didn't really help much. She even tried some cotton swabs and there's these really fancy plastic ear wax cleaners.

that she tried to help with her symptoms, but it only made things worse. So with a complaint like this, what is your approach? What are your initial thoughts other than why did she use Q -tips? I have a big Q -tip in my office. It says, do not use. I probably will wield it in the clinic with me and when I see her. Did hit on one of your pet peeves? Oh, maybe.

The Curbsiders (50:43.63)
So, yeah, one of the main things with her presentations I'm worried about is her diabetes and having an infection in the setting of her having diabetes. Hopefully, one of things I would ask her is make sure her diabetes is well controlled or how well controlled it is and what her glucose levels have been, because that helps me determine how severe her infection could be. And obviously, I'm...

One thing that I'm thinking of in the back of my mind is some type of otitis externa. Looking at the ear canal, I would see some kind of swelling and edema and redness and pyrrolence usually associated with this. And one of the things also I kind of have to think in my mind is this is bacterial or fungal. Here in Houston, a very humid environment, we actually tend to have more

fungal infections. So it depends on where you're in the country. Back when I trained in Minnesota, we didn't see as many fungal infections. And versus here in Houston, I see a ton of them. And so those are the things I kind of watch out, you know, come thinking about when I when I when she first presents and I am talking to her. That fungus is something, it's a little tricky sometimes to differentiate.

the fungus from a bacterial, is there something visually that you look for? I've heard the fuzzy stuff. I don't think it's fuzzy, but I call it fungal. So I feel like the bacteria is more that kind of green, purulent, kind of the usual pus that you would think what an infection would look like. But a fungal infection, the skin is actually more friable. If you touch it, it bleeds a little bit more easily. It has that cottage cheesy,

kind of chunky kind of debris look. Sometimes you'll see hyphae, the white, that's the white fuzzy stuff I'm talking about, that's more Canada. But alternatively, you can actually see black debris and you can confuse that sometimes with cerumen, but it's actually aspergillus that's actually causing the, that's the organism causing the infection. And diabetes and aspergillus, unfortunately, is a very bad mix.

The Curbsiders (53:06.382)
Paul, have you seen that? I don't, boy, I hope not. Me too. Unfortunately, we see that quite a bit actually here in Houston. I haven't seen it yet. Now I'm getting nervous. And then those people actually probably come in as an inpatient. So, you know, people who practice in the hospital probably see them or in the ER. They're the ones who, gosh, they're actually in a pretty excruciating pain.

Um, they have pain, not just in the ear canal, but just all in their head. They have headaches, that kind of thing. And so you would also be concerned about, um, you know, besides just otitis externa, is this something called malignant otitis externa or necrotitis, otitis externa, AKA osteomyelitis. So, uh, basically the infection has gotten so severe that it's actually involved the temporal bone. Yeah, that.

I guess, fortunately, I can only remember one case of that that I've seen where the person's whole ear was red and there was red spreading around their face, like around the skin of the ear and they were very tender and we sent them to the hospital. I think it seems like malignant otitis externa, not super common that would just be walking into a primary care office. Those patients more are coming into an ER, like they're sick, they're in severe pain.

You know, the diabetics, as you know, with VCID, they have symptoms, sometimes may not be congruent with the severity of the disease. I have people who come in, like my ear has been draining and they just have a polyp in the ear and some pus that has been there for a long time. That's just been draining for months and months. And then you get a scan and you're like, wow, this is really involved. So people who have

and like now Tycexterna who have like carotid involvement and, you know, all they're complaining about is pain. Sometimes maybe some neurological, like cranial nerve deficits, but sometimes they don't have any symptoms besides pain and drainage. Once again, I will say, yipes. That is, that's scary, Paul. Yeah, I, yes. And I also just tend not to mess around with your stuff. Actually, anything.

The Curbsiders (55:32.27)
head stuff I tend not to do too much with. So I think it makes me even slightly nervous with a background of immunosuppression, neuro -controlled diabetes, that kind of stuff who even looks borderline. It doesn't take much for me to ask for a care because as we've established, I'm a scaredy cat. One of the things I do appreciate when patients do come into my practice is primary care practitioners who culture actually the ear sometimes before they come in. And so...

especially if they tried something like cortisporin drops, you know, even with dexamethasone, something that's affordable for them. And then it actually didn't get any better or it's still, you know, draining or having a lot of pain. You know, they culture the stuff that's inside the ear and you can better direct their therapy rather than trying the therapy again or trying different, you know, and then try another antibiotic. And basically that span of time,

that you haven't tried the antibiotics you could spend on finding out and, you know, elucidating what kind of bacteria organism is causing their symptoms. And that saves a cost, I think, and time for the patient. And sending the culture, that's those long tubes with the long Q -tips. So that's one, at the time it's okay to put a Q -tip in the air to get the culture. That is correct. Only we can do it. If you can see what you're putting inside the ear, then... Sure.

