UPDATED CLINICAL PRACTICE GUIDELINE
Earwax (Cerumen Impaction)

December 2016/January 2017 - Vol. 35, No. 11

Adapted from the January 2017 Supplement to Otolaryngology–Head and Neck Surgery. Read the guideline at otojournal.org. (Available after January 3, 2017.)

The primary purpose of the update to the Clinical Practice Guideline Earwax (Cerumen Impaction) is to help clinicians identify patients with this condition who may benefit from intervention. New evidence, systematic reviews, randomized controlled trials, observational studies, and an evolved methodology, which included consumers, were at the foundation of the update.

The 2017 update was chaired by Seth R. Schwartz, MD, MPH, with Anthony E. Magit, MD, serving as the assistant chair, and Richard M. Rosenfeld, MD, MPH, as the methodologist. All three were involved in the original 2008 guideline.

“The update to the 2008 guidelines encompasses a variety of tools for clinicians in treating and communicating with their patients,” said Dr. 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.”

Differences between the 2008 guideline and the 2017 update include:

  • a consumer added to the development group;
  • new evidence (one guideline, six systematic reviews, five randomized controlled trials [RCTs], and six observational studies);
  • expanded action statement profiles to explicitly state quality improvement opportunities, confidence in the evidence, intentional vagueness, and differences of opinion;
  • an enhanced external review process to include public comment and journal peer review; and
  • three new key action statements on managing cerumen impaction that focus on primary prevention, contraindicated intervention, and referral and coordination of care.

The update is endorsed by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American Geriatric Society (AGS), American Neurotology Society (ANS), American Otological Society (AOS), American Society of Geriatric Otolaryngology (ASGO), and the Society of Otorhinolaryngology and Head-Neck Nurses (SOHN). Additionally, it is supported by the American Speech-Language-Hearing Association (ASHA). The update replaces the 2008 guideline, which was created by a multidisciplinary panel of clinicians representing the fields of otolaryngology, audiology, family medicine, geriatrics, internal medicine, nursing, and pediatrics.

The full guideline, as well as other resources, will be available after January 3, 2017, at www.entnet.org/node/334 as well as in Otolaryngology—Head and Neck Surgery as published at otojournal.org.

The guideline is intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction, and it applies to any setting in which cerumen impaction would be identified, monitored, or managed. It does not apply to patients with cerumen impaction associated with the following conditions: dermatologic diseases of the ear canal; recurrent otitis externa; keratosis obturans; prior radiation therapy affecting the ear; previous tympanoplasty/myringoplasty, canal wall down mastoidectomy, or other surgery affecting the ear canal.

Guideline recommendations

1. Primary prevention

Clinicians should explain proper ear hygiene to prevent cerumen impaction when patients have an accumulation of cerumen.

2a. Diagnosis of cerumen impaction

Clinicians should diagnose cerumen impaction when an accumulation of cerumen seen with otoscopy 1) is associated with symptoms, or 2) prevents needed assessment of the ear, or 3) both.

2b. Modifying factors

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: anticoagulant therapy, immunocompromised state, diabetes mellitus, prior radiation therapy to the head and neck, ear canal stenosis, exostoses, non-intact tympanic membrane.

3a. Need for intervention if impacted

Clinicians should treat, or refer to another clinician who can treat, cerumen impaction, when identified.

3b. Non-Intervention if asymptomatic

Clinicians should not routinely treat cerumen in patients who are asymptomatic and whose ears can be adequately examined.

3c. Need for intervention in special populations

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 promptly evaluate the need for intervention.

4. Intervention in hearing aid users

Clinicians should perform otoscopy to detect the presence of cerumen in patients with hearing aids during a healthcare encounter.

5a. Recommended interventions

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.

5b. Contraindicated intervention (ear candling/coning)

Clinicians should recommend against ear candling/coning for treating or preventing cerumen impaction.

6. Cerumenolytic agents

Clinicians may use cerumenolytic agents (including water or saline solution) in the management of cerumen impaction.

7. Irrigation

Clinicians may use irrigation in the management of cerumen impaction.

8. Manual removal

Clinicians may use manual removal requiring instrumentation in the management of cerumen impaction.

9. Outcomes assessment

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.

10. Referral and coordination of care

Clinicians should refer patients with persistent cerumen impaction after unsuccessful management by the initial clinician to a clinician with specialized equipment and training for cleaning and evaluating the ear canal and tympanic membrane.

11. Secondary prevention

Clinicians may educate/counsel patients with cerumen impaction/excessive cerumen regarding control measures.

Guideline authors

Seth R. Schwartz, MD, MPH; Anthony E. Magit, MD, MPH; Richard M. Rosenfeld, MD, MPH; Bopanna B. Ballachanda, PhD; Jesse M. Hackell, MD; Helene J. Krouse, PhD, RN; Claire M. Lawlor, MD; Kenneth Lin, MD, MPH; Kourosh Parham, MD, PhD; David R. Stutz, MD; Sandy Walsh; Erika A. Woodson, MD; Ken Yanagisawa, MD; and Eugene R. Cunningham Jr, MS

AAO-HNSF Guideline development process and the obligations associated with the guideline recommendations are documented in the Clinical Practice Guideline Development Manual, Third Edition: a quality-driven approach for translating evidence into action. (http://oto.sagepub.com/content/148/1_suppl/S1.long)

Disclaimer
The clinical practice guideline is provided for information and educational purposes only. It is not intended as a sole source of guidance in managing cerumen impaction. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition and may not provide the only appropriate approach to diagnosing and managing this program of care. As medical knowledge expands and technology advances, clinical indicators and guidelines are promoted as conditional and provisional proposals of what is recommended under specific conditions, but they are not absolute. Guidelines are not mandates; these do not and should not purport to be a legal standard of care. The responsible physician, in light of all circumstances presented by the individual patient, must determine the appropriate treatment. Adherence to these guidelines will not ensure successful patient outcomes in every situation. The AAO-HNS, Inc emphasizes that these clinical guidelines should not be deemed to include all proper treatment decisions or methods of care or to exclude other treatment decisions or methods of care reasonably directed to obtaining the same results.