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Abstract
Background:
Ear syringing is a very common practice among general practitioners (GPs). It is used by many as the treatment of choice for cerumen (ear wax), and is usually effective and safe. However, complications from syringing are an increasingly common reason for presentation to ear, nose and throat (ENT) specialists and medico-legal complaints against GPs.
Objective:
The aim of this article is to provide GPs with the knowledge to safely manage cerumen.
Discussion:
Ear wax is an important part of a normal functioning ear. It is mostly asymptomatic and requires no treatment. Softening ear drops may be necessary to help the ear fulfil its self-cleaning function, and should be considered first-line treatment. Syringing can be safely performed if this fails by taking a thorough history and examination to exclude contraindications, gaining patient consent and ensuring the appropriate use of equipment. Referral to an ENT clinic for manual removal with microsuctioning may be necessary in the event of contraindications, complications or failure.
... CM removal techniques include mechanical removal, suction and aural irrigation (Johnson et al. 2013;Poulton et al. 2015;Saana et al. 2014). The choice of procedure is often based on practitioner competence, medical conditions and considerations of the patient, consistency of cerumen, as well as available resources (Saana et al. 2014). ...
... Aural irrigation should be performed only after obtaining a full medical history, performing an ear examination, and giving the patient information regarding the procedure and its possible complications (Poulton et al. 2015). A jet of body-temperature water is introduced into the ear canal with a syringe. ...
... It is important to make sure the tip of the syringe does not go deep into the ear canal to avoid exerting extreme pressure to the tympanic membrane, which can result in perforation, otalgia or bleeding. Along with the jet of water, cerumen and other debris should flow out of the auditory meatus (Armstrong 2009;Poulton et al. 2015). The procedure should be stopped immediately if pain or bleeding occurs. ...
Objective: To determine the training, self-reported competence and practice patterns of South African audiologists (SAAs) regarding cerumen management (CM).
Design: Prospective cross-sectional survey. An online questionnaire was completed by SAA between July and September 2016. The questionnaire addressed sections on educational training, experience and practice patterns of SAAs regarding CM.
Study sample: Three hundred and fifty-six SAAs responded to an email invitation sent to 382 actively-practicing audiologists.
Results: Majority of the participants (85%) were employed for less than 10 years. Forty-nine percent received less than 10 hours of theoretical training while 57% received less than 10 hours of clinical education. A total of 96% of the participants indicated they felt competent to perform CM, with 96% preferring manual, ear syringing, or a combination of the two. Handwashing pre- and post-procedure was the preferred method of infection prevention and control by 87% of the participants with 66% of these indicating they only wore gloves. Majority (85%) of the participants indicated that they always explained the possible complications of CM to their patients.
Conclusion: Findings from this study indicate that South African audiologists feel that they are adequately trained and competent to perform CM.
... Symptoms of wax include pain, itching, sensation of fullness, hearing loss, tinnitus, odor, discharge, and cough. [4,6] There are several methods and products for wax removal. Methods include irrigation, suctioning, and manual removal with curette, probe, forceps, or hooks. ...
... Methods include irrigation, suctioning, and manual removal with curette, probe, forceps, or hooks. [4,6] Products include acetic acid, triethanolamine, almond oil, camphor oil, glycerol and propylene glycol preparations. [4,7] These products are instilled in the ear canal several times a day for a few days and then the patient is recalled for removal. ...
Introduction: There are various methods of ear wax extraction and there are no specific guidelines on this subject. Many times we ask patients to instil some wax softening product for a few days and revisit for wax removal. This revisits result in increased cost, discomfort and loss of time. We conducted this study to determine the effectiveness of same-day ear wax removal as an office procedure with one or more techniques. Our secondary objective was to find the association between various factors and successful wax removal. Methods: During the study period, all patients with ear wax managed by a single ENT surgeon were included. History and examination were done and findings noted. One or more methods including probe, forceps, hooks, curette, suction, wax softening with wax softening agents, syringing were applied for wax removal. Complete wax removal was noted as success. Results: There were a total of 63 cases of ear wax among 34 participants. Wax was successfully removed in 52 (82.5%) cases in the same day. Presence of ear ache, narrow canal, complete obstruction and hard dry wax were adversely associated with successful wax removal. Presence of ear fullness, ear discharge, or use of ear drops in home was not significantly associated with successful ear wax removal. Conclusion: We were able to extract wax from a large proportion of patients on the same day of visit, thereby reducing their cost of revisit, however there were 17.5% of cases who could not be treated successfully on the same day.