then you can clean your ear. Yeah. Yeah. I like that. That's great. So otitis externa, at least mild cases, I see a lot of that. And I'm never sure quite what's the best starting liquid that I'm going to give them to drop in there. So can you give us some guidance on that? Cranberry is fine. Cranberry. It's good cranberry. For...

patients who have a lot of water exposure, swimmers and such, I do recommend mixing half and half of rubbing alcohol and distilled white vinegar. And you can actually pre -make this concoction and put it in your gym bag or swim bag or whatnot. And after you go swimming, put a couple of drops in the ear to kind of disinfect the ear. You don't need to deluge the ear canal with this solution, but.

The Curbsiders (57:56.622)
just to kind of disinfect a little bit as well. So that's kind of the over -the -counter stuff that you can consider having patients use, especially if they're repeat offenders for ear infections. Otherwise, for yourself, in the clinic, Ophloxacin is very commonly used, but that can be pretty expensive, especially when it's combined with dexamethasone. One of my patients said that even if they had good insurance, the combination drug,

cost them, I think $150 per bottle. And so that's just sometimes not affordable. And so I actually split them up into two different drops, two different bottles. So you can, they can buy the Ophloxacin, Ophthalmic and Dexamethasone Ophthalmic as well. And just combine them. It's the same thing. And two, even those two bottles, but the combination, the two of them purchased is actually cheaper than the combination itself.

I want to underscore this point. You're saying these are the ophthalmic formulations and not - Correct. That's a good point. Not for the ears specifically. Gotcha. Correct. You can use eye drops in the ear, but you can't use ear drops in the eye. The eye drops - That's a good tip. The eye drops are actually pH balanced. And so you don't have to worry about any - Some people put ear drops in there like, oh, it burns and stings too much. Okay. You just reminded me something I learned from my first boss. That's true. You can -

can put ice stuff in the ear but not the other way around. That's brilliant. And that would work if we, with any combination, like a one -to -one, I guess. Correct. So, so quinolones, because I know there's also ciprofloxacin and dexamethasone drops or... Correct. I think maybe even hydrocortisone is combined with it. I've had, I've had some pretty big price tags when I tried to order some of those. So sometimes it's taken a little bit of guessing.

What about the, just like the acetic acid or aren't there some, some non -antibiotic, like suppose drying agents that you could put in? I'm not sure if you ever use those or if those, if those work. So, um, one of the ones I actually used to use all the time was acetic acid, hydrochloric cortisone combination, but that's actually been more and more difficult to get and purchase. Um, you know, at least by prescription.

The Curbsiders (01:00:22.734)
But that's why I, you know, see a gas is basically, um, white vinegar. And so it's diluted white vinegar. So if you have distilled white vinegar that you're trying not to use apple cider vinegar or any other vinegar, just distilled white vinegar will do just as well. You can just, I know that's, that's great. Yeah. And what if, if a patient has a history of say, tympanostomy tubes or ruptured TMS or anything like that, does that change?

the management plan, like should I then be more cautious about stuff that I'm just pouring into the ear or does that not matter so much? A thousand percent, yes. So people who have a perforation or any opening into their middle ear, they should not actually be using the over -the -counter ear drops. This includes the deep, like the over -the -counter like serum mellilidics. I would only recommend prescription ear drops for somebody who has perforations in the eardrum or opening.

That's a good question. So the O -Floxacin -Odic formulation could be used even if there's an open ear drum. It's not... It's not contraindicated, no. It's not contraindicated. Is that because you're worried about sterility with the over -the -counter or just the quality? Why are the over -the -counter ones more dangerous than the prescription in that case? One of the reasons is probably not pH balance. So if you put it inside the ear, it's going to burn.

like heck, so it's not going to feel very good for the patient. So yeah, and yes, I think there's always a risk of infection as well. And then you could make their problem even worse. And quick follow up, the alfalfa would be okay to use in that setting as well. Correct. Thank you. So it sounds like we can do this rubbing alcohol and distilled white vinegar 50 -50 mix and you know, for my kids during swim season when they're getting...

ear and, you know, otitis externa, we can do that to either prevent it or to treat it if they have a mild infection. But what if there's wax plugged in the ear? That's the other really common thing that we see. How can we flush this out in primary care or should we scrape it out, vacuum it out? I don't know what's available. What should we be doing? If it's very solidly packed in there,

The Curbsiders (01:02:45.23)
like due to a Q -tip or keys or any other instrumentation, I would probably recommend some mineral oil. They over the count and probably one or two drops every other day or every third day if it's really impacted. What that does is it actually loosens up this cerumen, lubricates it so that hopefully it'll come out on its own or when you're actually cleaning it out, it actually will come out a lot easier.

