Ears - ear wax

Earwax is produced by the ear as part of its natural process of cleaning and protection, and, in the majority of cases, it does not need to be removed. Offer earwax removal under what conditions?

->Earwax is contributing to hearing loss or other symptoms. ->The tympanic membrane is obscured by wax but needs to be viewed to establish a diagnosis. ->An impression needs to be taken of the ear canal.

how do you use the cerumenolytics?

->Hold in hands or place in warm (not hot) water ->Lie down with the affected ear uppermost ->Gently pull pinna back and up (pull down and back in children) to open the ear canal ->Place correct number of drops into ear canal ->Stay in position for about 5 min to allow the drops to soak into the earwax ->once patient's head is returned to normal position, any excess solution should be wiped away with clean tissue

give 2 examples of brands fixed and volatile oils

-Earex -Cerumol

who is more prone to ear wax?

-People with lots of hair in the ear -Those with narrow ear canals People who use hearing aids or ear plugs Elderly (ear wax becomes drier) esp. over 50 years old, age younger than 5 years (prevalence of impacted cerumen is 10% in children)

what are the contraindications to irrigation?

-Perforated ear drum -Previous surgery for some ear problems -Unilateral deafness (deaf in other ear) -Grommets (small plastic tubes placed in the eardrums in an operation) in place -Middle ear infection in previous 6 weeks -Mucous discharge from ear (which may indicate an undiagnosed perforation) within 12 months

risks of irrigation?

-failure of wax removal -otitis externa -pain -bleeding (usually self-limiting)

name the 4 available cerumenolytics

-fixed and volatile oils (olive oil, almond oil, earex) -docusate sodium (waxsol) -Na+ bicarbonate -Urea, hydrogen peroxide (Exterol, Otex)

give examples of fixed and volatile oils (3)

-olive oil -almond oil -arachis (peanut)oil

what is ear wax?

A normal secretion from the ear canal from ceruminous glands in the external auditory canal

safetynetting for patient after irrigation?

After it seek immediate advice from ENT specialist if severe pain, deafness, vertigo occur during or after irrigation or if perforation is seen. Refer person to specialist care service or ENT service for removal of earwax if irrigation is unsuccessful after 2nd attempt.

how does irrigation work?

Body temp water squirted into ear (with syringe) Use ear drops 3-5 days to soften beforehand (to soften beforehand & reduce potential of trauma to ear canal i.e. perforating ear drum)

1st line treatment for ear wax

Cerumenolytics

can you offer adults manual syringing to remove ear wax?

DO NOT offer adults manual syringing to remove earwax.

explain the procedure for examination of ear wax?

Examine both ear canals with an otoscope to ensure the tympanic membrane is intact, without perforation or tympanostomy tubes, and to assess for any abnormalities. Note whether wax is present and whether it appears to be impacted. Whilst wax occluding the whole meatus may cause hearing loss, it is more likely to cause a loss when adherent to the tympanic membrane. Note that: It may not be possible to view the tympanic membrane if wax is present. Children may present with yellow, waxy discharge; this is less common in adults.

give 2 examples of brands urea, hydrogen peroxide

Exterol®, Otex®

with ear eax, what is the safety netting advice?

Go to GP if: · you develop a fever, ear pain, significant itching of the ear, discharge from the ear (otorrhoea), or swelling of the external auditory meatus, as these may indicate infection

which people have predominantly wet, honey to dark brown, sticky ear wax?

In African and European descent.

which part of the ear controls balance?

Inner Ear only

name a treatment that is used for ear wax patients

Irrigation

cerumenolytics are more comfortable to use if cold or warm?

More comfortable if the drops are warmed (room temp) first

What are the three sections of the ear?

Outer Ear (O) Middle Ear (M) Inner Ear (I)

how long should it take the ear wax to come out when using Earex?

Over about 2 weeks, lumps of earwax should fall out of ear, esp. at night when lying down.

which people have predominantly dry, grey and flaky, brittle ear wax?

Predominant in people of Asian and Native American descent.

what does wax normally do?

Wax normally migrates to outer ear - 'self cleaning'

give 1 example of a brands docusate sodium

Waxsol

name the two main types of ear wax

Wet, honey to dark brown, sticky Dry, grey and flaky, brittle

In what case should syringing be used?

Where drops alone do not clear ear wax

what is the purpose of cerumenolytics (wax softening agents) ? do they prevent ear wax?

