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Clinical Practice Keywords Ear care/Cerumen/ Impaction/Irrigation/Microsuction Discussion This article has been Ear care double-blind peer reviewed In this article... ● Prevalence and negative effects of earwax impaction ● Needs of vulnerable patient groups regarding ear care ● How earwax impaction needs to be treated in primary care

Earwax impaction: why it needs to be treated in primary care

Key points Author Hilary Harkin is ear, nose and throat clinical nurse specialist at the ear, nose Earwax can cause and throat outpatient department, Guy’s and St Thomas’ NHS Foundation Trust. hearing loss, vertigo, tinnitus, pain, Abstract Many people who present to their general practice with impacted earwax discharge, infection are not offered removal services locally, but referred to secondary care, advised to and cough self-care or directed to private services. Earwax impaction can have severe negative effects on health, wellbeing and quality of life. General practices have a duty to offer Earwax impaction earwax removal. In addition, patient groups that are vulnerable or unlikely to complain can compound about earwax or loss of hearing – such as children, older people and people with age-related cognitive impairment – need to have their ears and hearing regularly assessed. hearing loss Citation Harkin H (2019) Earwax impaction: why it needs to be treated in primary Patients with care. Nursing Times [online]; 115: 8, 38-40. uncomplicated earwax impaction should be treated arwax impaction is a buildup of (Schwartz et al, 2017). These are significant in primary care wax in the ear canal (Fig 1) that symptoms that can adversely affect patient’s causes symptoms ranging from health outcomes, safety and quality of life. Patients with loss Emild to severe. It is becoming In the UK, it is estimated that 2.3 mil- of hearing that is more common for UK general practices lion people annually have problems with not due to earwax not to provide earwax removal services, earwax, but because many people do not impaction need to despite the fact that the National Institute undergo routine ear examinations, the be seen by an for Health and Care Excellence recom- figure is likely to be much higher. Impacted audiologist mends that earwax removal should be earwax is present in one in 10 children, one offered in the community (NICE, 2018). in 20 adults, over 30% of older people and Children, older In a letter to the BMJ, Harvey (2018) more than 30% of people with learning dis- people and people wrote that getting earwax removed was a abilities (Sevy and Singh, 2019). with cognitive real frustration for both patients and GPs. Al Khabori et al (2007) warned that wax impairment or The provision of ear care seems to be a in the ear canal causes “a sizeable burden” learning disabilities “postcode lottery”. In areas where there are on the healthcare resources of a country. need regular ear no nurse-led clinics, patients often have to They conducted a study in Oman and assessments use private clinics. GPs can feel that wax found that 11.7% of 11,402 people had removal is not within their contract and impacted earwax, of which 23.9% were unless there is a nurse in the surgery who over the age of 60 years. The cost of man- is passionate about ear care, it is often the aging the problem was estimated at that first service removed. time to be 3.6m US dollars.

Extent of the problem Loss of hearing Earwax can be an innocuous problem that Hearing decreases with age. Presbycusis is simply causes a sensation of blockage in the a common age-related hearing loss caused ear, but it can also cause debilitating symp- by degeneration of the cells in the organ of toms such as hearing loss, vertigo, tinnitus, Corti (the receptor organ for hearing). As pain, discharge, infection and cough hearing loss is gradual, progressive and

