Clinical Practice Guidelines Issued for Managing Earwax Impaction
September 5, 2008 — The American Academy of Otolaryngology–Head and Neck Surgery Foundation has issued evidence-based, clinical practice guidelines for managing cerumen (earwax) impaction and has published them in the September issue of Otolaryngology–Head and Neck Surgery. The new guidelines, which are intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction, discourage routinely cleaning out cerumen.
"Unfortunately, many people feel the need to manually remove earwax, called cerumen, which serves an important protective function for the ear," lead author Peter S. Roland, MD, chairman of Otolaryngology–Head and Neck Surgery at University of Texas Southwestern Medical Center in Dallas, said in a news release. "Cotton swabs and some other home remedies can push cerumen further into the canal, potentially foiling the natural removal process and instead cause build-up, known as impaction."
Cerumen impaction is defined as an accumulation of cerumen that causes symptoms, prevents ear examination, or both. Although the term impaction suggests complete obstruction of the ear canal with cerumen, this working definition of cerumen impaction does not require complete obstruction.
The water-soluble mixture of secretions in cerumen produced in the outer third of the ear canal, along with hair and dead skin, serves a critical protective function for the ear and should not be removed unless it causes symptoms or prevents evaluation.
The objectives of these guidelines are to improve diagnostic accuracy regarding cerumen impaction, facilitate appropriate management for patients with cerumen impaction, highlight the need for assessment and intervention in special populations, ensure the implementation of indicated therapies with outcomes assessment, and improve counseling and education for the prevention of cerumen impaction.
The American Academy of Otolaryngology–Head and Neck Surgery Foundation appointed an expert panel of specialists in audiology, family medicine, geriatrics, internal medicine, nursing, otolaryngology–head and neck surgery, and pediatrics to review the appropriate evidence and to formulate these guidelines.
The panel made a strong recommendation that the indications for treating cerumen impaction are symptoms reported by the patient, or build-up sufficient to prevent indicated clinical examination.
Recommendations made by the panel were as follows:
Cerumen impaction should be diagnosed when accumulated cerumen is symptomatic or when it prevents needed examination of the external auditory canal, tympanic membrane, or both.
History and physical examination of the patient with cerumen impaction should focus on factors that could affect management, including a tympanic membrane that is not intact, ear canal stenosis, exostoses, diabetes mellitus, immunocompromised state, or anticoagulant therapy.
Patients with hearing aids should be evaluated during a healthcare encounter for the presence of cerumen impaction because cerumen can cause feedback, reduced sound intensity, or damage to the hearing aid. However, it is not necessary to perform this examination more often than once every 3 months.
Appropriate interventions for cerumen impaction may include ceruminolytic agents, irrigation, and/or manual removal other than irrigation. Ceruminolytic agents are effective, but evidence is lacking regarding the superiority of any particular agent. Irrigation or ear syringing is most effective when a ceruminolytic agent is instilled 15 to 30 minutes before treatment.
When in-office treatment of cerumen impaction is completed, clinicians should evaluate the patient and document that the impaction has resolved. Additional treatment should be prescribed if the impaction has not resolved. Alternative diagnoses should be considered if full or partial symptoms persist despite resolution of the impaction.
Options, which carry less weight than the recommendations, offered by the panel were as follows:
Patients with cerumen that is not impacted, is asymptomatic, and does not prevent adequate examination when an evaluation is indicated may be observed without active intervention.
In a patient who may not be able to express symptoms but who has cerumen obstructing the ear canal, clinicians may promptly evaluate the need for intervention.
The patient with cerumen impaction may be treated with ceruminolytic agents, irrigation, or manual removal other than irrigation.
Clinicians may educate and counsel patients who have cerumen impaction and/or excessive cerumen regarding appropriate control measures.
To avoid damaging the ear or create more impaction, suction devices or other specialty instruments should be used only under supervised medical care. Removal with specialty instruments is preferred for patients with narrow ear canals, eardrum perforation or tube, or immune deficiency.