You cannot prevent earwax. It's there to protect your ears from dirt and germs. But you can keep using eardrops for a few days to soften the wax. This will help it fall out on its own and should prevent blocked ears. Regular use of ear drops may be indicated for patients with recurrent earwax problems.

what are cerumenolytics ?

agents to soften wax

What is the main function of the inner ear?

balance

how is excessive ear wax determined?

by examination

who can use cerumenolytics (wax softening agents)?

can be used by all

what s formed when wax migrates to outer ear in 'self cleaning' and accumulates in the external auditory canal?

can form a "plug"

what is the colour of dry, and flaky, brittle ear wax?

can vary in colour from a light to brownish grey.

another word for ear wax?

cerumen

What is irrigation of ear wax?

flushing the wax out using water

What is the function of the outer, middle and inner ear?

hearing

is it recommended to use cotton buds?

no

what medications interact with cerumenolytics (wax softening agents)?

none

what are the symptoms of excessive ear wax?

o Discomfort o Feeling of fullness o Sensation that the ear is blocked o Gradual hearing loss (temporary) - wax affects sound passage (conductive hearing impairment)

what are the rare symptoms of excessive ear wax?

o Itching, Pain, Tinnitus (ringing or buzzing in the ear), Vertigo (Feel dizzy + sick) - rarely

what are the causes of earwax?

o Overproduction - if the rate of production of earwax exceeds the rate of elimination out of the ear, impaction will occur. Some people with recurrent impaction may suffer from idiopathic earwax overproduction. o Obstruction - variation in anatomy of ear canal can lead to earwax accumulation o Inadequate epithelial migration - cerumen glands progressively atrophy and become less numerous with age, resulting in drier earwax. The drier earwax is less readily transported by the epithelial conveyor mechanism. Also, the natural process of epithelial migration may be insufficient for some earwax subtypes. o Cerumen phenotype — earwax can be divided into two genetically determined phenotypes: dry and wet. It is though that having a wet or dry earwax phenotype may affect efficacy of diff. earwax removal techniques.

what is the purpose of ear wax? (4)

o Protects tympanic membrane o Trap foreign particles, hair and dust o Repel water o It is acidic and normally coats the walls of the ear canal, inhibiting growth of bacteria & fungi -> Bactericidal and fungicidal activity In summary earwax cleans, lubricates and protects the lining of the ear canal.

link between swimming and ear wax?

o There may be a history of exposure to water (this causes expansion of the earwax and may cause complete blockage of the ear canal).

Referal criteria for ear wax

o Trauma / history of surgery o Foreign body in ear canal o Where OTC treatments have failed - will need syringing (Rx fail after 3-5 days (NHS Inform) o Ringing or dizzy sensation (suggests inner ear problem; requires investigation) o Severe pain / earache o Fever and malaise in children (middle ear infection?) o Presence of discharge

discharge of the ear is also called?

otorrhoea

how may patients feel after syringing?

patients may feel dizzy after syringing

What are the ears?

sensory organ that controls hearing and balance

excessive ear wax is one of the commonest causes of what?

temporary deafness

practical advice for ear wax patients?

· Advise not to remove earwax to clean their ears by inserting small objects such as cotton buds, fingers into the ear canal. Let the ear clean itself. Explain this could: · Damage the EAR (ear canal and eardrum) · Cause the wax to become impacted by pushing it further into the canal and may cause ear infection · Perforate the tympanic membrane (ear drum) · Use of ear candles has no benefit in management of earwax removal and may result in serious injury.

What warnings should you provide to the patient when handing out cerumolytics (wax softening agents)?

· Warn the person that instilling ear drops may cause transient hearing loss, discomfort, dizziness, and irritation of the skin. Using drops may make your hearing or symptoms a little worse at first before getting better. Advise that removal of earwax may not necessarily relieve the symptoms (for example hearing loss may be a sensorineural loss and not due to impacted wax).

What are the important questions to ask someone with ear wax?

Ø Determines why the patient is presenting (to buy cotton buds to clear ear wax) Ø Asks about other symptoms (sound is muffled, feeling of fullness in ear) Ø Ask about medical history (nil) · Symptoms - hearing loss? Blocked ears? Ear discomfort? Feeling of fullness of the ear? Earache? Noises in the ear? Itchiness? Any discharge from the ear? · Medical conditions? · Have you ever had impacted earwax removed? · Foreign body in ear canal? (suspect with children) · Allergies? (do not recommend almond or arachis oil to person allergic to almonds) Have you recently tried to clean your ears i.e with a cotton bud, hairpins, pens?

what are the option/management strategies for ear wax?

Ø Does not sell cotton buds Ø Explains that cotton buds are likely to worsen the problem by causing compaction of ear wax Ø Suggests wax softener as an alternative to cotton buds i.e. olive oil, cerumol, sodium bicarbonate, Otex Ø Provides appropriate counselling for product (see OTC directory, eMc)