AAO-HNS Updates Guideline on Diagnosis, Treatment of Cerumen Impaction

After Rigorous Scrutiny, AAFP Endorses New Guidance

January 09, 2017 03:08 pm Chris Crawford

On Jan. 3, the American Academy of Otolaryngology--Head and Neck Surgery Foundation (AAO-HNS) published an updated clinical practice guideline on the diagnosis and treatment of cerumen impaction,(journals.sagepub.com) as well as patient information on the dos and don'ts of earwax management and healthy ear care. The AAFP has endorsed this guideline, which appears in the January issue of Otolaryngology--Head and Neck Surgery.

"This update is significant because it not only provides best practices for clinicians in managing cerumen impaction, it is a strong reminder to patients that ear health starts with them, and there are many things they should do, as well as many things that they should stop doing immediately to prevent damage to their ears," said Seth Schwartz, M.D., M.P.H., chair of the AAO-HNS guideline update group, in a news release.(www.entnet.org) "There is an inclination for people to want to clean their ears because they believe earwax is an indication of uncleanliness. This misinformation leads to unsafe ear health habits."

The AAO-HNS said the primary purpose of the updated guideline is to help clinicians identify patients with cerumen impaction who may benefit from intervention. The update features new evidence, including three clinical guidelines, five systematic reviews and six randomized controlled trials, as well as observational studies and an evolved methodology that included adding a patient representative to the guideline development group.

Story highlights
  • On Jan. 3, the American Academy of Otolaryngology--Head and Neck Surgery Foundation published its updated clinical practice guideline on the diagnosis and treatment of cerumen impaction.
  • The update features new evidence, including recently published clinical guidelines, systematic reviews and randomized controlled trials, as well as observational studies and an evolved methodology.
  • The AAFP has summarized key recommendations from this guideline, which it endorsed.

"The update to the 2008 guidelines encompasses a variety of tools for clinicians in treating and communicating with their patients," said Schwartz. "This includes an algorithm showing the interrelationship of key action statements in a cohesive and understandable way, as well as enhanced information on patient education.

"Having the consumer perspective on the guideline update group provided us a value-added opportunity to incorporate more extensive patient counseling within our treatment protocols."

AAFP Commission on Health of the Public and Science member Kenneth Lin, M.D., M.P.H., of Washington, D.C., also participated in the guideline update group and told AAFP News: "The AAFP's full endorsement of this guideline means that family physicians can trust that its recommendations are the result of a rigorous development process, based on the best evidence available on this condition, and practical and easy to implement in their practices."

The updated guideline also was endorsed by the American Academy of Pediatrics, the American Geriatric Society, the American Neurotology Society, the American Otological Society, the American Society of Geriatric Otolaryngology, and the Society of Otorhinolaryngology and Head-Neck Nurses. Additionally, it was supported by the American Speech-Language-Hearing Association.

Guideline Background

According to the AAO-HNS, excessive or impacted cerumen is present in 10 percent of children, 5 percent of adults and more than 33 percent of geriatric and developmentally delayed populations.

"Patients often think that they are preventing earwax from building up by cleaning out their ears with cotton swabs, paper clips, ear candles or any number of unimaginable things that people put in their ears," said Schwartz. "The problem is that this effort to eliminate earwax is only creating further issues because the earwax is just getting pushed down and impacted further into the ear canal.

"Anything that fits in the ear could cause serious harm to the ear drum and canal with the potential for temporary or even permanent damage."

Impacted earwax can cause symptoms such as ear pain, itching, feeling of fullness in the ear, tinnitus, hearing loss, discharge or odor coming from the ear, cough, and/or a change in hearing aid function.

Key Recommendations

The AAFP has summarized key recommendations from the guideline, including the following:

  • Individuals with an accumulation of cerumen should be counseled on proper ear hygiene to prevent cerumen impaction.
  • An individual should be diagnosed with cerumen impaction when an accumulation of cerumen is associated with symptoms, prevents needed assessment of the ear, or both.
  • Individuals with cerumen impaction should be assessed by history and/or physical examination for factors that modify management, such as one or more of the following: nonintact tympanic membrane, ear canal stenosis, exostoses, diabetes mellitus, immunocompromised state or anticoagulant therapy.
  • Individuals who are asymptomatic and whose ears can be adequately examined should not be routinely treated for cerumen accumulation.
  • An individual with cerumen impaction should be treated with an appropriate intervention, including one or more of the following: cerumenolytic agents, irrigation or manual removal requiring instrumentation.
  • Individuals should be reassessed at the conclusion of in-office treatment of cerumen impaction and the resolution of impaction should be documented. If the impaction is not resolved, additional treatment should be prescribed. If full or partial symptoms persist despite resolution of impaction, alternative diagnoses should be considered.

Lin said that ear examination is part of the general physical exam in children and adults, and during these exams cerumen is assessed.

"The guideline makes clear, however, that cerumen impaction should only be diagnosed if it's bothering the patient (e.g., pain, decreased hearing) and/or prevents needed assessment of the ear," he said. "In other words, there's no reason for family physicians to irrigate the ears or do anything else to clean them out if neither of these conditions are met."

Lin added that certain groups of patients, such as those with hearing aids, will often have earwax buildup and should be routinely evaluated for cerumen impaction. The same goes for young children and cognitively impaired adults, who may be unable to express symptoms of cerumen impaction.

"Clinicians should also strongly advise patients not to use Q-tips or ear candles to self-remove impacted cerumen from their ears, as studies show that both can be harmful," he said. "When I was working in urgent care, at least once a week I had to remove broken Q-tips or other objects from the ear canals of patients who had been trying to clean their ears."

More From AAFP
American Family Physician: Cerumen Impaction

American Family Physician: Information from Your Family Doctor: Earwax: What You Should Know

Additional Resources
American Academy of Otolaryngology--Head and Neck Surgery Patient Information: Frequently Asked Questions: Earwax Prevention(www.entnet.org)

AAO-HNS Foundation Patient Information: Dos and Don'ts of Earwax(www.entnet.org)

AAO-HNS Foundation Patient Information: Shared Decision Making for Patients and Caregivers for Earwax Management(www.entnet.org)

AAO-HNS Foundation Patient Information: Ways to Help Reduce Earwax Buildup(www.entnet.org)