However, serious complications can result and the risks increase with immunocompromise, diabetes, and poor compliance, all of which are more prevalent in increasing ageing populations. For many patients, irrigation is a safe and effective approach. Effective treatment of this condition is therefore an important aspect of a holistic approach to managing patients.Ĭerumenolytic agents alone are often not fully effective in clearing impacted wax. The presence of impacted ear wax has significant implications, not only on hearing, but also with regard to psychological and emotional health, as well as communication and social functioning. ![]() Furthermore, a small UK-based study found that the use of audiovisual distraction significantly lowered patients’ perception of pain during microsuction - a potentially useful technique in improving acceptance and patient understanding. An additional finding in this study was that prior use of cerumenolytics significantly reduced the experience of pain and vertigo. 10 The most commonly reported symptoms were dizziness, loudness of the procedure, and reduced hearing. A prospective study of 164 patients in an ENT outpatient clinic found that 55% of patients reported adverse effects, although these were minor and short-lived in most cases. There are far fewer reports on the safety of microsuction for removal of earwax. A recent study by Prowse and Mulla looked at the efficacy of microsuction, and found that in a study population of 159 patients, the procedure was successful in clearing the wax in 91% of cases. It is also usually quicker than irrigation, and does not expose the ear canal to moisture. The main advantage of this technique is that it is performed under direct vision, and so can be used in clinical scenarios where irrigation would be contraindicated. Microsuction is the most commonly employed technique for manual removal of wax. Therefore, it has been suggested that irrigation should be avoided in elderly, immunocompromised and diabetic patients. There is also evidence that malignant otitis externa (caused by Pseudomonas) is more common following ear irrigation, particularly in immunocompromised and diabetic patients. 7 Although this seems small, it equates to 69 000 additional cases of otitis externa per year in England and Wales. Bruins et al estimate that the risk of otitis externa after irrigation is 3%. ![]() Iatrogenic otitis externa following ear irrigation is a complication which has been looked at in more detail. ![]() Wallis and Dovey looked at the rates of primary care treatment injury claims in New Zealand over 5 years ear syringing and cryotherapy combined caused 13.5% of reported injuries. 3 Other cited complications include pain, vertigo, and otitis media, in addition to more serious but thankfully rare sequelae. A survey by Sharp et al estimated complications occur in 1:1000 ears irrigated, the most common being failure of wax removal (37%), otitis externa (22%), perforated tympanic membrane (19%) and damage to the external auditory canal (15%). 1, 5 Contraindications to irrigation include previous ear surgery, anatomical abnormalities of the ear canal (congenital, osteoma, exostosis), history of tympanic membrane perforation (including grommet/ventilation tubes), only hearing ear, under 16 years of age, history of active or recurrent otitis externa, or previous intolerance of irrigation. ![]() However, it is accepted practice that referral on to specialist ear, nose, and throat (ENT) services for manual removal should be considered when irrigation has failed, or if there are contraindications to irrigation. There are no high quality studies comparing irrigation to manual removal of wax. Please refer to the full guidelines for comprehensive information on contraindications to irrigation. *Previous ear surgery, anatomical abnormality of canal, history of drum perforation/grommet, only hearing ear, infection, under 16 years, previous intolerance of irrigation. NICE Clinical Knowledge Summaries guidelines on management of earwax.
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