Earwax: a clinical practice guideline for management and treatment

The guideline aims to help clinicians identify patients with cerumen impaction who may benefit from intervention.
The guideline aims to help clinicians identify patients with cerumen impaction who may benefit from intervention.

The American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) has released an updated clinical practice guideline on earwax to help clinicians identify patients with cerumen impaction who may benefit from intervention and to highlight needs and management options in special populations or in patients who have modifying factors.

The following recommendations, published in Otolaryngology–Head and Neck Surgery, were made for clinicians regarding the treatment of cerumen accumulation in patients:

  1. Clinicians should explain proper ear hygiene to prevent cerumen impaction when patients have an accumulation of cerumen.

  2. Clinicians should diagnose cerumen impactions when an accumulation of cerumen, as seen on an 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 or more 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, such as young children and cognitively impaired children and adults.

  6. Clinicians should perform otoscopy to detect the presence of cerumen in patients with hearing aids during a healthcare 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 or more of the following: cerumenolytic agents, irrigation, or manual removal requiring instrumentation.

  8. Clinicians should recommend against ear candling/coning 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 for clinicians treating cerumen impaction in patients:

  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.

The guideline does not apply to patients with cerumen impaction associated with the following conditions: dermatologic diseases of the ear canal; recurrent otitis externa; keratosis obturans; prior radiation therapy affecting the ear; previous tympanoplasty/myringoplasty, canal wall down mastoidectomy, or other surgery affecting the ear canal.

Reference

  1. Schwartz SR, Magit AE, Rosenfeld RM, et al.  Clinical practice guideline (update): earwax (cerumen impaction). Otolaryngol Head Neck Surg. January 2017. doi: 10.1177/0194599816678832.
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