Monday, July 30, 2018

Impacted Earwax: "I’m sorry, could you repeat that?"

We have all had congested nostrils before, but have we all experienced congested ears? The goal of this post is to explain how cumbersome ear congestion can be, and how to help anyone caught in this sticky situation.  

Common Reasons for Build-Up: 
Before we talk about what we can do for congested ears, let us first discuss what causes earwax build up. There are many factors that cause earwax build-up in a person including old age and anatomical anomalies.1 The most common cause of earwax buildup for younger individuals is ear hygiene practices, primarily the use of cotton swabs.2 Placing objects into your ear canal pushes earwax back and impedes the natural cleaning mechanism of the ear causing a build-up. Once enough ear wax has collected it can cause: 

    • Ear discomfort (mainly ear fullness & itchiness) 
    • Hearing loss 
    • Chronic Cough 
    • Ear infections 

What’s Next? 
These symptoms can affect one's ability to function in their daily activities, so it is important to treat for quick relief. Cerumenolytic products are the primary option for treating impacted earwax. Cerumenolytics work by either softening the impacted earwax or lubricating the ear canal. Currently there is no evidence suggesting any cerumenolytic product to be superior.2 Therefore, a recommendation based on practice experience or patient preference is the most suitable approach. Cerumenolytic products do not work instantly and may take up to 7 days to provide relief. For those who would prefer their hearing restored promptly, ear irrigation is an option. 

Quick Tip #1: Some cerumenolytic products contain peanut oils, always double check a patient's allergy status before recommending a product. 

Ear irrigation is the finishing move for removing troublesome earwax. It can be difficult to complete without assistance but the technique is relatively simple. Ear irrigation is not recommended for individuals with a current or past perforated tympanic membrane. Although pharmacist cannot view a patient's ear canal to confirm if the tympanic membrane is still intact, a perforated tympanic membrane presents differently than impacted earwax. 

Quick Tip #2Patients can use both cerumenolytic products and water irrigation together. For patient’s that opt for this it is recommended to use a water based cerumenolytic 10-30mins prior to water irrigation. 

Differentiating between the two1: 
Impacted Earwax
Perforated Tympanic Membrane
Unlikely, unless ear is also infected.
Pain is sudden and sharp.
Refer if rash is present.
Hearing status
Gradually fades, may become better through jaw movement.
Suddenly occurs.
Unlikely, unless ear is also infected.

If a patient presents with any of the signs favoring a perforated membrane or infection they should be referred.  Using cerumenolytic products and water irrigation should relive most patients' symptoms within 1-5 days. If relief is not obtained by this point a patient should be referred to a physician.  
Quick Tip #3: If, a patient already has lost their hearing in one ear prior to current circumstances refer patient immediately. 

Impacted earwax is a nuisance that can disturbs anyone’s ability to function in their daily life. Although physicians can clear out earwax for patients providing, this knowledge can help decrease those visits. 

Thank you & hope to see you next post, 

Derick Oduro 

1) Ely JW, Hansen MR, Clark EC. Diagnosis of ear pain. Am Fam Physician 2008;77:621-8. 
2) Schwartz SR, Magit AE, Rosenfeld RM. Clinical Practice Guideline (Update): Earwax (Cerumen Impaction). Otolaryngology– Head and Neck Surgery. 2017. Vol 156: S1-S29.