... All rights reserved. ear canal occlusion (63,64). Different ear drops may be used (65). ...
Ichthyosis is the term used to describe continual and widespread scaling of the skin. There are several genetic types which are present from birth and persist life‐long – the “congenital ichthyoses”. There is no agreed treatment ‐ different doctors use different approaches, so this group of experts from all over Europe worked together to develop guidelines. They reviewed the medical literature and met to discuss the evidence and to make recommendations. A separate paper (Part 1) covered treatments for the skin condition itself. This paper, Part 2, provides guidelines for managing complications of the congenital ichthyoses. Itch, pain and infections are common, particularly fungal infection, and cancers sometimes occur. Tight skin often prevents eyelids from shutting properly so the eye surface must be protected with lubricant; eyelid massage may help and retinoid medicine may soften tight skin but can dry the eyes further. Surgical options include injecting filler or grafting extra skin to the eyelid: if the patient's own ichthyotic skin is used the problem eventually recurs and mucous membrane from inside the mouth is a promising alternative. Hearing is commonly affected: blockage of ears by a build‐up of skin may be prevented by regular oil drops but syringing or suction may be necessary. In children, growth may be affected and vitamin D supplements are usually recommended. There are special considerations for newborn babies and those with complex ichthyotic disorders such as Netherton Syndrome, epidermolytic ichthyosis and Ichthyosis Prematurity Syndrome. These treatment guidelines should help to improve outcomes and quality of life for patients with congenital ichthyoses. Linked Article: Mazereeuw‐Hautier et al. Br J Dermatol 2019; 180:484–495
... Commonly used methods were ceruminolytic agent installation to soften and liquefied the earwax and help the ear fulfill its selfcleaning function. This method should be considered first-line treatment of earwax impaction [23]. It is very easy for patient to apply ceruminolytic agent at home and this could lead to its high prescription. ...
Introduction Earwax impaction occurs when it is symptomatic or prevents ear canal and tympanic membrane examination [1,2]. Annually earwax is responsible for about 12 million people consultation in the United States and 8 million earwax removal procedures [3]. Earwax impaction is one of the most common otologic conditions seen in primary care. Removing impacted earwax is the most common ear, nose, and throat procedure carried out in our community by general practitioner [4]. Often it causes unpleasant symptoms and present with hearing impairments, discomfort, itching and vertigo or asymptomatic [4-8]. It is common and serious sequel are hearing loss, social withdrawal, poor work function, ear injury from self-cleaning and so on [9]. It is major causes of primary care and secondary care consultation in ear, nose and throat clinic among the elderly people, mentally retarded people and infirm people [1,9,10]. There is still poor knowledge on the physiology, pathology, clinical significance and management of impacted earwax. So, there is a further need in the investigation of management of impacted cerumen [11]. Earwax impaction removal may be complicated with, trauma, bleeding, otitis externa, perforated eardrum and so on [9]. When the management of earwax impaction is comorbid with perforated eardrum, immune compromised patients and so on this may pose further problem the managing physician. Abstract Background: Earwax impaction removal is one of the common otolaryngological procedures performed by general practitioner and nurses worldwide. This study aimed at determined the number, methods and complications of impacted earwax removal by general practitioner.
... This is because of widely documented complications, which include ear canal trauma, traumatic perforated tympanic membrane, hearing impairment, impacted ear wax, infection, and retention of the cotton bud. [8][9][10][11][12] Little research work has been conducted on the usage of cotton bud in developing country. This study aimed at determining the cotton bud: usage, presentation, complications, and management among otorhinolaryngology patients in developing country. ...
