It is important to check carefully for a number of problems among elderly patients, who may be unaware of the insidious development of hearing loss, balance deficits, or intraoral or pharyngeal cancers. Unsuspected balance deficiencies may be putting the patient at risk for falls. Nasal obstruction may be dismissed by the patient; however, inspection may reveal easily treatable problems such as benign polyps or life-threatening disease such as a neoplasm.

OUTER EAR

The anterior and posterior surfaces of the pinna are common sites for actinic keratoses and skin cancers. The eardrum, especially the pars flaccida, is a common location for an occult cholesteatoma (see later). If cerumen obstructs the examiner's view it can be removed by direct manipulation or by irrigation with clean water at body temperature, provided there is no eardrum perforation. Alternatively, instilling mineral oil will soften and lubricate the impaction, making removal easier and more comfortable. Cerumen impaction can usually be avoided by keeping the ear oily (by adding a couple of drops of mineral oil weekly) and keeping soapy water away from the ear canal.

Swelling of the external auditory canal associated with purulent secretions indicates an external otitis. External otitis should be treated by applying eardrops containing an antibiotic (typically polymyxin and neomycin combined with hydrocortisone) in an acidic solution. Cortisporin, Coly-mycin or VoSoL are commonly used preparations. Drops should be applied three times daily. It is important that a) the canal orifice should be cleared of secretions and debris before the application and b) the patient's head must be adjusted so that the ear canal is tilted upward.