Clinical Practice Guideline (Update): Earwax (Cerumen Impaction)

Otolaryngology—Head and Neck Surgery

Schwartz, S. R., Magit, A. E., et al. (2017).

Otolaryngology—Head and Neck Surgery, 156(1 Suppl), S1-S29.

This is an updated, evidence-based guideline providing recommendations for the management of cerumen impaction. The guideline applies to any population. Specific recommendations are made for special populations. The audience for this guideline includes clinicians likely to identify, manage, or monitor cerumen impaction.

American Academy of Otolaryngology—Head and Neck Surgery Foundation

<p>This clinical practice guideline is as an update and replacement for an earlier guideline published in 2008 by the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF). Changes in content and methodology from the prior guideline include the following:</p> <ul> <li>addition of a consumer advocate to the guideline update group (GUG);</li> <li>new evidence: 3 guidelines, 5 systematic reviews, and 6 randomized controlled trials (RCTs);</li> <li>emphasis on patient education and counseling with new explanatory tables;</li> <li>expanded action statement profiles to explicitly state quality improvement opportunities, confidence in the evidence, intentional vagueness, and differences of opinion;</li> <li>enhanced external review process to include public comment and journal peer review;</li> <li>new algorithm to clarify decision making and action statement relationships; and</li> <li>3 new key action statements on managing cerumen impaction that focus on primary prevention, contraindicated intervention, and referral and coordination of care.</li> </ul>

<p>Recommendations for intervention include:</p> <ul> <li>Regarding cerumenolytic agents, "clinicians may use cerumenolytic agents (including water or saline solution) in the management of cerumen impaction" (Recommendation, Grade B Evidence; p. S16).</li> <li>Regarding irrigation, "clinicians should recommend against ear candling/coning for treating or preventing cerumen impaction" (Recommendation Against, Grade C Evidence; p. S18).</li> <li>Regarding manual removal, "clinicians may use cerumenolytic agents (including water or saline solution) in the management of cerumen impaction" (Option, Grade C Evidence; p. S19).</li> <li>"Clinicians should recommend against ear candling/coning for treating or preventing cerumen impaction" (Recommendation Against, Grade C Evidence; p. S18).</li> </ul>

<p>Regarding outcomes assessment:</p> <p>"Clinicians should assess patients at the conclusion of in-office treatment of cerumen impaction and document the resolution of impaction. If the impaction is not resolved, the clinician should use additional treatment. If full or partial symptoms persist despite resolution of impaction, the clinician should evaluate the patient for alternative diagnoses" (Recommendation, Grade C Evidence; p. S22).</p>

<p>Regarding intervention in users with hearing aids:</p> <p>"Clinicians should perform otoscopy to detect the presence of cerumen in patients with hearing aids during a health care encounter" (Recommendation, Grade C Evidence; p. S16).</p>

<p>Regarding referral and coordination of care:</p> <p>"If initial management is unsuccessful, clinicians should refer patients with persistent cerumen impaction to clinicians who have specialized equipment and training to clean and evaluate ear canals and tympanic membranes" (Recommendation, Grade C Evidence; p. S23).</p>

Recommendations for the prevention of cerumen impaction include: <ul> <li>For primary prevention: <ul> <li>"Clinicians should explain proper ear hygiene to prevent cerumen impaction when patients have an accumulation of cerumen" (Recommendation, Grade C Evidence; p. S8).</li> </ul> </li> <li>For secondary prevention: <ul> <li>"Clinicians may educate/counsel patients with cerumen impaction or excessive cerumen regarding control measures" (Option, Grade C Evidence; p. S24).</li> </ul> </li> </ul>

<p>Regarding whether to provide intervention:</p> <ul> <li>"Clinicians should treat, or refer to another clinician who can treat, cerumen impaction when identified" (Strong Recommendation, Grade B Evidence; p. S13).</li> <li>"Clinicians should not routinely treat cerumen in patients who are asymptomatic and whose ears can be adequately examined" (Recommendation Against, Grade C Evidence; p. S14).</li> <li>"Clinicians should identify patients with obstructing cerumen in the ear canal who may not be able to express symptoms (young children and cognitively impaired children and adults), and they should promptly evaluate the need for intervention" (Recommendation, Grade C Evidence; p. S15).</li> <li>"Clinicians should treat, or refer to a clinician who can treat, the patient with cerumen impaction with an appropriate intervention, which may include one or more of the following: cerumenolytic agents, irrigation, or manual removal requiring instrumentation" (Recommendation, Grade B Evidence; p. S16).</li> </ul>

<p>Regarding diagnosis of cerumen impaction:</p> <ul> <li>"Clinicians should diagnose cerumen impaction when an accumulation of cerumen, as seen with otoscopy, <ul> <li>is associated with symptoms;&nbsp;</li> <li>prevents needed assessment of the ear; or&nbsp;</li> <li>both" (Recommendation, Grade B Evidence; p. S10).</li> </ul> </li> <li>"Clinicians should assess the patient with cerumen impaction by history and/or physical examination for factors that modify management, such as one or more of the following: <ul> <li>anticoagulant therapy;</li> <li>&nbsp;immunocompromised state;&nbsp;</li> <li>diabetes mellitus;&nbsp;</li> <li>prior radiation therapy to the head and neck;&nbsp;</li> <li>ear canal stenosis;</li> <li>exostoses; or</li> <li>nonintact tympanic membrane" (Recommendation, Grade C Evidence; p. S12).</li> </ul> </li> </ul>