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Ear Wax Management Glos Care Pathway Overview

This pathway has been developed to provide clear guidance to GPs on the management of ear wax in adults, children and young people and provide guidance on appropriate onward referral. It has been published to coincide with the launch of the new community microsuction service that provides a countywide service for the removal of earwax for patients where ear irrigation is contraindicated or has failed.

This service is in addition to existing ENT service that offer microsuction such as Tetbury Hospital, Care UK, and Gloucestershire Hospitals NHS Foundation Trust.

Please click the relevant flowchart box to be taken directly to textual information

 

Presentation
  • Earwax totally occluding the ear canal and any of the following are present:
    • Hearing loss
    • Earache
    • Tinnitus
    • Vertigo
    • Cough suspected to be due to earwax
  • Tympanic membrane obscured by wax but needs to be viewed to establish a diagnosis.
  • The person wears a hearing aid, wax is present and an impression needs to be taken of the ear canal for a mould, or if wax is causing the hearing aid to whistle.
Initial Primary Care Assessment
  • Examine both ear canals with an auriscope.
  • Assessment of conductive hearing loss may include Rinne's test and the Weber's test.
Differential Diagnosis
  • Other causes of acute deafness - e.g., Eustachian tube dysfunction, foreign body.
  • Otitis externa.
Primary Care Management

Practice Point

Ear wax should usually be managed through self-care, but when necessary should be removed via irrigation in Primary Care. Provide patient with self-care leaflet.

  • 5-7 days of appropriate ear drops intended to soften wax. Low cost preparations intended to soften ear wax can be purchased over the counter (e.g. sodium bicarbonate ). Advice regarding suitable preparations can be obtained from a community pharmacist. Please note that in accordance with NHS England Guidance ear drops such as these for the removal of ear wax are not routinely available on  NHS prescription.
  • Try irrigation twice unless contraindicated. Further use of ear drops for 3-5 days should be considered prior to a second attempt at irrigation.

Contraindications to irrigation:

  • There is a foreign body, including vegetable matter, in the ear canal that could swell during irrigation
  • Patients who have previously undergone ear surgery (other than grommet insertion that have been extruded for at least 18 months), including radical mastoidectomy
  • Patients with a recent history of otalgia and/or middle ear infection (in the past 6 weeks)
  • Patients suffering from acute otitis externa
  • Patients with a current perforation of the tympanic membrane or history of ear discharge in the past 12 months
  • Patients who have had previous complications following ear irrigation including perforation of the ear drum, severe pain, deafness or vertigo
  • Patients with cleft palate, whether repaired or not
  • Patients with hearing in only one ear if it is the ear to be treated, as there is a remote chance that irrigation could cause permanent deafness.

Advise anyone who has had earwax removed to return if they develop otalgia, or significant itching of the ear, discharge from the ear (otorrhoea), or swelling of the external auditory meatus, as this may indicate infection.

Note: Prior to attending Audiology for a hearing test the ears must be completely clear of wax.

When to Refer

Primary care management must have been attempted prior to referral including use of ear drops and two attempts at ear irrigation unless contraindicated as described in the management section.

Practice Point

Referrals to the new Community Microsuction service should be made via eRS using the appropriate referral formPlease advise patient to use an over the counter ear wax softening product (such as sodium bicarbonate) for the 5 days prior to their appointment

Referrals to other providers such as Tetbury Hospital can be made through a letter via eRS.

Referral for microsuction should only be made if one of the following referral criteria are met:

  • There is a foreign body, including vegetable matter, in the ear canal that could swell during irrigation
  • The patient has previously undergone ear surgery (other than grommet insertion that have been extruded for at least 18 months), including radical mastoidectomy
  • The patient has a recent history of otalgia and / or middle ear infection (in the past 6 weeks)
  • The patient suffers from acute otitis externa
  • The patient has a current perforation of the tympanic membrane or history of ear discharge in the past 12 months
  • The patient has had previous complications following ear irrigation including perforation of the ear drum, severe pain, deafness or vertigo
  • The patient has cleft palate, whether repaired or not
  • The patient only has hearing in one ear and that is the ear to be treated, as there is a remote chance that irrigation could cause permanent deafness
  • Two attempts at irrigation of the ear canal have been unsuccessful
Ongoing Primary Care

Managing recurrent wax

  • To prevent wax becoming impacted, advise that regular use of ear drops may be helpful.
    • Explain that there is no evidence to suggest the best type of ear drops or how frequently they should be used.
    • Low cost preparations intended to soften ear wax can be purchased over the counter (e.g. sodium bicarbonate ). Advice regarding suitable preparations can be obtained from a community pharmacist. Please note that in accordance with NHS England Guidance ear drops such as these for the removal of ear wax are not routinely available on  NHS prescription.
    • It is not known if such treatment is effective and the person may need to return for repeat wax removal.

Refer to Primary Care Management section

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