AAO-HNSlogoAn updated clinical practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF), Alexandria, Va, published in the January 3 edition of Otolaryngology–Head and Neck Surgery is designed to provide evidence-based recommendations on diagnosis and treatment of earwax (cerumen impaction), as well as important patient information on the dos and don’ts of earwax and healthy ear care.

A summary of the guidelines was also made available by AAO-HNS. The organization says the purpose of the updated guideline is to help clinicians identify patients with cerumen impaction who may benefit from intervention. The update features new evidence, including three clinical guidelines, five systematic reviews and six randomized controlled trials, as well as observational studies and an evolved methodology that included adding a patient representative to the guideline development group.

For patients: Earwax or cerumen is a normal substance that the body produces to clean, protect, and “oil” ears. It acts as a self-cleaning agent to keep ears healthy. At times, the ear’s self-cleaning process might not work very well and may lead to a buildup of earwax. When this happens, earwax can collect and block, or partly block, the ear canal. Excessive or impacted cerumen is present in 1 in 10 children, 1 in 20 adults, and more than one-third of the geriatric and developmentally delayed populations, says AAO-HNSF.

“Patients often think that they are preventing earwax from building up by cleaning out their ears with cotton swabs, paper clips, ear candles, or any number of unimaginable things that people put in their ears,” says Seth R. Schwartz, MD, MPH, chair of the guideline update group. “The problem is that this effort to eliminate earwax is only creating further issues because the earwax is just getting pushed down and impacted further into the ear canal. Anything that fits in the ear could cause serious harm to the ear drum and canal with the potential for temporary or even permanent damage.”

Impacted earwax can cause symptoms like ear pain, itching, feeling of fullness in the ear, ringing in the ear (tinnitus), hearing loss, discharge coming from the ear, odor coming from the ear, cough, and/or change in hearing aid function. The update provides a table of dos and don’ts for clinicians to further educate patients about cerumen impaction, including:

  • DON’T overclean your ears. Excessive cleaning may irritate the ear canal, cause infection, and even increase the chances of cerumen impaction.
  • DON’T put anything smaller than your elbow in your ear. Your mother was right! Cotton swabs, hair pins, care keys, toothpicks…these can all injure your ear and may cause a laceration (cut) in the ear canal, a perforation (hole) in the eardrum, and/or dislocation of the hearing bones, leading to hearing loss, dizziness, ringing, and other symptoms of ear injury.
  • DON’T use ear candles. There is no evidence that they remove impacted cerumen, and candling can cause serious damage to the ear canal and eardrum.
  • DO seek medical evaluation if you have symptoms of hearing loss, ear fullness, and ear pain if you are not certain that they are from cerumen.
  • DO ask your provider about ways that you can treat your cerumen impaction at home. You may have certain medical or ear conditions that may make some options unsafe.
  • DO seek medical attention with ear pain, drainage, or bleeding. These are not symptoms of cerumen impaction and need further evaluation.

“The update to the 2008 guidelines encompasses a variety of tools for clinicians in treating and communicating with their patients,” said Dr. Schwartz. “This includes an algorithm showing the interrelationship of key action statements in a cohesive and understandable way as well as enhanced information on patient education. Having the consumer perspective on the guideline update group provided us a value-added opportunity to incorporate more extensive patient counseling within our treatment protocols.”

For clinicians: The panel made a strong recommendation that clinicians should treat, or refer to a clinician who can treat, cerumen impaction, defined as an accumulation of cerumen that is associated with symptoms, prevents needed assessment of the ear, or both.

  1. Clinicians should explain proper ear hygiene to prevent cerumen impaction when patients have an accumulation of cerumen.
  2. Clinicians should diagnose cerumen impaction when an accumulation of cerumen, as seen on otoscopy, is associated with symptoms, prevents needed assessment of the ear, or both.
  3. Clinicians should assess the patient with cerumen impaction by history and/or physical examination for factors that modify management, such as ?1 of the following: anticoagulant therapy, immunocompromised state, diabetes mellitus, prior radiation therapy to the head and neck, ear canal stenosis, exostoses, and nonintact tympanic membrane.
  4. Clinicians should not routinely treat cerumen in patients who are asymptomatic and whose ears can be adequately examined.
  5. Clinicians should identify patients with obstructing cerumen in the ear canal who may not be able to express symptoms (young children and cognitively impaired children and adults), and they should promptly evaluate the need for intervention.
  6. Clinicians should perform otoscopy to detect the presence of cerumen in patients with hearing aids during a health care encounter.
  7. Clinicians should treat, or refer to a clinician who can treat, the patient with cerumen impaction with an appropriate intervention, which may include ?1 of the following: cerumenolytic agents, irrigation, or manual removal requiring instrumentation.
  8. Clinicians should recommend against ear candling for treating or preventing cerumen impaction.
  9. Clinicians should assess patients at the conclusion of in-office treatment of cerumen impaction and document the resolution of impaction. If the impaction is not resolved, the clinician should use additional treatment. If full or partial symptoms persist despite resolution of impaction, the clinician should evaluate the patient for alternative diagnoses.
  10. Finally, if initial management is unsuccessful, clinicians should refer patients with persistent cerumen impaction to clinicians who have specialized equipment and training to clean and evaluate ear canals and tympanic membranes.

The panel offered the following as options:

  1. Clinicians may use cerumenolytic agents (including water or saline solution) in the management of cerumen impaction.
  2. Clinicians may use irrigation in the management of cerumen impaction.
  3. Clinicians may use manual removal requiring instrumentation in the management of cerumen impaction.
  4. Last, clinicians may educate/counsel patients with cerumen impaction or excessive cerumen regarding control measures.

For more details, see the full guidelines.

The update is endorsed by American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American Geriatric Society (AGS), American Neurotology Society (ANS), American Otological Society (AOS), American Society of Geriatric Otolaryngology (ASGO), and Society of Otorhinolaryngology and Head-Neck Nurses (SOHN). Additionally, it is supported by American Speech-Language-Hearing Association (ASHA).

The guideline authors are: Seth R. Schwartz, MD, MPH; Anthony E. Magit, MD, MPH; Richard M. Rosenfeld, MD, MPH; Bopanna B. Ballachanda, PhD; Jesse M. Hackell, MD; Helene J. Krouse, PhD, RN; Claire M. Lawlor, MD; Kenneth Lin, MD, MPH; Kourosh Parham, MD, PhD; David R. Stutz, MD; Sandy Walsh; Erika A. Woodson, MD; Ken Yanagisawa, MD; and Eugene R. Cunningham Jr, MS.

Source: AAO-HNSF