Cerumen

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Earwax enters medical attention when it is impacted, and either obscures the patient's hearing or our view of the Tympanic membrane.

Read Code (Version 2, 5 byte) CERUMEN Impacted cerumen (wax in ear) F504.  

Contents

Aetiology

The wax is secreted by apocrine glands in the ear canal. Postulated functions are many i.e we don't know. Is it just a form of sebum produced in an inaccessible corner? [1]

Genetics

Many UK doctors will be surprised to find that there are two types.

  • Wet - a honey coloured material which may harden. This is found in Caucasians and Afro-Americans. (A gene involved also is involved in Bromhidrosis.)
  • Dry - Greyish and brittle, it is found in East Asians and North American Indians.

The understanding of this and its relation to choreoathetosis is on Chromosome 16.[2]

Avoiding Impaction

Patients should be advised not to use cotton buds or "Q-Tips". (By their parents). Because when you stick something that wide into the ear canal, it inevitably pushes wax inward, thus tending to pack it against the eardrum and preventing it migrating outward.

Clearing Impacted Cerumen

Info bulb.pngIn countries where patients have direct access to medical care, without a primary care gatekeeper, it is more common for patients to present directly to ENT specialists, who spend much of their time extracting ear wax with a wax hook, using the head mirror so rarely seen outside ENT clinics, but so beloved of cartoonists.
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  • Understand the technique
  • Examine the ear beforehand
  • Check the equipment (nozzle fixed properly etc)
  • Don't push too hard
  • Make a note

This is a hazardous procedure, although not very, in most people.

Traditionally wax has been softened with Sodium Bicarbonate or Olive Oil at body temperature dripped into the ear (and the position with the canal pointing vertically upward maintained for 10 minutes) followed if necessary by syringing (now called irrigation) with water and caution twice daily for four days. When successful this is one of the more satisfying procedures for a patient and therefore the operator.

In the ENT Clinic, use of micro-suction under view through the operating microscope is effective.

The wax hook is also used, sliding between the anterior canal wall and the plug, then rotating 90 degrees to catch the wax plug and pulling it out. Perforating the ear drum and removing it and the ossicles is an incorrect technique.

Clinical Evidence has a chapter on Ear wax [3]. This reports that syringing is a trade off between benefits and harm. The view is consensus based. Other techniques such manual removal (other than ear syringing), wax softeners and wax softeners before syringing are rated as having unkown effectiveness.

It has been suggested (and a successful trial conducted) that having soaked the wax with an attempt to remove it by irrigation, plugging the ear and leaving the patient to wait quarter of an hour may result in it being soft enough to syringe out.

Various ad hoc techniques have been used[4]. Ingenuity is valuable, but caution is paramount.

UPDATE - US guidance on treating cerumen impaction

In January 2017 the American Academy of Otolaryngology updated its guidelines.[5] These have been summarised by Louis Bell in NEJM JournalWatch as follows:

The American Academy of Otolaryngology-Head and Neck Surgery has updated its 2008 clinical practice guidelines on management of cerumen impaction.

Sponsoring Organization: The American Academy of Otolaryngology-Head and Neck Surgery

Target Audience: All clinicians likely to diagnose and manage patients with cerumen impaction

Target Population: Patients older than 6 months

Background and Objective

Cerumen naturally migrates out of the ear canal assisted by jaw movement but may occlude or become impacted in the canal, sometimes causing hearing loss, tinnitus, itching, pain, or cough or impeding assessment of the tympanic membrane and middle ear structures. Cerumen impaction is diagnosed in 10% of children and 5% of adults. The new guidelines include consumer input, new published evidence, and a new management algorithm.

Key Points

  • Diagnosis should be made using otoscopy during routine visits.
  • If cerumen impaction is discovered and there are no contraindications, remove the cerumen.
  • Contraindications to cerumen removal: anticoagulant therapy, immunocompromise, diabetes mellitus, prior radiation therapy to head and neck, ear canal stenosis, nonintact tympanic membrane.
  • Options for cerumen removal:
  • Cerumenolytic agents: water-based agents (e.g., Cerumenex, hydrogen peroxide), oil-based agents (e.g., almond oil, mineral oil), nonwater/nonoil-based agents (e.g., Debrox). No evidence shows any of these agents to be more effective than another.
  • Irrigation
  • Manual removal (e.g., with plastic curette loop or spoon)
  • Evidence shows that a week of a cerumenolytic agent followed by irrigation is most effective.
  • In patients with cerumen impaction, prevention counseling is indicated. Few studies have determined the best prevention measures. These can include prophylactic drops, periodic canal irrigation, or routine cleaning for those with hearing aids. Olive oil and ear candling (also called ear coning or thermal-auricular therapy) could be harmful and should not be used.

Comment In my years of practice, I have always had great success with irrigation using a solution of equal parts saline and hydrogen peroxide. For particularly difficult impactions, cerumenolytic drops followed by irrigation is nearly always effective. The guidelines are very detailed and provide good illustrations of ear anatomy and cerumen impaction as well as tables and algorithms.

Special Circumstances

Complete occlusion of the external ear canal can cause damaging pressure effects in diving and aviation and may encourage special efforts to clear the ear. This of course adds risk.

Diving with an occluded ear is not permissible.

External links

References