Instrumenting it while it's really packed in there really hurts the patient because sometimes the instrument may be actually right on the eardrum. And so any manipulation of it will actually cause more swelling and pain. Just the same as the irrigation. I'm actually not a big proponent of the irrigation as well. The irrigation, if you put water in there and it doesn't flush out.

the water gets trapped behind the surrogate and then you get an otitis externa because of that. So the irrigation has to be, you have to be careful with who you select, who you do the irrigation on. And then thirdly, if patients who have had a lot of ear infections before already in the past, who has surgery or had holes or ear tubes, definitely should not be flushed either because there's a risk of.

perforating their eardrum if it's not perforated already and causing more damage. I actually, I love cleaning ears. It brings me joy to do ear irrigation. So hearing you say not to do that, I'm so sorry. I do this all the time, but I have criteria. If the ear wax is really dark and it almost looked like a little pebble in there, it gets so dark and it looks pretty firm. So I send the patients home to do some...

oil, mineral oil or something for a few days before I even attempt it because it takes forever to do also. Like I don't have all day. As much as I'd like to spend all day doing it, I can't. Yeah. Isabel is actually like the pimple popper MD of the years. That's what I'm gathering from this revelation. I love it. So I'm not hearing you mention the sermonalytics. I'm not hearing.

The Curbsiders (01:05:04.918)
hydrogen peroxide or that kind of stuff. Is that because you don't use them? You prefer mineral oil to those or are there circumstances where that stuff might be indicated? Because I feel like typically the move is you kind of give the patient those drops to put in their ears, then they don't get better than you send them to ENT. And I don't know if you've made ENT's job easier or not. So do they have a role in this type of patient? They could. The problem with the serum analytics, because sometimes they have hydrogen peroxide in them. And what that does is it does not.

um, move the cerumen, it just basically, it's absorbed by the cerumen and you know, a lot of people hear the fizzle cracking, popping sounds, uh, and it swells up the cerumen, but it actually does not dislodge the cerumen. And so that's why I actually don't like the hydrogen peroxide as much. Yeah. You're hydrating the cerumen, Paul. That sounds great.

You're not quite occluded yet, so let me help with that. Yeah, exactly. Exactly. Yeah, that's definitely, yeah. That's practice changing for me because I do like, okay, we have to do one part warm water and hydrogen peroxide, but now I'm just going to go straight for just warm water, no sense in doing the hydrogen peroxide. Yeah, it's, it's, it's, I'm not saying never, but I just don't feel that that is as effective as what I've seen like mineral oil to do with removing cerumen.

So yeah, and I've seen they sell the ear scrapers. It almost looks like, you know, like a ring pop, how they have, how the ring pop has that circle. And then the Q -tip part of it or the scoop part of it only goes, you know, so far. So it's not going to hit your eardrum. I have not used those. I just, I've seen them out there and I was like, I bet you ENT doctors hate these. There's also like, there's these fiber optic.

things that you can sort of see in your ear as you're cleaning, which I also just gives me the screaming heavies. Like I feel like if I was a TNT doc, I would lose my mind if my patient had those. I can't Yes. I mean, how do they really know what they're seeing? They don't, pathology wise, it just, yes, yes. Again, if it just stems down to the regular Q -tip. So you don't need technology. Just don't instrument your ear. And how do you tell patients, like once you get the wax out of there,

The Curbsiders (01:07:23.15)
What's your counseling to patients to prevent this from happening again? Again, coming back to the mineral oil, I have them use one or two drops in the ear at night before they go to bed once a week. And I tell them after I clean that ear, they have a clean slate. And now it's up to them to maintain it without, you know, putting anything inside the ear except potentially the mineral oil.

One thing I do recommend and especially some people who use a lot of earplugs for work or listening to music or have hearing aids, they will probably accumulate more serumin just by the nature of their keeping something plugged in their ear and it's going to push the serumin deeper and deeper. So it's important to make sure they first of all clean off the apparatuses so that they don't get infections. And number two, have C or

you know, primary care provider or ENT to help them keep their ears clean to avoid issues. All right. So we have just a couple of things left. We were mentioning people that have itchy ears. We get a lot of itchy ears in primary care. So what do you tell them to do for that? I was mentioning Tri -Em Cynolone ointment, but you had a better solution. What I like to use is FluoCynolone oil. It's a mix of steroids.

