in two or three months. It is probable that it requires a longer time than this, for cerumen to become so hard or so tightly packed in the canal, that it cannot be readily removed by the patient or a non-medical friend. It is always well to examine both ears, even when only one is complained of. I have often found the ear in which the hearing was still unimpaired, quite as full of wax as the other, although it had not yet become pressed upon the drum-head, and thus had given no trouble. <Callout type="important" title="Regular Ear Checks">Regular examinations are crucial to prevent unnoticed issues.</Callout> I append a few cases, which illustrate what has been said, and which will, perhaps, contribute to a knowledge of the etiology of the disease. The first was one of the last upon my case-book when this chapter was finished, but it happens to be of interest, inasmuch as sudden and acute pain was one of the symptoms. It is inserted, however, not for its peculiarity, but as an illustration of the ordinary type of these cases. Case I. — March 5, 1873, Mr. De. S., set. 28, consulted me about a pain in his ear. Two days since lie experienced a 'buzzing noise' in the ear, and last night he had severe pain in it, which was relieved by some liquid application. The buzzing noise still continues, and he cannot hear well from the left side. The hearing distance is— Eight ear normal ; Left ear, ^, or the watch is heard when pressed upon the auricle. Tuning-fork is heard much better on the left side. Diagnosis — Inspissated cerumen in left ear. The mass was removed by syringing, and the hearing distance became $ f in a few moments. Case II. — A. B., coachman, at N. T. Eye and Ear Infirmary, in 1864. The patient complained of head symptoms for some months. He ascribes them to a sunstroke. On cross-examination it was found that he had never actually suffered from sunstroke ; but that since his head symptoms — chiefly buzzing in the ear and deafness — had begun, he imagined that they were caused by a fancied sunstroke. He stated that he had been treated in a New York hospital for some weeks, but without benefit. His ears had never been examined, and he had concluded to have their condition investigated, as many of the symptoms which made him 'bad in the head' were referred to his ears. An examination showed inspissated cerumen in both ears. I have mislaid the record which gave an account of his hearing power ; but all the troublesome symptoms were at once relieved by the removal of the mass, which was done by the use of the syringe. This case is almost as striking as that related by Von Troltsch, in which a poor fellow was blistered and cupped to the verge of severe depression, for a supposed concussion of the brain, which proved to be a case of inspissated cerumen. Case III. — The following case shows, I think, that a swelling of the canal may prevent the normal exit of the cerumen, and thus favor its impaction : Miss Johnson, set. 29, consulted me, March 23, 1873, on account of her ears, and gave the following history: For fourteen or fifteen years she had suffered at intervals from abscesses in both ears. The hearing has been seriously impaired on the right side from an ulcer resulting from scarlet fever, since she was five years old. For the past two or three months the hearing has been impaired in the left ear, and she has suffered from abscesses near the external meatus, which have caused great swelling and tenderness of the parts. The impairment of hearing was most marked in the morning. For the last four weeks she has been constantly deaf, although for a few moments a few days ago she heard very well ; she then felt as if something had broken in the ear. <Callout type="risk" title="Ear Abscesses">Abscesses can cause significant hearing impairment and should be treated promptly.</Callout> Hearing distance, tested by the watch— Right ear, -.h ; L., -fa. Diagnosis. — Right ear, chronic suppuration in tympanic cavity. Left ear, Inspissated cerumen. A small furuncle was found in the outer part of the canal, which was a very narrow one. The mass of cerumen was removed in about 20 minutes by syringing, when the hearing distance became -458-. Politzer's method of inflating the ear was then employed. March 6, H. D. H- After the use of Politzer's method, the hearing distance became |f. The above case illustrates the theory of the preceding chapter, that inspissated cerumen is in reality but one of the symptoms of certain forms of inflammatory affection. In this case the inflammation had not fully run its course, for the canal was red and swelled. Perhaps, indeed, this was an habitual condition of the part. The following case, which may be considered a remarkable one, illustrates not only the etiology of inspissated cerumen, but also the effect of quinine upon the ear ; and I insert it as much to show the influence of this agent upon the auditory apparatus, as for its bearing upon the subject now under discussion. It has already been published,* but I think it worthy a wider circulation than it has hitherto obtained. Case IV.— On the 3d of May, 1870, 1 was consulted by Dr. K, set. 34, on account of his throat and ears. He stated that he had had acute pharyngeal and laryngeal disease some ten years before. He also informed me that neither he nor his parents have any recollection of any serious difficulty with his ears prior to the date of the attack, from whose consequences he is now suffering. The laryngeal inflammation was followed by chronic naso-pharyngeal catarrh, and in 1863 he was obliged to take five-grain doses of quinine for some weeks on account of nervous prostration from malarial fever contracted in the Southern States. These doses were increased to ten grains, and cinchonism was produced. The symptoms of cinchonism were, ringing in the ears and dizziness. In 1864, the doctor again took quinine until the constitutional effects were produced, the dose finally reached being twenty to twenty-five grains, which was taken every other day. While employing the quinine in this manner a severe attack of otitis occurred. The patient states in a written history taken from his diary that he recovered from the otitis under antiphlogistic treatment. After recovery from the aural disease, Dr. N. was obliged to resort to the use of the quinine on account of the constitutional disease,— a severe malarial neuralgia. He took one dose of fifteen grains, which was followed by pain in the ears. Several efforts were made to return to the use of the quinine, but pain in the ear supervened on each dose. 