Authors (including presenting author) :
Chang W (1)(2)(3) , Cheung HK (1) , Lee CP (1) , Chan LP (1) , Hui MT (1)(2)(3) , Chan L (2) , Leung SY ( 3) , Leung MKW (1)(2)(3)
Affiliation :
(1) Wong Siu Ching Family Medicine Centre
(2) Tai Po Jockey Club General Out-patient Clinic
(3) Fanling Family Medicine Center
Introduction :
Earwax (cerumen) is commonly encountered in general practice. Excessive or impacted cerumen is present in approximately 1 in 10 children, 1 in 20 adults and 1 in 3 older adults (>65 years old). In a foreign study, prevalence of earwax impaction ranged from 7%-35%, and general practitioners in the United Kingdom (UK) performed 9 ear syringing per month. Symptoms of earwax impaction include hearing loss, earache, ear fullness, itchiness, reflex cough, dizziness and tinnitus. In vitro studies have proven that olive oil appeared to be almost totally ineffective as an earwax dispersant6. Water, which was originally intended as a control substance – surprisingly proved to be one of the fastest working and most effective agent7,8. Another in vitro study has shown that earwax is largely disintegrated in water within 15 minutes. Prolonged use of water in external ear canal may cause softening of skin and secondary otitis externa. Systemic review was able to show that earwax softeners have an effect in clearing earwax in their own right and as precursors to irrigation, but it remains uncertain which specific softeners are superior. Successful earwax syringing improves patient symptoms, and also increases job satisfaction for doctors11. However, ear syringing is time-consuming and not commonly performed in GOPD setting due to excessive workload. Without treatment, spontaneously complete clearance of wax occurred in 5% of ears. With ear softener, complete clearance occurred in 21%-39% of ears. Immediate syringing with no preparation was successful in 70% of subjects. Water based ear softener plus ear syringing came to 78% success rate. Oil based earwax softener plus ear syringing increased the success rate to 90%.
Ear syringing is not without risks, including failure of wax removal, otitis externa, perforation of the ear drum, damage to external auditory canal, pain, vertigo and otitis media. Ear syringing can have medicolegal consequences.
Consistency, color, and amount of cerumen may vary from individual to individual, with ethnicity being associated with one’s predisposition to cerumen type. Two phenotypic types of cerumen, regulated by two autosomal alleles, have been described and are commonly identified as “wet” or “dry”. The wet form, honey-colored and sticky in nature, is most frequently encountered in Caucasians and African Americans, while the dry form, brittle in consistency and gray or tan in color, is more common in Asians and Native Americans.
Objectives :
The primary objective of this study was to assess the success rate of ear syringing and the mean number of syringing attempts for those with or without pre-ear oil application. The secondary objective was to assess complication rate of the ear syringing such as ear canal bleeding and ear drum perforation.
Methodology :
Study design and subject selection
This was a multicenter controlled trial. Patients in general outpatient clinic (GOPC) A and GOPC B found to have earwax after physical examination were referred to the principal investigator immediately for ear syringing without pre-ear oil application. On the other hand, patients in GOPC C with earwax would be given olive oil one week before performing ear syringing. Randomization was not used because patients in GOPC C were known to have received olive oil. Inclusion criteria were Chinese patients aged >5 years old, who complained of ear symptoms with impacted earwax on examination and were able to sign consent (and minor consent) in general outpatient clinics. Patients contraindicated to ear syringing were excluded such as uncooperative patients, patients with otitis externa, otitis media, unilateral deafness, history of tympanic membrane perforation, ear surgery or vertigo after ear syringing. The study was approved by the New Territories East Cluster Research Ethics Committee (CREC 2019.531).
Recruitment and wax assessment
The study was conducted between 1st April 2020 and 30th September 2020. Patients in both groups were assessed by principal investigator for hardness of wax. For simplicity and expediency, hardness of wax was classified as soft, mixed and hard type by the principal investigator. Soft earwax was defined as oily wet yellow brown wax. Hard earwax was defined as dry, dark wax. Medium earwax was defined as something in between hard dry and soft wet type. Hardness of earwax and degree of impaction of earwax were recorded in clinical notes. We classified degree of occlusion as below7:
0. No occlusion: no effective impairment of tympanic membrane visualization due to cerumen. (0% occlusion)
1. Mild occlusion: slight impairment of tympanic membrane visualization due to cerumen. (1/5-3/5 occlusion)
2. Moderate occlusion: significant impairment of tympanic membrane visualization due to cerumen. (4/5 occlusion)
3. Complete occlusion: complete impairment of tympanic membrane visualization due to cerumen. (5/5 occlusion)
We only included patients with grade 2-3 earwax occlusion. Consent form was signed by each patient after explanation of ear syringing procedure and risks of ear syringing. For those < 15 years old, consent was signed by guardians.
Intervention and procedure
Patient would sit on a chair with a towel covering the shoulder of the side with earwax. An ear syringe of 50ml was used with 14G angiocath. The angiocath was cut to 1.5cm long because length of external auditory canal of newborn infant is 1.68cm15. The syringe was filled with preheated normal saline at
Result & Outcome :
59 males (84 ears) and 63 females (79 ears) were recruited . Total 163 ears were syringed. 68 patients (31 males, 35 females, 2 patients had second ear syringing without olive oil, while 1 patient had second ear syringing with olive oil), 80 ears (38 males’ ears 42 females’ ears) received no olive oil were convenient sample and 67 patients (93 ears) received olive oil. 5 ears (5 patients) were excluded because there was no earwax after applying olive oil for 7 days. Another 5 ears (3 patients) were excluded because the earwax was < 4/5 occlusion to the ear canal after applying olive oil for 7 days. Therefore 59 patients (32 males 27 females) (83 ears 46 males’ ears, 37 females’ ears) were recruited as pre-olive oil treatment group. There was no significant difference in the success rates of ear syringing with olive oil (80/83 96.4 %) and without olive oil (73/80, 91.3%) (P=0.205) (table 1). The overall success rate of ear syringing was 93.9% (153/163). The overall referral rate to ENT was 1.2% (2/163) (1.3%, 1/79 in non-olive oil group 1.2%, 1/82 in olive oil group). One case was failed ear syringing as mentioned above but did not apply olive oil before follow-up and failed syringing 2nd time. The 2nd case referred to ENT was a patient complained of persistent tinnitus after successful ear syringing for earwax removal. There was significant difference in the mean number of ear syringing for those without olive oil (mean number of syringing is 3.50 95% interquartile range IQR 1-4) and with olive oil (mean number of syringing is 2.46 95 % IQR 1-3) (P=0.005) .There was no significant difference in the number of ear canal bleeding in non-olive oil group (9/80, 11.3%) and olive oil group (4/83, 4.8%) (P = 0.13) (table 1). Overall rate of ear canal bleeding was 8% (13/163). For those with ear canal bleeding, 84.6% (11/13) were medium to hard earwax while 15.3% (2/13) were soft earwax. The prevalence of consistence of earwax (non-olive oil group) was 10% for soft earwax, 50% for medium hard earwax and 40% for hard earwax .
Conclusions
For both soft and medium earwax groups, success rate of ear syringing is high in both non-olive oil group and pre-olive oil group (figure 3) and rate of ear canal bleeding is low (table 3). We suggest trial of ear syringing without pre-olive oil for these groups.