It's mixed in oil, so it not only lubricates the ear canal, especially if they have a lot of wax, but it has steroids for the anti -inflammatory conditions, so like psoriasis or eczema. Very helpful. Because a lot of times, patients may not actually have otitis externa. It's basically just an exacerbation of eczema inside the ear canal. And so once you give them the oil, it actually helps relieve the system, that there's symptoms, and actually decrease their burden of wax as well.

Yeah. Okay. So that's fantastic. So don't, so basically not forgetting that when they, when somebody has a complaint, we think maybe it could be an otitis externa that, that there is, you know, a dermatitis is on the, from a non -infectious sources on the, on the differential or even psoriasis. So, okay. That's great. So we've really, I mean, we've covered so much here. I guess to quickly recap our,

The Curbsiders (01:09:42.239)
rubbing alcohol and distilled white vinegar, not apple cider vinegar, 50 -50 mix is something that we can use as a, you know, over -the -counter hack to treat the ear. Acetic acid and hydrocortisone drops are, for some reason, expensive now, so not using as much, but the white vinegar is basically acetic acid. We can prescribe O -Floxacin either alone or with dexamethasone.

So the combination may be more expensive, but you can also give them two drops and kind of approximate that. And we can use eye formulations in the ear, but don't use the ear formulations in the eye with the drops. Mineral oil is one, it sounds like that's one of our workhorses for dislodging wax. And then once we, they use it every one or two drops every other day. And then once the wax is gone, they have their clean slate. They can use it once a week.

and to try to prevent that from building back up. And then irrigation, the caution there is if all the liquid gets trapped and doesn't drain out, then you're going to get otitis externa behind a big ball of wax. So be careful about that. Don't stick Q -tips in your ear. And hydrogen peroxide gets absorbed by this rumen and could make it bigger.

I don't know why I find that so funny, Paul. It's kind of great because you can also see why people will be like, it must be working in the same way. You remember how, well, I won't put this on your parents, but when you had, we skinned your knee and we would just dump hydrogen peroxide and it would foam up. And now everyone's like, please don't do that. But it looks like it's going to do something. I feel like this sounds like it might actually be working. So I'm sure we're breaking a lot of parts of this episode. Sorry. Well, that's what I tell the patients that I hear the fuzzing. It's working. It's working. I look.

Look, if I want something to burn or tingle, you know, that's how I know it's working, Isabel. Come on. Medicine is pain. It's engraved over my office door. That's great. How do I do this pain on the next Curbsiders? Oh, wow. I might have to make you a plaque for your office, Paul. That's it.

The Curbsiders (01:12:05.006)
It says, medicine is pain. Can we get like a merch t -shirt? Yeah, maybe we will. Quoting Paul Williams. All right, Angela, I think we have to ask for take home points. It's been so much fun. A couple things you want the audience to remember from this recording. I think you summarized a lot of the points that we had talked about already, but the main thing is do a good examination, ask questions appropriately, and

And don't forget the nasal sinus components to ear problems because that can kind of help resolve the underlying issue of the ear problem to begin with. So yeah, that's about it. Thank you so much for having me. our wheelhouse. So we can do that. And thank you so much for all your time. This has been fantastic. A lot of practice changing stuff from this discussion tonight.

That's my pleasure. Thank you so much for having me.

The Curbsiders (01:13:10.126)
This has been another episode of the Curbsiders, bringing you a little knowledge food for your brain hole. Yummy, yummy. Not an echo. Still hungry for more? Join our Patreon and get all of our episodes ad free, plus twice monthly bonus episodes at patreon .com slash curbsiders. You can find our show notes at thecurbsiders .com and sign up for our mailing list to get our weekly show notes in your inbox, including our Curbsiders Digest, which recaps the latest practice changing articles, guidelines, and news and information.

and we're committed to high value practice changing knowledge and to do that we want your feedback so please send an email to askcurbsiders at gmail .com or you can subscribe, rate, and review the show on YouTube, Spotify, Apple podcasts, anywhere you get your podcasts really. A reminder that this and most episodes are available for CME through vcuhealth at curbsiders .vcuhealth .org. Special thanks to our writer and producer for this episode, Isabel Valdez.

And to our whole Curbsiders team, our technical production is done by the team at PodPaste, Elizabeth Proto runs our social media, Chris the Chew Man Chew runs our Discord, Stuart Brigham composed our theme music, and with all that, until next time, I've been Dr. Matthew Frank Wadden. And I've been Isabel Valdez. And as always, our main Dr. Colin Nelson -Williams, thank you and goodbye.