AIMS AND OBJECTIVES: Cotton bud usage is a common bad health practice among many patients despite associated complications. This study aimed at determining the cotton bud: usage, presentation, complications, and management among otorhinolaryngology patients in developing country. MATERIALS AND METHODS: This is a prospective hospital-based study of cotton bud usage. The study was carried out over a period 6 months between June and November 2017. Verbal consent was obtained from consented patients. Interview-assisted questionnaire was administered to obtain data. Data obtained were collated and statistically analyzed by using SPSS version 16. RESULTS: Prevalence of cotton bud usage was 83.4%. There were 45.7% male respondents and male to female ratio of 1:1. Common reasons for cotton bud usage were personal hygiene in 25.5%, itching in 23.9%, water in ear in 11.7%, and dirty/earwax in 11.3%. Cotton bud usage for ear cleaning was by self in 54.6%, parent in 32.8%, friend in 6.7%, and spouse in 5.8%. Bilateral ears were most commonly cleaned by cotton bud in 57.1%. The right ear in 25.2% was more common than left ear in 17.8%. No complications were in 37.7%. There were 28.2% injury to external ear, 23.9% impacted cotton bud, and 10.1% traumatic perforated tympanic membrane. On patients' understanding on danger of cotton bud usage, dangerous, not dangerous, and not sure were 28.5, 60.4, and 11.1%, respectively. Common clinical features were earache, itching, hearing loss, and dirty/earwax 33.7, 19.6, 19.0, and 18.7%, respectively. Long-time (chronic) cotton bud usage accounted for 63.8% while short-time (acute) ear cleaning accounted for 36.2%. Frequency of cotton bud usage in these patients was daily in 54.9%, weekly in 20.9%, monthly in 4.9%, and occasionally in 19.3%. The most common diagnosis of cotton bud usage was personal hygiene in 25.5%. Other diagnosis of cotton bud usage was allergy in 18.7%, otitis externa in 18.1%, earwax impaction in 13.2% foreign body impaction in 11.3%, and hearing impairment in 8.3%. No information, information from family, and information from neighborhood were 31.6, 43.6, and 24.8%, respectively. Treatments offered were health education in all the patients, conservative/medical treatment in 88.7%, and cotton bud removal in 11.3%. KEYWORDS external ear canal, cotton bud, Ekiti, otology RESEARCH ARTICLE 2 | Adegbiji and Aremu MedLife Open Access (ENT-Otolaryngology)
... All rights reserved. ear canal occlusion (63,64). Different ear drops may be used (65). ...
These guidelines for the management of congenital ichthyoses have been developed by a multidisciplinary group of European experts following a systematic review of the current literature, an expert conference held in Toulouse in 2016, and a consensus on the discussions. These guidelines summarize evidence and expert‐based recommendations and intend to help clinicians with the management of these rare and often complex diseases. These guidelines comprise two sections. This is part two, covering the management of complications and the particularities of some forms of congenital ichthyosis.
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... 8 The external auditory meatus has the ability to clean itself, which is made possi-ble by the cleansing function of cerumen, a naturally occurring substance that cleans, protects and lubricates the external auditory canal. 1 It is usually unnecessary to clean the ear canal, as excessive cleaning increases humidity and softens the ear canal lining, which can result in infection and irritation of the ear that can cause changes to the skin lining and thereby impair normal functioning. 9,10 Cerumen, with its content of lysosomes, glycoproteins, immunoglobulins, lipids and trace elements, has a bactericidal action that plays a significant role in maintaining the local host defence mechanism in the ear. 11 It has a high acidic pH (about 4 to 5), which is unfavourable for organisms and helps reduce the risk of infection in the auditory canal. ...
Self-ear cleaning is the insertion of objects into the ear canal to clean it, a widespread practice that has the potential to compromise its integrity as a natural, selfcleansing mechanism, and a risk factor for possible injuries. The practice is common among young adults and highest in university than any other graduates. This study aimed to determine the self-ear cleaning practices and associated risk of injury and related symptoms in undergraduate students at KwaZulu-Natal University. The descriptive survey utilized a self-administered questionnaire. Of the 206 participants that responded, 98% engaged in self-ear cleaning, with 75% indicating that it was beneficial. The commonest method (79.6%) being the use of cotton buds, with an associated injury rate of 2.4%. There was no statistically significant associations between those who used or did not use cotton buds and the symptoms experienced. The complications indicate that self-ear cleaning does pose a risk for injury, necessitating more community information and education.
Objectives:
To evaluate the efficacy of 2.5% sodium bicarbonate and docusate sodium in patients with complete occlusion of the ear canal from impacted cerumen.
Study design:
Randomized controlled trial.
Method:
We enrolled patients with unilateral complete cerumen occlusion of the ear canal that was unable to be removed using suction. Either 2.5% sodium bicarbonate or docusate sodium was applied and allowed to sit for 15 minutes. The ear canal was then cleaned under a microscope for up to 3 minutes until the tympanic membrane was completely visible. A second attempt with the same agent was performed in subjects in whom the first application was unsuccessful. The outcomes were compared between the two groups in terms of cleaning, the success rate, time taken to clean the canal, and adverse events.
