Patients presenting with earwax impaction need access to earwax removal services in primary care. All general practices should have a nurse trained in delivering ear irrigation with water.
Abstract
Many people who present to their general practice with impacted earwax are not offered removal services locally, but referred to secondary care, advised to self-care or directed to private services. Earwax impaction can have severe negative effects on health, wellbeing and quality of life. General practices have a duty to offer earwax removal. In addition, patient groups that are vulnerable or unlikely to complain about earwax or loss of hearing – such as children, older people and people with cognitive impairment – need to have their ears and hearing regularly assessed.
Citation: Harkin H (2019) Earwax impaction: why it needs to be treated in primary care. Nursing Times [online]; 115: 8, 38-40.
Author: Hilary Harkin is ear, nose and throat clinical nurse specialist at the ear, nose and throat outpatient department, Guy’s and St Thomas’ NHS Foundation Trust.
Introduction
Earwax impaction is a buildup of wax in the ear canal (Fig 1) that causes symptoms ranging from mild to severe. It is becoming more common for UK general practices not to provide earwax removal services, despite the fact that the National Institute for Health and Care Excellence recommends that earwax removal should be offered in the community (NICE, 2018).
n a letter to the BMJ, Harvey (2018) wrote that getting earwax removed was a real frustration for both patients and GPs. The provision of ear care seems to be a “postcode lottery”. In areas where there are no nurse-led clinics, patients often have to use private clinics. GPs can feel that wax removal is not within their contract and unless there is a nurse in the surgery who is passionate about ear care, it is often the first service removed.
Extent of the problem
Earwax can be an innocuous problem that simply causes a sensation of blockage in the ear, but it can also cause debilitating symptoms such as hearing loss, vertigo, tinnitus, pain, discharge, infection and cough (Schwartz et al, 2017). These are significant symptoms that can adversely affect patient’s health outcomes, safety and quality of life.
In the UK, it is estimated that 2.3 million people annually have problems with earwax, but because many people do not undergo routine ear examinations, the figure is likely to be much higher. Impacted earwax is present in one in 10 children, one in 20 adults, over 30% of older people and more than 30% of people with learning disabilities (Sevy and Singh, 2019).
Al Khabori et al (2007) warned that wax in the ear canal causes “a sizeable burden” on the healthcare resources of a country. They conducted a study in Oman and found that 11.7% of 11,402 people had impacted earwax, of which 23.9% were over the age of 60 years. The cost of managing the problem was estimated at that time to be 3.6m US dollars.
Loss of hearing
Hearing decreases with age. Presbycusis is a common age-related hearing loss caused by degeneration of the cells in the organ of Corti (the receptor organ for hearing). As hearing loss is gradual, progressive and often bilateral, older people may not realise that their hearing is reduced until others point it out to them. Hearing loss has been shown to increase risk of isolation, confusion, increased accidents at home and depression.
Wax obstructing the ear canal compounds age-related hearing loss and might transform an acceptable level of reduced hearing into a significant and disabling loss of hearing. Earwax buildup occurs over time, so the gradual deterioration in hearing it causes may be mistaken for part of the natural process of ageing.
There is a wealth of research looking at the increased incidence of earwax buildup in older adults, as well as conclusive evidence of the association between hearing loss and social isolation (Mick et al, 2014) and between earwax impaction and reduced cognitive function (Dawes et al 2015).
Vulnerable patients
Older adults and people with learning disabilities have a high incidence of earwax impaction (Dy and Lapeña, 2018). If ear examinations were carried out routinely in these vulnerable groups, earwax could be identified and removed before it became impacted. There have been a number of cases where earwax in patients from these groups had become so hard that it had eroded into the ear canal, causing extreme pain and often requiring a general anaesthetic to be removed.
Nakashima et al (2016) found that the cognitive function of people with dementia improved once they had impacted earwax removed. As people in that patient group are unlikely to ask for their ears to be examined, the authors advised that they should undergo annual ear assessments. Research in Israel on earwax impaction in older adults and people with learning disabilities has led to awareness and training programmes being initiated to educate health professionals (Roth et al, 2011).
Removal techniques
Earwax can be safely removed using one of three techniques:
- Irrigation with water;
- Microsuction;
- Manual removal using specifically designed instruments.
Each method has its advantages and disadvantages. Michaudet and Malaty (2018) found that there was “not enough evidence supporting the superiority of one option over the other”. It is the job of the health professional to ensure the most appropriate technique is used depending on patient history, clinical indications and earwax presentation.
In children, Propst et al (2012) advocate the use of irrigation, although they recognise that every patient needs individual assessment. Children may find it hard to keep their head still, so irrigation may be much safer, as the tip of the irrigation device remains at the entrance of the ear canal, while the tip of a microsuction device reaches into the ear canal. Children with autism may find the sensation and noise of microsuction frightening, yet they may also enjoy the ‘waterfall’ in their ear.
Current situation
Earwax buildup and associated hearing loss can be easily dealt with, provided earwax removal services are accessible locally and promptly. However, this is far from being the case everywhere in the UK. Despite the fact that the Primary Ear Care Centre trains nurses, healthcare assistants, audiologists and pharmacists in irrigation with water and microsuction (Mills, 2018), there are currently few NHS general practices where both techniques are available.
In general practices that do not offer microsuction, patients are often told that they should self-treat using eardrops, referred to specialist services in secondary care (if that pathway is available to them) or directed to private services that provide microsuction at an average cost of £70 for both ears. It appears that, in some areas, ear care is being covertly privatised. If that is the case, patients must be informed in an honest and timely manner, so they can have their earwax removed before symptoms increase.
Although there is no financial incentive for general practices to remove earwax, patient comfort, safety and quality of life aside, there are financial benefits to be gained from not referring patients to secondary care and not having to treat the adverse effects of earwax impaction.
How to address the problem
Patients with normal ears and earwax buildup should not be referred to the ear, nose and throat department. Earwax should be removed in the community by irrigation with water, unless there is a contraindication to that method. Every surgery should have a nurse or healthcare assistant trained in, and willing to carry out, irrigation with water and instrumentation. The gold standard of ear care provision is also the availability of microsuction for patient safety, choice and clinical need. Box 1 features general ear care advice for patients; Box 2 details ear care advice for patients before and after irrigation; and Box 3 contains advice on earwax softeners.
At their first appointment, new patients should be asked about their hearing, advised on how to care for their ears and provided with written information. All patients over the age of 50 years should be asked about their hearing, and have their ears checked, at every opportunity. Children, people with cognitive impairment and those with learning disabilities should have their ears examined at every appointment, whether by a GP, a practice nurse, a healthcare assistant or an audiologist. Pharmacists are realising the need for ear care services and attending courses offered by the primary ear care centre in both microsuction and irrigation with water. Ear health promotion material should be displayed in the practice.
If patients have hearing loss but their ear canals are clear of wax, they need to be referred to audiology services. They can also be advised to take the telephone hearing test offered by Action on Hearing Loss. Faced with an increase in demand, audiology services are changing their referral criteria. Many now offer direct access to patients aged ≥18 years who have loss of hearing in the absence of other ear-related symptoms (such as vertigo, tinnitus, discharge, unilateral hearing loss and pain) and whose ear canals and tympanic membranes look normal on examination.
