Experts Update Best Practices for Diagnosis and Treatment of Earwax (Cerumen Impaction)Important Patient Education on Healthy Ear Care

“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 R. Schwartz, MD, MPH, chair of the guideline update group. “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.”

Earwax or cerumen is a normal substance that the body produces to clean, protect, and ‘oil’ ears. It acts as a self-cleaning agent to keep ears healthy. Dirt, dust, and other small matter stick to the earwax which keeps them from getting farther into the ear. Chewing, jaw motion, and growing skin in the ear canal help to move old earwax from inside the ears to the ear opening where it then flakes off or is washed off during bathing. This normal process of making wax and pushing the old wax out is continual.

At times, the ear’s self-cleaning process might not work very well and may lead to a buildup of earwax. When this happens, earwax can collect and block, or partly block, the ear canal. Excessive or impacted cerumen is present in 1 in 10 children, 1 in 20 adults, and more than one-third of the 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. 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,” Dr. Schwartz said. “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 like ear pain, itching, feeling of fullness in the ear, ringing in the ear (tinnitus), hearing loss, discharge coming from the ear, odor coming from the ear, cough, and/or change in hearing aid function.

The update provides a table of dos and don’ts for clinicians to further educate patients about cerumen impaction. Following are a few of those listed in the update:

• DON’T overclean your ears. Excessive cleaning may irritate the ear canal, cause infection, and even increase the changes of cerumen impaction.• DON’T put anything smaller than your elbow in your ear. Your mother was right! Cotton swabs, hair pins, care keys, toothpicks…these can all injure your ear and may cause a laceration (cut) in the ear canal, a perforation (hole) in the eardrum, and/or dislocation of the hearing bones, leading to hearing loss, dizziness, ringing, and other symptoms of ear injury. • DON’T use ear candles. There is no evidence that they remove impacted cerumen, and candling can cause serious damage to the ear canal and eardrum. • DO seek medical evaluation if you have symptoms of hearing loss, ear fullness, and ear pain if you are not certain that they are from cerumen.• DO ask your provider about ways that you can treat your cerumen impaction at home. You may have certain medical or ear conditions that may make some options unsafe. • DO seek medical attention with ear pain, drainage, or bleeding. These are not symptoms of cerumen impaction and need further evaluation.

The primary purpose of the updated guideline is to help clinicians identify patients with cerumen impaction who may benefit from intervention. New evidence, systematic reviews, randomized control trials, observational studies, and an evolved methodology, which included a consumer representative, were at the foundation of the update.

“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.”

The update is endorsed by 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 Society of Otorhinolaryngology and Head-Neck Nurses (SOHN). Additionally, it is supported by American Speech-Language-Hearing Association (ASHA).

The guideline authors are: 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.

Members of the media who wish to obtain a copy of the guideline or request an interview should contact: Tina Maggio at 703-535-3762, or [email protected]. Upon release, the guideline can be found at www.entnet.org.

About the AAO-HNS/FThe American Academy of Otolaryngology—Head and Neck Surgery, one of the oldest medical associations in the nation, represents about 12,000 physicians and allied health professionals who specialize in the diagnosis and treatment of disorders of the ears, nose, throat, and related structures of the head and neck. The Academy serves its members by facilitating the advancement of the science and art of medicine related to otolaryngology and by representing the specialty in governmental and socioeconomic issues. The AAO-HNS Foundation works to advance the art, science, and ethical practice of otolaryngology-head and neck surgery through education, research, and lifelong learning. The organization's vision: "Empowering otolaryngologist-head and neck surgeons to deliver the best patient care."

FACT SHEET: AAO-HNSF Updated Clinical Practice Guideline: Earwax (Cerumen Impaction)

“The update to the 2008 guidelines encompasses a variety of tools for clinicians in treating and communicating with their patients. 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.”— Seth R. Schwartz, MD, MPH, guideline chair

What is the purpose of this guideline?• The primary purpose of this guideline is to help clinicians identify patients with cerumen impaction who may benefit from intervention and to promote evidence-based management and treatment.

What is earwax (cerumen impaction)?• At times, your ear’s self-cleaning process might not work very well and may lead to a buildup of earwax. When this happens, earwax can collect and block or partly block your ear canal. Impacted earwax can cause symptoms like hearing loss, itching, or ear pain. The impaction also makes it hard for your health care provider to see in your ears. You can have symptoms when your ear canal is completely blocked by earwax or only partly blocked.

Why is the Earwax Impaction guideline important?• Excessive or impacted cerumen is present in 1 in 10 children, 1 in 20 adults, and more than one-third of the geriatric and developmentally delayed populations. • About 12 million people in the United States annually seek medical care for problematic cerumen, resulting in nearing 8 million cerumen removal procedures.• Nearly $50 million was spent by Medicare in 2012 for cerumen-related procedures, and cerumen impaction was a diagnosis in up to 5 percent of Medicare patients. • Estimates suggest that between 19 percent and 65 percent of patients 65 years or older have cerumen impaction. In the developmentally delayed adult population, 28 percent to 36 percent have excessive or impacted cerumen. The presence of cerumen impaction has been associated with hearing loss and diminished cognitive function in these populations.