Results:
There were 91 participants enrolled in this study. The mean age of the participants was 48.0 years. The patients' demographic did not differ between the two groups. At the end of the treatment, the tympanic membrane was completely visible in 41 (91.11%) subjects treated with 2.5% sodium bicarbonate and 38 (82.61%) subjects treated with docusate sodium, with a 1.10 success ratio between the two groups (95% CI: 0.94-1.29, p = 0.23). The mean successful suctioning time was 103.61 seconds using 2.5% sodium bicarbonate and 124.13 using docusate sodium. The mean difference was 20.52 seconds (95% CI: -10.55-51.59).
Conclusion:
2.5% sodium bicarbonate demonstrated non-inferior efficacy and safety compared with docusate sodium. We recommend using this agent in clinical practice.
Trial registration:
Clinicaltrials.in.th/TCTR20160803001.
Background:
Build-up of earwax is a common reason for attendance in primary care. Current practice for earwax removal generally involves the use of a softening agent, followed by irrigation of the ear if required. However, the safety and benefits of the different methods of removal are not known for certain.
Objectives:
To conduct evidence synthesis of the clinical effectiveness and cost-effectiveness of the interventions currently available for softening and/or removing earwax and any adverse events (AEs) associated with the interventions.
Data sources:
Eleven electronic resources were searched from inception to November 2008, including: The Cochrane Library; MEDLINE (OVID), PREMEDLINE In-Process & Other Non-Indexed Citations (OVID), EMBASE (OVID); and CINAHL.
Methods:
Two reviewers screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text or retrieved papers and data were extracted by two reviewers using data extraction forms developed a priori. Any differences were resolved by discussion or by a third reviewer. Study criteria included: interventions - all methods of earwax removal available and combinations of these methods; participants - adults/children presenting requiring earwax removal; outcomes - measures of hearing, adequacy of clearance of wax, quality of life, time to recurrence or further treatment, AEs and measures of cost-effectiveness; design - randomised controlled trials (RCTs) and controlled clinical trials (CCTs) for clinical effectiveness, cohort studies for AEs and cost-effectiveness, and costing studies for cost-effectiveness. For the economic evaluation, a deterministic decision tree model was developed to evaluate three options: (1) the use of softeners followed by irrigation in primary care; (2) softeners followed by self-irrigation; and (3) a 'no treatment' option. Outcomes were assessed in terms of benefits to patients and costs incurred, with costs presented by exploratory cost-utility analysis.
Results:
Twenty-six clinical trials conducted in primary care (14 studies), secondary care (8 studies) or other care settings (4 studies), met the inclusion criteria for the review - 22 RCTs and 4 CCTs. The range of interventions included 16 different softeners, with or without irrigation, and in various different comparisons. Participants, outcomes, timing of intervention, follow-up and methodological quality varied between studies. On measures of wax clearance Cerumol, sodium bicarbonate, olive oil and water are all more effective than no treatment; triethanolamine polypeptide (TP) is better than olive oil; wet irrigation is better than dry irrigation; sodium bicarbonate drops followed by irrigation by nurse is more effective than sodium bicarbonate drops followed by self-irrigation; softening with TP and self-irrigation is more effective than self-irrigation only; and endoscopic de-waxing is better than microscopic de-waxing. AEs appeared to be minor and of limited extent. Resuts of the exploratory economic model found that softeners followed by self-irrigation were more likely to be cost-effective [24,433 pounds per quality-adjusted life-year (QALY)] than softeners followed by irrigation at primary care (32,130 pounds per QALY) when compared with no treatment. Comparison of the two active treatments showed that the additional gain associated with softeners followed by irrigation at primary care over softeners followed by self-irrigation was at a cost of 340,000 pounds per QALY. When compared over a lifetime horizon to the 'no treatment' option, the ICERs for softeners followed by self-irrigation and of softeners followed by irrigation at primary care were 24,450 pounds per QALY and 32,136 pounds per QALY, respectively.
Limitations:
The systematic review found limited good-quality evidence of the safety, benefits and costs of the different strategies, making it difficult to differentiate between the various methods for removing earwax and rendering the economic evaluation as speculative.
Conclusions:
Although softeners are effective, which specific softeners are most effective remains uncertain. Evidence on the effectiveness of methods of irrigation or mechanical removal was equivocal. Further research is required to improve the evidence base, such as a RCT incorporating an economic evaluation to assess the different ways of providing the service, the effectiveness of the different methods of removal and the acceptability of the different approaches to patients and practitioners.
Objective:
Cerumen impaction is a common problem, and aural microsuction is a technique frequently employed for its management. This study aimed to quantify the patient perception, safety and efficacy of this procedure.