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Fig 1. Earwax blocking the ear canal Current situation Earwax buildup and associated hearing loss can be easily dealt with, provided earwax removal services are accessible locally and promptly. However, this is far from being the case everywhere in the UK. Tympanic membrane Despite the fact that the Primary Ear Care Centre trains nurses, healthcare assistants, audiologists and pharmacists in irrigation with water and microsuction (Mills, 2018), there are currently few NHS general prac- Earwax tices where both techniques are available. In general practices that do not offer microsuction, patients are often told that they should self-treat using eardrops, referred to specialist services in secondary care (if that pathway is available to them) Ear canal or directed to private services that provide microsuction at an average cost of £70 for both ears. It appears that, in some areas, Eustachian tube ear care is being covertly privatised. If that is the case, patients must be informed in an honest and timely manner, so they can have their earwax removed before symp- often bilateral, older people may not removed. As people in that patient group toms increase. realise that their hearing is reduced until are unlikely to ask for their ears to be exam- Although there is no financial incentive others point it out to them. Hearing loss ined, the authors advised that they should for general practices to remove earwax, has been shown to increase risk of isola- undergo annual ear assessments. Research patient comfort, safety and quality of life tion, confusion, increased accidents at in Israel on earwax impaction in older aside, there are financial benefits to be home and depression. adults and people with learning disabilities gained from not referring patients to sec- Wax obstructing the ear canal com- has led to awareness and training pro- ondary care and not having to treat the pounds age-related hearing loss and might grammes being initiated to educate health adverse effects of earwax impaction. transform an acceptable level of reduced professionals (Roth et al, 2011). hearing into a significant and disabling How to address the problem loss of hearing. Earwax buildup occurs Removal techniques Patients with normal ears and earwax over time, so the gradual deterioration in Earwax can be safely removed using one of buildup should not be referred to the ear, hearing it causes may be mistaken for part three techniques: nose and throat department. Earwax of the natural process of ageing. l Irrigation with water; should be removed in the community by There is a wealth of research looking at l Microsuction; irrigation with water, unless there is a con- the increased incidence of earwax buildup l Manual removal using specifically traindication to that method. Every sur- in older adults, as well as conclusive evi- designed instruments. gery should have a nurse or healthcare dence of the association between hearing Each method has its advantages and assistant trained in, and willing to carry loss and social isolation (Mick et al, 2014) disadvantages. Michaudet and Malaty out, irrigation with water and instrumen- and between earwax impaction and reduced (2018) found that there was “not enough tation. The gold standard of ear care provi- cognitive function (Dawes et al 2015). evidence supporting the superiority of one sion is also the availability of microsuction option over the other”. It is the job of the for patient safety, choice and clinical need. Vulnerable patients health professional to ensure the most Box 1 (see page 40) features general ear care Older adults and people with learning dis- appropriate technique is used depending advice for patients; Box 2 details ear care abilities have a high incidence of earwax on patient history, clinical indications and advice for patients before and after irriga- impaction (Dy and Lapeña, 2018). If ear earwax presentation. tion; and Box 3 contains advice on earwax examinations were carried out routinely in In children, Propst et al (2012) advocate softeners. these vulnerable groups, earwax could be the use of irrigation, although they recog- At their first appointment, new patients identified and removed before it became nise that every patient needs individual should be asked about their hearing, impacted. There have been a number of assessment. Children may find it hard to advised on how to care for their ears and cases where earwax in patients from these keep their head still, so irrigation may be provided with written information. All groups had become so hard that it had much safer, as the tip of the irrigation device patients over the age of 50 years should be eroded into the ear canal, causing extreme remains at the entrance of the ear canal, asked about their hearing, and have their pain and often requiring a general anaes- while the tip of a microsuction device ears checked, at every opportunity. Chil- thetic to be removed. reaches into the ear canal. Children with dren, people with cognitive impairment Nakashima et al (2016) found that the autism may find the sensation and noise of and those with learning disabilities should cognitive function of people with dementia microsuction frightening, yet they may also have their ears examined at every appoint-

PETER LAMB PETER improved once they had impacted earwax enjoy the ‘waterfall’ in their ear. ment, whether by a GP, a practice nurse, a