'From this period, February, 1865,' * Transactions of the American Otological Society, 1873. 156 INSPISSATED CERUMEN — CASES. to quote the exact words of the patient, 'my ears Legan to give me constant trouble. I was incessantly annoyed by unnatural noises, which would frequently reach such a pitch, for a few moments, as to exclude all other sounds.' The naso-pharyngeal disease also increased, and in March, 1805, he was seen, on account of the state of his ears, by a distinguished practitioner. The throat was considered the origin of the aural affection, and it was accordingly treated, and was improved ; but the ears remained in the same condition', that is, they were sensitive and affected by tinnitus, and there was some impairment of hearing. After the pharynx had been treated, until July of this year (1865), and while undergoing treatment, another attack of otitis media occurred, which was preceded by five weeks of facial neuralgia. The use of quinine for the relief of these attacks had been avoided ; but at last, the patient, worn out by pain, took a fifteen-grain dose of the sulphate, upon which the ear disease immediately supervened. The quinine was taken on July 30th, and the attack of otitis media occurred on the next day. The otitis was of so severe a character as to place the doctor in a very depressed condition, and when he recovered from this and the neuralgia, which he did simultaneously, to use the patient's own language, 'he was a perfect wreck.' He then sailed for Europe, and in the Scotch Highlands recovered from the malarial disease, never having suffered from it since up to the present time. The ears, however, became very sensitive to the air, and cotton plugs were resorted to, and Dr. N. has never from this time been able to leave the meatus open, even while in-doors, until the past week. The hearing power was also greatly impaired while in Scotland ; the patient therefore went to the south of France, where his ears were still troublesome. The aural symptoms were tinnitus, a sense of pressure in the auditory canal, and frequent attacks of neuralgia of the fifth pair. The intellect also became somewhat obscured. After a year's stay abroad, Dr. N. returned home, when the naso-pharyngeal catarrh returned. He then, under the advice of a physician, began the use of the nasal douche for its relief, taking all the precautions that are enjoined, using a warm solution of common salt in water. It was observed, however, that in an hour or two after using the douche, there was an uncomfortable sensation in the ears which became more prominent after each application. The physician then advised 'less pressure' in the use of the douche ; but the next application was followed by severe pain, and this method of treatment was abandoned. The patient was then suffering from what was called an infiammaticn of the auditory canal ; all treatment was given up until September of this year, when another attack of otitis media and of facial neuralgia occurred. The next two years were spent in Italy. The general health of the patient was then excellent, but the hearing did not improve, and the patient was obliged to use the cotton plugs. Eeturning to America in the spring, the naso-pharyngeal catarrh, which had not appeared while in Italy, returned, and in April, pain occurred in both ears, for which he was treated by leeches, diaphoretics, and hot fomentations ; after this attack the patient describes himself as totally deaf,— unable to distinguish the loudest sounds. 'There was a feeling of spasmodic constriction, and fulness invading the cavity of the tympanum, and a sensation of pressure upon the drum-head.' On the third day the patient became able to hear what was said to him, if the words were spoken very loudly and with the mouth applied close to the ear ; as time passed he became still more improved, so that he could hear conversation addressed specially to him at a short distance, and a watch usually heard at four feet, at a distance of two inches on each side, H.=:&. This was his condition when he first came under the writer's observation, on May 3, 1870. I found that the general nervous system of Dr. N., from his years of suffering, was in a highly sensitive condition. His pharynx was highly congested, the uvula very long, and both auditory canals were extremely sensitive and plugged with hard wax. For two weeks the patient was under my care, during which time I cut off the uvula, and made many attempts to remove the impacted wax by syringing, and the use of the forceps ; but in all these attempts I failed, in consequence of the hardness of the cerumen and the tightness with which it was held by the auditory canal, and also because the ear was extremely tender to the slightest touch. At the end of this time, the patient was suddenly called to Minnesota, and I did not see him again until June 26, 1872, when he presented himself and gave the following history of the time that had elapsed. The very small quantity of wax removed, and the cutting off of the uvula, had relieved the pharynx and ears to some slight extent, and, the climate being adapted to his condition, he did very well, except that the hearing was impaired. On June 18, 1871, another attack of otitis occurred, which caused some considerable discomfort, although it was a less severe attack than those which had preceded it. The otitis again occurring, the patient came to me, on the date above mentioned ; more than two years from the first visit. I found him suffering severe pain, for which he was taking anodynes ; the ears were about in the same state as when I last saw him. The hearing distance was about -/«, the canals were plugged with hardened wax ; the patient appeared in fair physical condition, but mentally he was excited and slightly irritable and depressed. I proceeded to remove the impacted wax, and that from the right ear came away on the second day. It was so tightly wedged in that