Methods:
Patients were asked to complete a questionnaire following cerumen clearance by microsuction. The perceived severity of pain, noise-related discomfort and vertigo was scored on a scale of 1 to 10. Patients with mastoid cavities and those who had used a cerumenolytic agent in the preceding week were analysed separately.
Results:
A total of 159 questionnaires were returned. Mean scores (95 per cent confidence intervals) were: pain, 2.34 (2.06-2.62); noise discomfort, 3.03 (2.71-3.35); and vertigo, 1.95 (1.66-2.25). There was successful clearance (i.e. sufficient to view the tympanic membrane) in 91 per cent of cases. Patients who had used cerumenolytics reported significantly less pain and vertigo (p = 0.008 and p < 0.001, respectively) compared with those who had not, whilst patients with mastoid cavities reported greater levels of vertigo (p < 0.001) than those without.
Conclusion:
Aural microsuction is well tolerated. Side effects are mild, and the prior use of cerumenolytics appears to further reduce their severity.
To measure the noise generated during suction aural toilet and to determine whether there is any clinically measureable effect on audiometric thresholds.
Prospective, controlled study with 14 patients.
The study was conducted in an aural toilet clinic in a district general ENT department.
Fourteen patients who attend regularly for suction aural toilet to clear cerumen.
Live direct measurement of noise levels during treatment. Pre-treatment and post-treatment pure tone audiometry.
Microsuction generated a broadband sound with a peak at 2 kHz. Sound levels peaked at over 120 dB(A) in two patients. We found no evidence of any shift in audiometric thresholds following microsuction aural toilet.
Microsuction is a noisy procedure that is uncomfortable for some patients. However, it does not appear to be sufficiently noisy to produce a clinically detectable threshold shift. We would suggest that it is safe but that the use of non-suction methods or a fine end may on occasion be preferable to improve patient comfort.
Problems attributed to the accumulation of wax (cerumen) are among the most common reasons for people to present to their general practitioners with ear trouble. Treatment for this condition often involves use of a wax softening agent (cerumenolytic) to disperse the cerumen, reduce the need for, or facilitate syringing, but there is no consensus on the effectiveness of the variety of cerumenolytics in use.
To assess the effectiveness of ear drops (cerumenolytics) for the removal of symptomatic ear wax.
We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2008 issue 2); MEDLINE; EMBASE; CINAHL; ISI Proceedings; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was April 2008.
We identified all randomised controlled trials in which a cerumenolytic was compared with no treatment, a placebo, or other cerumenolytics in participants with obstructing or impacted ear wax, and in which the proportion of participants with sufficient clearance of the external canal to make further mechanical clearance unnecessary (primary outcome measure) was stated or calculable.
The two authors reviewed all the retrieved trials and applied the inclusion criteria independently.
Nine trials satisfied the inclusion criteria. In all, 679 participants received one of 11 different cerumenolytics. One trial compared active treatments with no treatment, three compared active treatments with water or a saline 'placebo', and all nine trials compared two or more active treatments. Eight trials included syringing as a secondary intervention.Overall, results were inconclusive. The majority of comparisons showed no difference between treatments. Meta-analysis of two high quality trials produced a statistical difference in favour of triethanolamine polypeptide over saline in preventing the need for syringing, but no other significant differences between treatments.In three trials of high to moderate quality, no difference was found between the effectiveness of either sodium bicarbonate ear drops, chlorbutanol, triethanolamine polypeptide oleate condensate or docusate sodium liquid versus a sterile water or saline 'placebo'.One trial of moderate methodological quality found all three treatments - sodium bicarbonate ear drops, chlorbutanol and sterile water - to be significantly better than no treatment at preventing the need for syringing.None of the higher quality trials demonstrated superiority of one agent over another in direct comparisons.
Trials have been heterogeneous and generally of low or moderate quality, making it difficult to offer any definitive recommendations on the effectiveness of cerumenolytics for the removal of symptomatic ear wax. Using drops of any sort appears to be better than no treatment, but it is uncertain if one type of drop is any better than another. Future trials should be of high methodological quality, have large sample sizes, and compare both oil-based and water-based solvents with placebo, no treatment or both.
The American Academy of Otolaryngology-Head and Neck Surgery Foundation has issued the first comprehensive clinical guidelines for assessment, management, and treatment of impacted cerumen, or earwax (Roland PS et al. Otolaryngol Head Neck Surg. 2008;139[3]:S1-S21).