Today’s pearl is on the sexy topic of cerumen disimpaction, make that evidence-based cerumen disimpaction!
So you’re working adult/peds/fast track and the patient who is there for chest pain/fractured hand/URI reports during your thorough ROS that he also has right ear pain and decreased hearing for two weeks. You take a peek, and you encounter a wall of wax. The attending says:
- Oh, just scrape it out with this nifty curette
- Or s/he says take some water/saline/saline-H2O2 mix/sodium bicarb/colace/mineral oil to soften the wax then irrigate it out with this nifty gadget composed of syringe and a hacked off 18g angiocath, irrigate the heck out of it and give the patient some relief.
And you’re scratching your head wondering which one would work best. The following is based on clinical practice guidelines from The American Academy of Otolaryngology–Head and Neck Surgery.
- Impaction is diagnosed when “accumulation of cerumen causes symptoms” – you don’t need to have 100% occlusion to call it impaction
- There’s no evidence to support one removal method over the other, so you can choose to use a cerumenolytic agent and irrigate, or manual removal based on your experience, resources and time. If the patient is not that symptomatic, you can send them home with a cerumenolytic with follow up at the PMD for later irrigation if the impaction is not resolved.
Here’s a list of cerumenolytic agents:
Many impactions (44% in one study, Crandell 1993) may resolve on their own, so observation of asymptomatic impactions is a reasonable choice. Though short-term cerumenolytics will be more effective than observation according to one study (Keane 1995).
If you’re going to irrigate, there is evidence to use an agent to soften the cerumen before irrigation (let it sit there for about 15 min); and all pre-irrigation softeners, including just plain water, have similar efficacy.
Irrigation has its associated complications. Don’t use devices designed for oral irrigation because their pressures are too high even at only 33% power setting. There have been rare reports of TM rupture even with just syringe irrigation, so when irrigating aim at the canal wall, not straight back at the TM. Do not irrigate patients who have a history of ear surgery or who have a non-intact TM.
Oh, and FYI, ear candling is a complete sham; it has been studied and it has absolutely no effect on the cerumen -in fact it usually deposits some candle wax in the ear. There have been published reports of candling complications including patients being burned and even TM rupture from this ‘alternative treatment’.
Roland PS, et al. Clinical practice guideline: cerumen impaction. Otolaryngol Head Neck Surg. 2008;139:S1-S21.
Keane EM, et al. Use of solvents to disperse ear wax. Br J Clin Pract. 1995;49:71-2.
Burton MJ, Doree C. Ear drops for the removal of ear wax. Cochrane Database Syst Rev. 2009;21:CD004326.
Seely DR, Langman AW. Ear candles. Arch Otolaryngol Head Neck Surg. 1995;121:1068.
Crandell CC, Roeser RJ. Incidence of excessive/impacted cerumen in individuals with mental retardation: a longitudinal investigation. Am J Ment Retard. 1993;97:568-74.