Abstract
Do you remember that sage advice from medical school about ‘never sticking anything smaller than your elbow in your ear’? Well, I have lost count of the patients who continue to blindly push cotton buds (or other sharp instruments of torture) into these narrow and sensitive orifices. And despite warning them of the dangers, they carry on regardless! ‘How then Doc, are we to keep our ears clean?’ ‘You don’t’, I retort. ‘They are already clean. Wax is good for the ears. Leave them alone!’
Ear canal epithelium naturally migrates outwards, and any wax produced should move out too, until it reaches the opening of the ear canal and sloughs off, thus providing a natural cleaning system (Robb & Watson, 2007). Wax (cerumen) is a normal protective secretion, which acts as a water repellent, and being slightly acidic, discourages bacterial and fungal growth too. Clearly, quite a helpful arrangement! Of course, there are some patients who have wax that does not clear naturally, resulting in blocked ear canals. Structural changes, such as exostoses or otitis externa, may interfere with the normal migratory process, and those with very narrow ear canals may also develop problems as the meatus blocks more easily.
I run a weekly ear microsuction service for my health locality, and underlying otitis externa is frequently present in those with impacted wax. Ear wax gets a bad press, but it is often this common inflammatory skin condition of the ear canal that disrupts the normal cleaning process. In this ear, nose, and throat (ENT) special issue, Emma Dickson reveals how broad a spectrum of severity otitis externa can be – from mild symptoms, such as itching, to the severe symptoms of malignant otitis externa, a potentially life-threatening condition. This article considers the importance of patient education and self-care in managing symptoms and preventing complications.
Confidence in examining ears comes with experience. It was only after seeing hundreds of normal ear drums that I started to feel confident in diagnosing those that were not. Young children, especially babies, provide an additional challenge, and the article by John Curran and colleagues on acute otitis media emphasises the importance of checking the ears in any unwell pre-lingual child.
It is not unusual for GPs to be confronted with dental complaints. The article by Garrett and Sarah Mills on managing dental emergencies in general practice strongly advises us to work within our scope of competence and experience. Many Clinical Commissioning Groups will have their own local guidance and care pathways for dental care, and I would urge you to become acquainted with these.
Neck lumps can induce anxiety in both patients and doctors, and the article by Adnan Darr and colleagues explores the various causes, including the red flag signs and symptoms for possible cancer. Likewise, Miklos Perenyei and colleagues provide us with a systematic approach to assessing hoarseness. In both conditions, I would draw your attention to the current National Institute for Health and Care Excellence (NICE) Cancer Guidelines (NICE, 2015), which have removed specific time frames and advise urgent 2-week rule referral for any patient aged 45 or over with persistent unexplained hoarseness, or an unexplained lump in the neck.
While the UK has been experiencing outbreaks of measles, we are reminded by Joshua Whittaker and Karan Jolly’s article on acute supraglottitis of the impact of successful national vaccination programmes – in particular, that of the Haemophilus influenzae type B (HIB) vaccine – with subsequent reduction in incidence of all-age supraglottitis through direct and herd immunity.
We all know ‘prevention is better than cure’, yet despite laryngeal cancer becoming less common, the incidence of oropharyngeal cancer has increased sharply in recent years, as highlighted in the article by Tobias Moorhouse and Daniel Edwards on head and neck cancer. The human papilloma virus (HPV) is once again implicated as a causative factor – so much so, that head and neck cancer is predicted to overtake cervical cancer as the leading HPV related cancer by 2020 (Paleri & Roland, 2016). Meanwhile, the debate about HPV vaccination for males continues.