the removal, which was effected by the syringe and forceps, caused severe pain, although the walls of the canal were not touched. On the fifth day, after the use of various agents to soften the mass of cerumen in the left ear, I burned it with nitric acid, and then succeeded in removing it. This removal also caused great pain. The membranse tympani were suppurating, that is, the outer layers, and they were somewhat sunken, especially along the handle of the malleus. The use of a solution, nitrate of silver 40 gr. ad 3 j, and inflation by Politzer's method, soon restored them to a normal appearance, except that the curvature remained altered. The sensitiveness of the ears was removed, so that they could be touched, applications made to the drum-head, and so on, without producing any unpleasant sensations. The hearing distance became -4a8- on the right side, and was improved on the left, but to what extent I do not know, not having seen the patient for some time. He became able to sleep without an anodyne. The cotton plugs which had been worn for years were now removed, and he became altogether a different person, as regards his mental condition. <Callout type="important" title="Quinine Risks">Quinine can cause severe ear inflammation and should be used cautiously.</Callout> I think we must regard the otitis in this case, although to a certain extent dependent upon the naso-pharyngeal catarrh, as chiefly caused by the use of quinine. By looking at the history and observing how promptly and invariably the pain in the ears occurred in several instances after the use of the agent, we are forced to the conclusion that quinine was the exciting cause of the aural inflammation. At what date the impaction of wax occurred, we cannot positively determine. I am disposed to believe that it was at the time the patient awoke profoundly deaf, in April, 1870, or more than two years before it was removed. The wax was certainly there one month after, in May, 1870, when I first saw him. The condition of the patient's mind is illustrated by the fact that he should allow two years to pass away with no attempt to remove a foreign body, from whose partial removal he had obtained some relief, and which he believed to be one of the causes of his impaired hearing. I can only partially account for this delay, by supposing that my efforts at softening and removing the mass had so far succeeded as to lift the cerumen from the drum-head, and thus give partial relief. Indeed, the plug, which I took out on the second day, was on its way out, and would, I think, have soon escaped spontaneously, with one of the loud reports with which hardened wax sometimes shoots from the auditory canal. The structure of the plugs was that usually found, that is, cerumen in layers ; but there was some epidermis exfoliated, and also some pus between the mass of wax and the canal. The case seems to me to be one of those which have been reported, where inflammation of the integument lining the canal was one of the causes of impaction of wax, and it may be a contribution to the etiology of that disease. The earlier history also illustrates the effect of quinine upon the ear, which I am inclined to suspect is sometimes an inflammation of the conducting portions, as well as of the acoustic nerve or labyrinth. We have long known of the latter effect, but the former has not been often observed. The following case occurred in my clinic at the Brooklyn Eye and Ear Hospital, and was reported by Dr. David Webster,* who was then House Surgeon. It illustrates the serious inflammatory trouble that may be caused by inspissated cerumen, a fact which has been already alluded to in this chapter. Case V. — 'D. H., aged 28, laborer, presented himself at Dr. Roosa's clinic, at this hospital, Nov. 1st, 1870. Five days previously his right ear was attacked with pain, tinnitus, and deafness, which symptoms had gradually increased up to date. He had slept but little for the last two nights, in consequence of the severity of the pain. He could hear the ticking of an ordinary watch at the distance of only one inch. Upon esamination we observed a little puffiness of mastoid process, and some swelling back of the angle of the lower jaw and of the walls of the meatus. * Medical Record, vol. v., p. 536.
Key Takeaways
- Regular ear examinations are important to prevent unnoticed issues like cerumen impaction.
- Quinine can cause severe ear inflammation and should be used cautiously.
- Abscesses in the ear can lead to significant hearing impairment.
- Impacted wax can cause tinnitus, pressure sensations, and even deafness.
Practical Tips
- Regularly check your ears for signs of cerumen impaction, especially if you experience hearing loss or ringing in the ears.
- Use over-the-counter ear drops to soften wax before attempting removal with a bulb syringe.
- Avoid using cotton swabs as they can push wax deeper into the ear canal.
Warnings & Risks
- Do not insert objects into your ear canal, as this can cause injury or further impaction of cerumen.
- Seek medical attention if you experience severe pain or hearing loss in one ear.
- Be cautious with quinine use, especially for those prone to ear inflammation.
Modern Application
While the techniques described in this chapter are historical, the importance of regular ear care and recognizing signs of potential issues remains crucial. Modern tools like bulb syringes and over-the-counter drops can help manage cerumen impaction safely, but professional medical advice should always be sought if symptoms persist or worsen.
Frequently Asked Questions
Q: How often should I check my ears for cerumen impaction?
Regular checks are recommended, especially if you experience hearing loss or ringing in the ears. However, avoid inserting objects into your ear canal as this can cause injury.
Q: Can quinine really cause ear inflammation and deafness?
Yes, according to historical records, quinine can cause severe ear inflammation and should be used cautiously, especially by those prone to ear issues.
Q: What are the signs of a potential ear abscess that I should look out for?
Look for swelling, redness, pain, and hearing loss. If you notice these symptoms, seek medical attention promptly as an ear abscess can be serious.