Clinical practice guideline: Cerumen impaction
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INVITED ARTICLE
Clinical practice guideline: Cerumen impaction
Peter S.
Roland, MD, Timothy L.
Smith, MD, MPH,
Seth R.
Schwartz, MD, MPH, Richard M.
Rosenfeld, MD, MPH,
Bopanna Ballachanda, PhD, Jerry M.
Earll, MD, Jose Fayad, MD,...
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INVITED ARTICLE
Clinical practice guideline: Cerumen impaction
Peter S.
Roland, MD, Timothy L.
Smith, MD, MPH,
Seth R.
Schwartz, MD, MPH, Richard M.
Rosenfeld, MD, MPH,
Bopanna Ballachanda, PhD, Jerry M.
Earll, MD, Jose Fayad, MD,
Allen D.
Harlor Jr, MD, Barry E.
Hirsch, MD, Stacie S.
Jones, MPH,
Helene J.
Krouse, PhD, Anthony Magit, MD, Carrie Nelson, MD, MS,
David R.
Stutz, MD, and Stephen Wetmore, MD, MBA, Dallas, TX; Portland
and Eugene, OR; Seattle, WA; Brooklyn, NY; Albuquerque, NM; Washington, DC;
Los Angeles and San Diego, CA; Pittsburgh, PA; Alexandria, VA; Detroit, MI;
Chicago, IL; Ann Arbor, MI; and Morgantown, WV
OBJECTIVE: This guideline provides evidence-based recommendations on managing cerumen impaction, defined as an accumulation
of cerumen that causes symptoms, prevents assessment of the ear, or
both.
We recognize that the term “impaction” suggests that the ear
canal is completely obstructed with cerumen and that our definition of
cerumen impaction does not require a complete obstruction.
However, cerumen impaction is the preferred term since it is consistently
used in clinical practice and in the published literature to describe
symptomatic cerumen or cerumen that prevents assessment of the ear.
This guideline is intended for all clinicians who are likely to diagnose
and manage patients with cerumen impaction.
PURPOSE: The primary purpose of this guideline is to improve
diagnostic accuracy for cerumen impaction, promote appropriate
intervention in patients with cerumen impaction, highlight the need
for evaluation and intervention in special populations, promote
appropriate therapeutic options with outcomes assessment, and
improve counseling and education for prevention of cerumen impaction.
In creating this guideline the American Academy of Otolaryngology–Head and Neck Surgery Foundation selected a panel
representing the fields of audiology, family medicine, geriatrics,
internal medicine, nursing, otolaryngology–head and neck surgery, and pediatrics.
RESULTS: The panel made a strong recommendation that
1) clinicians should treat cerumen impaction that causes symptoms
expressed by the patient or prevents clinical examination when
warranted.
The panel made recommendations that 1) clinicians
should diagnose cerumen impaction when an accumulation of
cerumen is associated with symptoms, or prevents needed assessment of the ear (the external auditory canal or tympanic membrane), or both; 2) clinicians should assess the patient with cerumen impaction by history and/or physical examination for factors
that modify management, such as one or more of the following:
nonintact tympanic membrane, ear canal stenosis, exostoses, diabetes mellitus, immunocompromised state, or anticoagulant therapy; 3) the clinician should examine patients with hearing aids for
the presence of cerumen impaction during a healthcare encounter
(examination more frequently than every three months, however,
is not deemed necessary); 4) clinicians should treat the patient with
cerumen impaction with an appropriate intervention, which may
include one or more of the following: cerumenolytic agents, irrigation, or manual removal other than irrigation; and 5) clinicians
should assess patients at the conclusion of in-office treatment of
cerumen impaction and document the resolution of impaction.
If
the impaction is not resolved, the clinician should prescribe additional treatment.
If full or partial symptoms persist despite resolution of impaction, alternative diagnoses should be considered.
The panel offered as an option that 1) clinicians may observe
patients with nonimpacted cerumen that is asymptomatic and does
not prevent the clinician from adequately assessing the patient
when an evaluation is needed; 2) clinicians may distinguish and
promptly evaluate the need for intervention in the patient who may
not be able to express symptoms but presents with cerumen obstructing the ear canal; 3) the clinician may treat the patient with
cerumen impaction with cerumenolytic agents, irrigation, or manual removal other than irrigation; and 4) clinicians may educate/
counsel patients with cerumen impaction/excessive cerumen regarding control measures.
DISCLAIMER: This clinical practice guideline is not intended
as a sole source of guidance in managing cerumen impaction.
Rather, it is designed to assist clinicians by providing an evidencebased framework for decision-making strategies.
It is not intended
to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate
approach to diagnosing and managing this problem.
© 2008 American Academy of Otolaryngology–Head and Neck
Surgery Foundation.
All rights reserved.
Cerumen, or “earwax,” is a naturally occurring substance that cleans, protects, and lubricates the external
auditory canal.
Cerumen forms when glandular secretions
from the outer one-third of the ear canal mix with exfoliated
Received June 17, 2008; accepted June 18, 2008.
Otolaryngology–Head and Neck Surgery (2008) 139, S1-S21
0194-5998/$34.
00 © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation.
All rights reserved.
doi:10.
1016/j.
otohns.
2008.
06.
026
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