Dr. Michael Clifford Fabian, FRCPC FRCSC FACS (biography and disclosures)
What I did before
Cerumen build-up is a common problem for patients and doctors alike. According to McCarter et al cerumen impaction is present in approximately 10 percent of children, 5 percent of normal healthy adults and up to 57 percent of older patients in nursing homes (1). If not managed well, this can result in persistent wax build-up (or impaction) for patients and added time to a busy physician’s office – sometimes without effective resolution in the short term. For patients this can sometimes result in sensation of blocked ears, pain and even hearing loss. I previously spent more time cleaning wax in the office, but less so as time went by. This has been an evolution in my practice for over a decade or more, where previously curetting and vacuuming was a regular occurrence in my clinical office. In the case of Family Physicians, syringing is often utilized, which is time-consuming and cumbersome, and sometimes without the desired response. Counseling patients on preventative measures for wax build-up was something I did not routinely do in the past, spending more time on the management of the problem.
What changed my practice
Wax build-up is a bothersome problem for patients and this is, for the large part, preventable. The more time I spent on explaining to patients how to care for their ears and related wax build-up, the less wax problems I encountered in the office. I also took for granted that patients knew that cotton buds are not for use in the external canals – a major factor contributing to wax impactions as well as potentially having more serious morbidity. I, not infrequently, saw patients in the office with a piece of cotton bud broken off in the ear, and occasionally a perforation that resulted from cotton bud trauma. The more I regularly spoke with patients about this basic subject, I more I realized that many patients did not appreciate the improper use of cotton buds. I also began to understand the misperception that water is not good to get in the ears (it is only contraindicated in a small population of people for specific reasons).
What I do now
The literature is not clear as to whether using cerumenolytic drops are beneficial to water alone (2,3) . For all patients presenting with wax related problems, I take the time to talk about aural hygiene. Providing there are no contraindications (eg. perforation or infection), I talk about the value of self-irrigation of the external ear canals with water and to refrain from using cotton buds. I show them how to aim their ear up towards the shower head to let water in the ear, and then tilt the head down to enable water run out. This can be followed by gentle use of facial tissue externally in the ear. For those individuals that bath instead, particularly in the case of children, I explain how to flush the ears with the help of a small cup or bulb syringe. Rinsing the ears, as mentioned above, can be performed with each shower/bath, or as frequently as patients desire. I usually recommend self-rinsing two to three times per week – keep in mind that this is not an exact science so these are my personal suggestions. For those patients who present in my office with unrelated ENT problems and I see that wax build up is, or can be, an issue, I always try to remember or make the time to provide them with this basic information on aural hygiene. I also, at whatever opportunity I can, speak with learners and practitioners about this common clinical scenario.
References (Note: Article requests require a login ID with CPSBC or UBC)
- McCarter DF, Courtney AU, and SUSAN M. Pollart SM, Am Fam Physician. 2007 May 15;75(10):1523-1528. http://www.aafp.org/afp/2007/0515/p1523.pdf
- Burton MJ, Doree C. Ear drops for the removal of ear wax. Cochrane Database Syst Rev. Jan 21 2009;CD004326. (View article with CPSBC or UBC)
- Cerumen Impaction Removal: http://emedicine.medscape.com/article/1413546-overview