Head, Neck Surgery Group Issues Evidence-based Guidance on Cerumen Impaction

Symptoms associated with cerumen impaction or obstruction are fairly common complaints among patients seeking help from their family physicians. But until now, clinicians have had little or no evidence-based guidance on managing cerumen impaction. A new guideline developed by a multidisciplinary committee selected by the American Academy of Otolaryngology-Head and Neck Surgery, or AAO-HNS, summarizes the evidence on this common condition and provides guidance to physicians in treating it.

According to Carrie Nelson, M.D., of Wheaton, Ill., program director of the Rush-Copley Family Medicine Residency in Aurora, Ill., and assistant professor of family medicine at Rush Medical College in Chicago, another motivation to develop the guideline was in anticipation of the creation of pay-for-performance standards on this topic. Nelson was a member of the committee that developed the guideline, which was published as a supplement to the September issue of Otolaryngology-Head and Neck Surgery (abstract available free; nonsubscribers pay a fee for full-text access).

The committee defined cerumen impaction as "an accumulation of cerumen that causes symptoms, prevents a needed assessment of the ear canal/tympanic membrane or audiovestibular system, or both." In their guideline, committee members distinguished between patients with cerumen impaction and those who have excessive, but asymptomatic, cerumen accumulation. This latter condition, they said, does not require active management, but may be handled using watchful waiting.

It should be noted that the guideline does not apply to all patients, such as those who have cerumen impaction that is associated with

The guideline also highlights the needs of and management options for special populations of patients who have modifying factors, such as nonintact tympanic membrane, ear canal stenosis, exostoses, diabetes mellitus, immunocompromised status or a history of anticoagulant therapy.

Among specific recommendations included in the guideline is a strong recommendation that "clinicians should treat cerumen impaction that causes symptoms expressed by the patient or prevents clinical examination."

In addition, the guideline recommends that clinicians should

The guideline notes that clinicians may distinguish and evaluate the need for intervention in patients who may not be able to express symptoms, but who present with cerumen that obstructs the ear canal. These patients may include the elderly, young children and the cognitively impaired, all of whom are at high risk for cerumen impaction.

Perhaps one of the most important aspects of the guideline concerns patients who use hearing aids. Nelson said that although clinicians may be hesitant to ask these patients to remove the aids, it's important to do so because cerumen can be a real problem for the devices. The guideline specifically recommends asking such patients to remove their hearing aids so that they can be inspected for cerumen build-up. "If we remove the aids when we have the opportunity to examine the patient's ear, we can save their hearing function," Nelson observed.

The guideline found no real differences between any of the available ceruminolytic agents, and Nelson pointed out that although there are "a lot of ceruminolytic agents, nothing is any better than plain water." Two of the most important things family physicians can take away from the guideline, she said, are the guidance it offers FPs regarding when they should or should not irrigate or remove the cerumen and its assertion that patients treated for cerumen impaction should always be reevaluated to ensure resolution of the problem.