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Box 1. General ear care advice for patients Box 3. What product to use to soften earwax? l The ear canal is self-cleaning. Do not use cotton buds or anything else to clean it. Cleaning will damage its lining and increase the risk of infection, itchiness and wax. Patients are often advised to instill a l To clean and dry the outside of the ear after showering or bathing, use a dry tissue drop of olive oil to soften earwax, or an alcohol-free baby wipe around and behind it. especially before wax removal with l If the entrance to the ear canal is dry and/or itchy, instill one spray of olive oil into irrigation. The olive oil spray has some the ear canal, as recommended by your ear care practitioner. Shampoos and soaps advantages. It comes in a dispenser may dry or irritate the skin, so keep your ears dry when you wash. that is easy to use and gives better l To keep your ears dry when you wash your hair, swim, shower or have a bath, place coverage of the liquid in the ear in cotton wool coated in petroleum jelly or ear plugs at the entrance of the ear canals. comparison to drops, which can pool l If you have had an external ear infection, make sure you keep your ears dry from on the floor of the ear canal. The tip is any entry of water as a lifelong habit. designed so it cannot be pushed too far l If your symptoms do not improve, make an appointment with a nurse, GP, into the ear canal. The oil can be audiologist or ear care-trained pharmacist. inserted in any position, sitting or lying down. The spray can be used to soften Box 2. Ear care advice for (such as vertigo, tinnitus, discharge, uni- earwax and to reduce itching in the ear. patients before and after lateral hearing loss and pain) and whose The product can be purchased in irrigation with water ear canals and tympanic membranes look pharmacies, supermarkets or online. normal on examination. Although studies have found Before irrigation inconclusive evidence (Aaron et al, Instill one spray of olive oil into the Conclusion 2018) which drops are superior there is ear(s) requiring wax removal every There is still no standardised ear care a consensus that liquid inserted into the evening at bedtime, starting three pathway in the UK. It is time for a national ear prior to wax removal does improve nights before and on the morning of baseline ear care standard that includes the chance of a successful procedure. your appointment (unless instructed annual assessments for children and for Many of the studies looking at wax- otherwise by your ear care practitioner) anyone with any form of cognitive impair- softening products do not examine the and bring the bottle with you. This will ment. There also needs to be more skin of the ear canal or question the help with the earwax removal process emphasis on ear care in healthcare patients after their use. I have found and reduce potential discomfort training. To the health professional it may that patients often complain of itchy during the procedure. be just earwax, but to the patient it may be ears and dry skin after using alkaline a source of debilitating symptoms. We drops such as Otex (contains urea After irrigation must ensure that there are options for hydrogen peroxide) and sodium Earwax has protective properties, so prompt and safe earwax removal in pri- bicarbonate. The natural pH of the ear after it has been removed the ear canal mary care. NT canal is acidic and the insertion of these is more vulnerable to infection. Until drops can also predispose to infection, the ear produces new wax, keep it References especially in patients with diabetes. dry from water entry for a minimum Aaron K et al (2018) Ear drops for the removal of ear wax. Cochrane Database of Systematic of five days after the procedure. In the Reviews; Jul 25:7:CD012171. unlikely event that you develop pain, Al Khabori M et al (2007) Magnitude of impacted Gerontology International; 16: 3, 392-395. dizziness, reduced hearing or discharge earwax in Oman, its impact on hearing impairment National Institute for Health and Care Excellence and economic burden of earwax on health (2018) Hearing Loss in Adults: Assessment and from the ear after the procedure, services. Indian Journal of Medical Sciences; 61: 5, management. Nice.org.uk/ng98 consult a nurse or doctor. 278-285. Propst EJ et al (2012) Removal of impacted Dawes P et al (2015) Hearing loss and cognition: cerumen in children using an aural irrigation healthcare assistant or an audiologist. the role of hearing aids, social isolation and system. International Journal of Pediatric depression. PloS One; 10: 3, e0119616. Otorhinolaryngology; 76: 12, 1840-1843. Pharmacists are realising the need for ear Dy AES, Lapeña JFF Jr (2018) External auditory Roth Y et al (2011) Limited good-quality evidence care services and attending courses offered canal dimensions, age, and cerumen retention or available on earwax removal methods; softeners by the primary ear care centre in both impaction in persons with Down syndrome. Annals more effective than no treatment, but evidence for microsuction and irrigation with water. of Otology, Rhinology and Laryngology; 127: 4, irrigation or mechanical removal is equivocal. 253-257. Evidence-Based Nursing; 14: 2, 60-61. Ear health promotion material should be Harvey JH (2018) Hearing loss in adults: getting Schwartz SR et al (2017) Clinical practice guideline displayed in the practice. earwax removed is a problem. British Medical (update): earwax (cerumen impaction). If patients have hearing loss but their Journal; 362: k4048. Otolaryngology – Head and Neck Surgery; 156: Michaudet C, Malaty J (2018) Cerumen impaction: Suppl1, S1-S29. ear canals are clear of wax, they need to be diagnosis and management. American Family Sevy JO, Singh A (2019) Cerumen impaction. referred to audiology services. They can Physician; 98: 8, 525-529. Bit.ly/StatPearlsEarwax also be advised to take the telephone Mick P et al (2014) The association between hearing test offered by Action on Hearing hearing loss and social isolation in older adults. Otolaryngology – Head and Neck Surgery; 150: 3, Loss (Bit.ly/AOHLCheckHearing). Faced 378-384. For more on this topic online with an increase in demand, audiology ser- Mills L (2018) Providing integrated ear care and vices are changing their referral criteria. audiology as a community service. Nursing Times l Providing integrated ear care and Many now offer direct access to patients [online]; 114: 7, 56-57. Nakashima T et al (2016) Cerumen impaction audiology as a community service aged ≥18 years who have loss of hearing in shown by magnetic resonance imaging in patients Bit.ly/NTIntegratedEarCare the absence of other ear-related symptoms with cognitive impairment. Geriatrics and

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