What Is that wax??

IRRIGATING ears can put clinicians in hot water, but new earwax impaction guidelines from the US aim to limit treatment complications.

Ear, nose and throat doctors from the American Academy of Otolaryngology – Head and Neck Surgery Foundation have issued new clinical guidelines on cerumen or "earwax" impaction, published in the journal Otolaryngology – Head and Neck Surgery Foundation.

The guidelines aim to help clinicians identify patients with cerumen impaction and provide evidence-based management of the condition. The guidelines also aim to educate patients on the role of cerumen in hearing health.

What is earwax impaction?

Cerumen impaction is a common problem with cerumen removal being the most common ear, nose and throat procedure performed by general practitioners, according to previous research.

The incidence of cerumen impaction varies by group. The condition can affect up to 57% of nursing home residents, 36% of people with a disability and around 5% of healthy adults.

Cerumen is a water soluble substance that occurs naturally in the ear. While commonly called earwax, cerumen is not a wax.

Excess cerumen usually travels out of the ear due to jaw movement such as chewing, and removes dirt and dust from the ear.

Impaction occurs for a number of reasons including an unusually shaped ear canal, excessive hair in the ear canal, use of hearing aids or trying to clean the ear with a cotton bud.

A build-up of cerumen in itself is not necessarily a problem. However, it can cause symptoms such as itching and pain. Serious problems include eardrum perforation and hearing loss.

Treatment options include observation, use of wax-dissolving agents, ear syringing or manual removal with suction or an instrument. The attempts to remove the cerumen can result in complications such as eardrum perforation, damage to the ear canal and ear infection leading to a significant number of medical negligence claims.

Summary: clinical practice guidelines

The AAO-HNSF offers clinicians the following guidelines:

• Cerumen impaction should be diagnosed when it is associated with symptoms and/or prevents a needed assessment of the ear;


• A patient history and/or physical examination should be done to rule out factors that will influence management such as an existing perforated eardrum, ear canal stenosis, exostoses, diabetes mellitus, an immunocompromised state or anticoagulant therapy;


• Observation is recommended for patients with asymptomatic, non-impacted cerumen that does not interfere with ear assessment;


• Clinicians should treat patients for cerumen impaction if the patient identifies symptoms that require treatment or if the impaction prevents ear examination;


• Patients, such as young children, who present with an ear canal obstruction and are unable to express symptoms should be evaluated by the clinician as to whether they require treatment;


• Patients with hearing aids should be examined for cerumen impaction when attending a health care facility;


• Treatment options for cerumen impaction include wax-dissolving agents, irrigation, manual removal or a combination of these options;


• After treatment for cerumen impaction, clinicians should assess the patient so see if the treatment worked. If not, additional treatments should be used; and


• Patients should be educated on measures to control excessive cerumen.

Risk of medical negligence

Dr Sara Bird, medical negligence claims manager for MDA National, welcomes more information on the topic. Dr Bird has written a number of educational articles on the risks of ear syringing for cerumen impaction for Australian Family Physician, a publication of the Royal Australian College of General Practitioners.

Ear syringing is the most common treatment for cerumen impaction, she said, and it is estimated that it has a complication rate of one in 1000 cases.

“I think more literature becoming available on the topic is a good thing," she said.

“The reason why I have written about it is because of my professional experience. I am a claims manager, so I get doctors who are members of our organisations who ring in with incident reports or claims relating to ear syringing.

“People think it is such a simple procedure but of course like any procedure there are important things that should be done. Simple things like the use of softening agents and making sure the flow isn't directed at the eardrum. It is important to take a history and know that there are contrary indications for the procedure."

Need for guidelines

Dr Bird also identified the need for staff education in limiting the risk of complications in treating cerumen impaction, especially with ear syringing.

“It is not a procedure that has changed that much over time," she said.

“In the past, I don't think it has been recognised as a procedure that requires much training or that can have many complications.

“I think training is an issue – ear syringing is a procedure like any other procedure in medicine. I think one of the difficulties both from a nursing and medical point of view is it is not a procedure that is performed often in the hospital setting.

“I believe people essentially only learn that procedure when they enter general practice. So from a nursing and medical point of view like any procedure there should be some training or guidelines."

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