PRACTICE CHANGER
Suggest that patients use drops to soften the wax in their ears and a bulb syringe to remove it. Reassure them that the process is safe, easy, and effective.1
B: A single well-designed randomized controlled trial (RCT)
Coppin R, Wicke D, Little P. Randomized trial of bulb syringes for earwax: impact on health service utilization. Ann Fam Med .2011;9:110-114.
ILLUSTRATIVE CASE
Alarmed because she recently noticed a decrease in her hearing, a 61-year-old woman requests an urgent visit. When you examine her ears, you find bilateral occlusion with cerumen. The patient says that she’s needed office irrigation multiple times in the past and wants to know how to clean her ears at home to prevent wax build-up. What can you recommend?
Cerumen impaction is associated with a variety of symptoms, including hearing loss, pain, itching, and a feeling of fullness, as well as dizziness, tinnitus, and a reflex cough.2 Eight million ear irrigations are carried out in US medical offices each year.3 Yet there is no reason to believe (and little evidence to suggest) that home irrigation would not be an effective approach.
Drops and wax removal kits are widely available
Patients can purchase wax-softening drops. Carbamide peroxide substances, for instance, are sold under a variety of trade names, such as Auraphene-B, Debrox, Mollifene, and Murine Ear Drops. Mineral oil is a common home remedy, as well, although it has no official indication for ear wax removal.
Home irrigation kits, which typically include a bulb syringe, are sold over the counter and cost anywhere from $3 to $400.4 These prices represent the varying degrees of automation available for cerumen removal, from wax-softening drops and a bulb syringe packed together in a “kit” to systems that connect to the faucet for continuous water pressure and include a temperature sensor. Most kits cost less than $20.
Bulb syringe irrigation is generally considered safe and effective. But it has never been compared with other methods5 and clinicians rarely recommend it, we suspect because of a lack of knowledge of its safety and efficacy.
STUDY SUMMARY: Every 2 patients given wax removal kits = 1 less office visit
Coppin et al conducted a blinded study of adults with cerumen impaction to assess the efficacy of bulb syringe irrigation compared with standard care.1 The authors recruited patients from 7 practices in England. To be eligible for the study, patients had to have symptoms of blockage and visible occluding ear wax. The researchers assessed 434 patients and randomized 237; of these, only 3 were lost to follow-up.
Using concealed allocation, a nurse randomly gave all the patients identical-looking envelopes. Half of the envelopes contained ear drops and instructions in usual care (ear irrigation by a clinician after the use of ear drops). The other half contained ear drops and a 25-mL ear bulb syringe (not available over the counter in the United Kingdom). Instructions provided with the syringes indicated that they could be cleaned and reused, but did not specifically instruct patients as to when to use them. Baseline characteristics were balanced between the 2 groups.
After 2 weeks, the nurse reassessed the patients and irrigated the ears of any patient with evidence of occlusion. The authors used National Health Service computerized records to track ear wax–related visits over the next 2 years for participants in both groups.
During the 2-year follow-up, more of the patients in the control group returned to the clinic with episodes of ear wax compared with those in the intervention group (73% vs 60%; risk ratio=1.21; 95% confidence interval [CI], 1.01-1.37; P=.038).
The researchers also found that, among the returnees, patients in the control group had, on average, 50% more visits. That is, for every 2 patients who were given a bulb syringe, there was one less visit (incidence rate ratio=1.79; 95% CI, 1.05-3.04; P=.032). A secondary analysis found no significant difference in adverse events between the intervention and the control groups.