Updated guideline advises on treating children with impacted cerumen

An AAP-endorsed clinical practice guideline on the diagnosis and treatment of cerumen impaction focuses on primary prevention, the decision to intervene, and referral and coordination of care.

The updated guideline was released today by the American Academy of Otolaryngology – Head and Neck Surgery Foundation. It is published in Otolaryngology — Head and Neck Surgery and is available at http://bit.ly/2j0y9O9.

Clinical Practice Guideline (Update): Earwax (Cerumen Impaction) is a revision of a 2008 guideline and includes evaluation of new evidence reviews, newly formulated action statements with an algorithm for implementation and enhanced tools for patient education. The authoring group represented otolaryngology, audiology, pediatrics, internal medicine, nursing and consumer health care advocacy, and the updated guideline has been endorsed by multiple professional societies.

Evaluating impaction

The guideline emphasizes that cerumen is a normally occurring secretion of the external ear and serves to trap external dirt and other substances, thus preventing these materials from getting deeper into the ear canal. The normal ear is self-cleaning such that cerumen and trapped debris are slowly but steadily pushed outward from the ear canal. Cerumen impaction, defined as an accumulation of cerumen in the ear canal that causes symptoms, prevents needed examination of the ear or both, is diagnosed by direct otoscopic visualization.

Indications for intervention 

Excessive or impacted cerumen may be present in as many as 10% of children on routine examination and may block a child’s smaller ear canals, making removal necessary to allow full evaluation of the tympanic membrane in cases of fever and irritability.

Intervention and treatment of cerumen impaction also are indicated when the patient has symptoms, including ear pain or pressure, fullness in the ear and hearing loss. However, therapy ordinarily is not warranted for excessive cerumen without symptoms or when the ability to examine the ear is not impaired. Special consideration is required for patients who are unable to communicate symptomatology, including infants and cognitively impaired patients, as well as those with structural abnormalities of the ear canal, immunosuppression, anticoagulant therapy, diabetes and non-intact tympanic membranes. Patients, including children, who wear hearing aids are at greater risk for cerumen impaction and should receive regular examination and treatment if necessary to optimize hearing efficiency.

Treating impaction

Appropriate methods to treat cerumen impaction include irrigation, manual removal of cerumen and the use of various types of cerumenolytic agents, including water and saline. All of these methods are of equal efficacy when used by trained practitioners.

Failure of first-line treatments to resolve the impaction should prompt referral of the patient to a practitioner with specialized equipment and training in this procedure. The guideline advises against the use of ear candling or coning, as these popular folk remedies have no demonstrated efficacy and are associated with the potential for complications.

Patient education

The guideline also includes a list of questions often asked by patients, along with a discussion of suggested responses, reflecting the presence of a consumer representative on the panel. As there are many misconceptions about earwax among the public, health care providers should not neglect patient education opportunities.

Patients should be instructed about normal earwax and the self-cleaning nature of the external ear. They also should be advised that attempts to clean one’s own ears or those of one’s children by using cotton swabs or other objects inserted into the ear may lead to further impaction of cerumen, damage to the skin of the ear canal or perforation of the tympanic membrane. Some patients with excessive cerumen buildup may benefit from regular removal, but this is unnecessary in the vast majority of patients.

Dr. Hackell represented the Academy on the panel that developed the guideline and is a co-author.