New Guidelines on Managing Cerumen Impaction Available

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published updated clinical practice guidelines on the management of cerumen impaction or earwax. The new recommendations, an update to the 2008 guidelines, include several updates such as a new treatment algorithm and three new key action statements that focus on primary prevention, contraindicated intervention, and coordination of care.

While the guidelines may not apply to all patients (eg, those with dermatological diseases of the ear canal, previous radiation therapy affecting the ear, recurrent otitis externa, surgery affecting the ear canal, keratosis obturans, previous tympanoplasty/myringoplasty, and canal wall down mastoidectomy), the primary purpose is to aid clinicians who are likely to diagnose and treat cerumen impaction.  

The following are recommendations made by the panel regarding diagnosis and treatment:

• Proper hygiene should be explained to patients with an accumulation of earwax
• If accumulation (as seen on otoscopy) is associated with symptoms or prevents assessment of the ear, or both, a diagnosis of impaction should be made
• Assess patients by history/physical exam for factors that modify management, for example, one or more of the following: treatment with anticoagulants, immunocompromised, diabetes, previous radiation therapy to head/neck, ear canal stenosis, exostoses, nonintact tympanic membrane
• If no symptoms are present and ears can be examined, routine treatment is unnecessary
• Patients who may not be able to express symptoms (ie, young children, cognitively impaired) should be evaluated to see if intervention is necessary
• During the healthcare encounter, perform otoscopy to detect presence of cerumen in those with hearing aids
• Treatment can include one or more of the following: cerumenolytic agents, irrigation, manual removal requiring instrumentation
• Ear candling/coning should not be recommended for treating or preventing impaction
• Assess patients after in-office treatment; if not resolved, use additional treatment; if full or partial symptoms continue despite impaction resolution, consider alternative diagnoses
• Refer to specialists with equipment and training to evaluate ear canals and tympanic membranes if initial management is unsuccessful

In addition, the panel offered several optional recommendations for clinicians, including:

• Use cerumenolytic agents (including water or saline solution) to manage cerumen impaction
• Use irrigation to manage cerumen impaction
• Manual removal requiring instrumentation may be used to manage cerumen impaction
• Counsel patients regarding control measures 

While the new guidelines are based on a significant amount of evidence, the panel does acknowledge there are still gaps in knowledge on the effective management of cerumen impaction. This includes data on the comparative impact of different cerumenloytic agents, as well as the assessment of various methods of cerumen removal, either as single or combined interventions.

The full guidelines which include the evidence quality for each statement are available here.