Why do I have earwax?• Earwax or “cerumen” (si-ROO-men) is a normal substance made by our bodies to clean, protect, and “oil” our ears. It acts as a self-cleaning agent to keep our ears healthy. Dirt, dust, and other small pieces of stuff stick to the earwax which keeps them from getting farther into the ear. Chewing, jaw motion, and growing skin in the ear canal help to move old earwax from inside our ears to the ear opening where it then flakes off or is washed off when we bathe. This normal process of making wax and pushing the old wax out continues nonstop.

What are the symptoms of earwax impaction?• Ear pain• Itching• Feeling of fullness in the ear• Ringing in the ear (tinnitus)• Hearing loss• Discharge coming from the ear• Odor coming from the ear• Cough• Change in hearing aid function What are significant points made in the guideline?

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

2a. Diagnosis of cerumen impactionClinicians 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 factorsClinicians 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 asymptomaticClinicians should not routinely treat cerumen in patients who are asymptomatic and whose ears can be adequately examined.

3c. Need for intervention in special populationsClinicians 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 usersClinicians should perform otoscopy to detect the presence of cerumen in patients with hearing aids during a healthcare encounter.

5a. Recommended interventionsClinicians 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 agentsClinicians may use cerumenolytic agents (including water or saline solution) in the management of cerumen impaction.

7. IrrigationClinicians may use irrigation in the management of cerumen impaction.

8. Manual removalClinicians may use manual removal requiring instrumentation in the management of cerumen impaction.

9. Outcomes assessmentClinicians 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 careClinicians 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 preventionClinicians may educate/counsel patients with cerumen impaction/excessive cerumen regarding control measures.

How is earwax impaction diagnosed?• Earwax impaction is diagnosed through a physical examination and review of your medical history. Your healthcare provider may look in your ear canal with a tool called an otoscope (OH-t-OH-scope) or other device to see if you have impacted earwax. If you do, you may be treated for the impaction at that time or you may be sent to another provider for treatment.

How is it treated?• Impacted earwax can be treated in several ways. Some of the treatments can be done at home, but you may have certain medical or ear conditions that could make home options unsafe. You and your health care provider should discuss possible treatments and decide on the best treatment for you. Available treatments are:o Watchful waiting, or observation for a period of time - Earwax removal by the body is a natural process and many impactions clear on their own. Your health care provider might offer the option to wait and see if the problem goes away or gets worse over time. o Irrigation, or ear syringing – This involves clearing the wax out of the ear canal by a stream of warm water. Self-irrigation can be done at home. Irrigation is not recommended for patients who get a lot of ear infections, have ear tubes, or a hole in the eardrum. Home-use of oral jet irrigators is not effective and is not recommended as they can lead to damage in the ear.o Wax softening agents (Cerumenolytics) – These are ear drops that soften or break up the wax to help in removal. These solutions can be used alone or together with irrigation or physical removal by a provider.o Physical removal of wax with special instruments or a suction device – Physical removal of earwax should only be performed by a health care provider.

Can I use cotton swabs to clean inside my ears?• You should avoid putting things in your ears. You may see some earwax come out on a cotton swab, bobby pin, paperclip, or other item you put in your ear canal, but you are really only pushing earwax back into your ear, which may cause problems. • Putting things in your ears irritates them and can cause even more wax to be produced. You can also injure your ear by putting a hole in an eardrum, cutting or scratching the ear canal skin, or even causing an ear infection.

What about ear candling?• Ear candling or ear coning is NOT a safe option for earwax removal. Research shows that ear candling does NOT create a vacuum to suck earwax from the ear. Any wax left on the ear candle is from the candle itself, not earwax. Some risks of the ear candling process are:o Burns to the ear canal o Ear blockage from candling waxo Hole in eardrumo Ear infection

Should I do anything to prevent earwax buildup?• Not everyone needs prevention, but it is best for some groups. If you are elderly, use hearing aids, or if you have a history of making too much earwax, you may need regular treatment. It is important to remember that earwax is natural and helpful to the body. It does not always need to be removed. You do not have to do anything unless you have earwax buildup that causes symptoms or prevents your health care provider from examining your ears.

Where can I get more information?• Healthcare providers should discuss all treatment options and find the best approach for the patient. There are printable patient handouts and materials that further explain earwax impaction and can help with decisions about care options. For more information on earwax impaction, go to http://www.entnet.org/CerumenCPG

About the AAO-HNS/F The American Academy of Otolaryngology—Head and Neck Surgery (www.entnet.org), one of the oldest medical associations in the nation, represents about 12,000 physicians and allied health professionals who specialize in the diagnosis and treatment of disorders of the ears, nose, throat, and related structures of the head and neck. The Academy serves its members by facilitating the advancement of the science and art of medicine related to otolaryngology and by representing the specialty in governmental and socioeconomic issues. The AAO-HNS Foundation works to advance the art, science, and ethical practice of otolaryngology-head and neck surgery through education, research, and lifelong learning. The organization's vision: "Empowering otolaryngologist-head and neck surgeons to deliver the best patient care."