Copyright EMAP Publishing 2019 This article is not for distribution except for journal club use 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 Nursing Times [online] August 2019 / Vol 115 Issue 8 38 www.nursingtimes.net Copyright EMAP Publishing 2019 This article is not for distribution except for journal club use Clinical Practice Innovation 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. ● Irrigation with water; should be removed in the community by There is a wealth of research looking at ● Microsuction; irrigation with water, unless there is a con- the increased incidence of earwax buildup ● 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 improved once they had impacted earwax enjoy the ‘waterfall’ in their ear. ment, whether by a GP, a practice nurse, a Nursing Times [online] August 2019 / Vol 115 Issue 8 39 www.nursingtimes.net Copyright EMAP Publishing 2019 This article is not for distribution except for journal club use Clinical Practice For more articles on practice nursing, go to Innovation nursingtimes.net/roles/practice-nurses Box 1.