Clinical Practice Guideline (Update): Earwax (Cerumen Impaction) Executive Summary

Abstract

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue of Otolaryngology-Head and Neck Surgery featuring the updated Clinical Practice Guideline: Earwax (Cerumen Impaction). To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 11 recommendations emphasize proper ear hygiene, diagnosis of cerumen impaction, factors that modify management, evaluating the need for intervention, and proper treatment. An updated guideline is needed due to new evidence (3 guidelines, 5 systematic reviews, and 6 randomized controlled trials) and the need to add statements on managing cerumen impaction that focus on primary prevention, contraindicated intervention, and referral and coordination of care. Differences from Prior GuidelineThis clinical practice guideline is as an update, and replacement, for an earlier guideline published in 2008 by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF).1 An update was planned for 5 years after the initial publication date and was further necessitated by new primary studies and systematic reviews that might suggest a need for modifying clinically important recommendations.2 Changes in content and methodology from the prior guideline include the following: addition of a consumer advocate to the guideline update group (GUG); 3 guidelines, 5 systematic reviews, and 6 randomized controlled trials (RCTs); emphasis on patient education and counseling with new explanatory tables; expanded action statement profiles to explicitly state quality improvement opportunities, confidence in the evidence, intentional vagueness, and differences of opinion; enhanced external review process to include public comment and journal peer review; new algorithm to clarify decision making and action statement relationships; and 3 new key action statements on managing cerumen impaction that focus on primary prevention, contraindicated intervention, and referral and coordination of care.

Randomized Trial of Irrigation and Curetting for Cerumen Removal in Young Children

“…Despite these limitations, we built on the very limited previous literature. To our knowledge, this is the first study in any age group comparing different methods of cerumen removal (1). Strengths of this study, not addressed in previous published reports, include use of examiners who were blinded to treatment assignment, assessing the change in cerumen occlusion for each ear before and after the procedure, documenting duration of procedures and measuring parental impressions—important because these children were too young to self-report procedural discomfort.…”

“…The sample in this pilot study was limited to a 2-month period of availability of a research assistant. There are no comparative data (1) from which we could estimate a sample size. We analyzed the data using an intention to treat analysis with Stata v14 (StataCorp, College Station, Texas), SAS 9.4 (SAS Institute Inc, Cary, NC) and R v3.5.2.…”

“…Cerumen impaction, present in about 1 in 10 children (1), can cause ear discomfort, reduced hearing and prevent the clinician from adequately visualizing the tympanic membrane (TM) to diagnose acute otitis media (AOM) and other conditions such as effusions, retraction pockets, foreign bodies, etc. Visualizing most of the TM is important to detect bulging, the most specific finding for AOM (2).…”

“…Although incidence of AOM is highest in children age 6–24 months, very few children in this age group are included in studies of cerumen removal. Furthermore, no studies in any age group have compared the effectiveness of different methods of cerumen removal (1).…”

“…Methods for cerumen removal in the office setting include curetting, suction, irrigation, and cerumenolytics (1). Each method has advantages and disadvantages in terms of patient comfort, parental tolerance, required training, time, manpower needed, and expense.…”