The guidelines warn against patients using cotton-tipped swabs and against home use of oral jet irrigators. Ear candling, an alternative to traditional methods of earwax removal, is ineffective and is potentially dangerous.
"The complications from cerumen impaction can be painful and include infections and hearing loss," Dr. Roland said. "It is hoped that these guidelines will give clinicians the tools they need to spot an issue early and avoid serious outcomes."
The authors note that this clinical practice guideline is not intended to be the only source of guidance in managing cerumen impaction, nor is it intended to replace clinical judgment or to establish a protocol for all individuals with this condition. Although it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies, it may not provide the only appropriate approach to diagnosing and managing this problem.
Three of the guidelines authors have disclosed various financial relationships with Alcon Labs, MedEl Corporation, Advanced Bionics, Cochlear Corporation, GlaxoSmithKline, Acclarent, Sinexus, National Institutes of Health, Krames Communication, Schering-Plough, and/or sanofi-aventis.
Otolaryngol–Head Neck Surg. 2008;139:S1-S21.
Study Highlights
The prevalence of cerumen impaction varies and in the United States has been estimated as affecting 10% of children, 5% of healthy adults, up to 57% of older persons in nursing homes, and 36% of those with mental disabilities.
12 million people seek treatment annually for cerumen impaction, and 8 million procedures are performed by healthcare professionals.
Treatment of impaction has resulted in complications such as ear canal laceration, infection, hearing loss, otitis externa, pain, syncope, and dizziness at the rate of 1 in 1000 ear irrigations.
Recommendations
The diagnosis of impaction requires a targeted history, physical examination, otoscopy, binocular microscopic examination, and audiologic evaluation.
Clinicians should diagnose impaction when it is associated with symptoms, prevents assessment of the ear, or both.
Factors that modify management include a tympanic membrane that is not intact, ear canal stenosis, exostosis, diabetes mellitus, anticoagulant treatment, or immunocompromise.
Narrow ear canals may be found in those with Down's syndrome and other craniofacial disorders.
Those with hearing aids should be examined for an impacted cerumen every 6 to 12 months because impaction can cause poor fit of the hearing aid and reduced sound intensity or feedback.
Appropriate interventions for an impacted cerumen include ceruminolytic agents, irrigation, or manual removal other than irrigation.
Manual removal other than irrigation includes a curette, probe, forceps, suction, and hook.
Mechanical removal is the preferred technique when the eardrum is not intact.
In the presence of anatomic anomalies, safe and effective irrigation is not always possible, and the binocular microscope with microinstrumentation may be needed.
Patients receiving anticoagulants are at higher risk for hemorrhage.
Clinicians should examine patients at the end of an intervention and document resolution of the impaction.
Alternative treatment and alternative diagnoses should be considered if resolution of the impaction does not occur.
Ear candling is potentially unsafe and is not endorsed by the US Food and Drug Administration to treat impaction.
Options
Observation of impaction is reasonable in the absence of symptoms, and a needs assessment of the ear can be conducted.
Elderly patients, young children, and those with cognitive impairment are at high risk for impaction and may not be able to express symptoms.
The clinician should weigh potential benefits and harms of treating impaction in this population.
Clinicians may use ceruminolytic agents including water or saline to manage impaction or instruct patients in home use.
Ceruminolytic agents may be water based or oil based.
No specific ceruminolytic agent has been found to be superior to another in clinical trials.
The use of cerumenolytics up to 15 minutes or days before irrigation improves the success of irrigation.
Clinicians may use irrigation in the management of impaction.
Clinicians may use manual removal other than irrigation for impaction, especially in those with abnormal otologic findings, systemic illness, or compromised immunity.
Clinicians should ensure adequate training and use of appropriate equipment for procedures.
Clinicians may educate patients on control measures including use of prophylactic topical preparations, irrigation of the ear canal, or routine cleaning by a clinician.
Θέμα: Practice Guidelines (Αναγνώστηκε 375019 φορές)
11 Αυγούστου 2010, 23:03:03