CC March 2016 Cerumen Impaction

echoecho's version from 2016-06-01 14:54


Question Answer
Define cerumen?1) a naturally occurring substance in the external ear canal composed of apocrine glandular secretions and exfoliated epithelial cells 2) it cleans, protects and lubricates the canal 3) is naturally ejected out of the ear by mandibular movements
Define the 2 types of cerumen?1) wet (dark brown, sticky, more common in children) 2) dry (lighter colored and harder and more common in adults and elderly)
Define cerumen impaction?compression of accumulated earwax causing symptoms or preventing assessment of the ear canal/tympanic membrane (TM) or audio-vestibular system, or both
Impaction is estimated to be present in over ____ million people and is prevalent at all ages but appears to be more common among ______, the elderly and teh developmentally delayed (over ____)?children; 1/3
Is there a sex difference?no
*** Symptoms of cerumen impaction?1) earache 2) pruritus 3) malodorous drainage involving the ear 4) hearing loss 5) tinnitus 6) aural fullness 7) dizziness 8) cough 9) cognitive dysfunction in the elderly and evelopmentally delayed
Cerumen impaction also impedes visualization of the TM and penumatic otoscopy, potentially masking the dx of what?OM
List procedures that are affected by earwax?1) audiometry 2) hearing aid fitting 3) acoustic immittance testing 4) electrocochleography 5) auditory brain stem response testing
Earwax also damanges hearing aids, how?interferes with proper fitting and prevents conductance of sound to the TM
*** In patients presenting with one or symptoms mentioned above, what should be performed and if cerumen is seen, would consider impacted cerumen?otoscopy
Clinical evaluation should focus on what?issues influencing treatment such as anatomical abnormalities and cutaneous pathology of the ear canal.
It should also focus on other co-existing factors complicating managements, name these?1) perforated TM 2) diabetes 3) other diseases undermining immune response 4)use of anticoagulants
What does an intact TM prevent?middle ear migration of irrigation fluid and cerumenolytics
Immunocompromised states and diabetes promote what? Anticoagulants increase what following mechanical removal of earwax?1) infections 2) increase risk of bleeding
*** Asymptomatic patients with ear wax not obstructing the ear drum or preventing needed otologic assessment may be ______? Whereas those presenting with attributable s/s or requiring further middle or inner ear assessment should be offered _____?observed; removal
Symptoms in subsets of patients, however may be difficult or impossible to obtain, list these subsets?elderly, cognitively impaired, children, those using hearing aids
List treatment options?1) manual removal by curettage 2) hooks or forceps 3) irrigation of ear canal 4) using solutions to soften cerumen (cerumenolytics) 5) removal often requires a combination of more than one technique
List the cerumenolytic options?1) water 2) wter-based preparations (acetic acid, docusate (Colace), hydrogen peroxide, saline, sodium bicarbonate) 3) oil-based preparations (almond oil, olive oil) 4) others (carbamide peroxide (Debrox)
Which agent is superior?no specific agent is superior to another and unless combined with irrigation, cerumenolytics are probably not more effective than no treatment
Side effects are uncommon and experienced least with what?saline or water
What type of irrigation is advocated?1) using available liquids (saline or water) 2) instilling cerumenolytics 15 minutes prior to irrigation 3) using irrigation liquids warmed to room temperature
Pretreatment with what prior to irrigation improves its effectiveness?cerumenolytics
Ear irrigation is safe if what is followed?1) low-pressure settings 2) fluid jet is directed at the walls of the ear canal and not directly at the TM
Comment on the mechanical methods of disimpaction?1) allows complete removal of earwax under direct visualization 2) recommended in immunocompromised patients (including those with DM and those with abnormalities of the ear canal and TM perforation) 3) requires training, experience and availability of proper equipment 4) though there is potential for trauma, infection and vertigo, these are uncommon
Comment on ear imicrosuction?1) done under direct microscopy 2) further reduce complications 3) also requires specialized equipment and training.
*** Those patients with persistent impaction should be _____? Those with persisting s/s despite adequate clearance of cerumen require what?1) retreated 2) reevaluation to detect other possible pathology.
Is there any evidence for or against the common practice of recommending home use of cerumenolytic agents?no
Is there any benefit in recommending regular ear toilet to prevent cerumen accumulation or removal of impacted cerumen in the absence of symptoms (even in those patients w/ a propensity for impaction)? no
What should a patient not use to remove cerumen or clean ears as this would minimize the risk of impaction?avoiding cotton tipped swabs
List the 3 categories of methods of removing impacted cerumen?1) cerumenolytics 2) irrigation 3) mechanical methods
Regarding cerummenolytics, comment on equipment needed?1) acetic acid 2) docusate 3) hydrogen peroxide 4) various oils (almond oil, arachis oil, olive oil, mineral oil) 4) saline 5) sodium bicarbonate 6) tap water 7) carbamide peroxide
Regarding cerumenolytics, comment on indications?1) recommended in patients without ear infections or ear surgery or TM perforation
Regarding cerumenolytics, comment on contraindications?1) active ear infection 2) TM perforation 3) ear canal abnormalities (congenital or acquired) 4) tumors 5) deformed ear canal secondary to trauma or surgery
Regarding cerumenolytics, commont on complications?1) may cause allergic reactions 2) may cause infections 3) may cause temporary hearing loss 4) may cause ear ache 5) may cause vertigo if TM perforated
Regarding irrigation, comment on equipment needed?1) oral dental jet irrigator 2) electronic irrigators with controlled water pressure
Regarding irrigation, comment on the indications? safe and effective in patients without active ear infection and intact TM
Regarding irrigation, comment on contraindications?avoided in patients with = 1) active ear infection 2) TM perforation 3) ear tubes 4) abnormalities of ear canal
Regarding irrigation, comment on complications?1) apin 2) trauma to ear canal or TM 3) infections (malignant otitis media) 4) dizziness
Regarding mechanical methods, comment on equipment needed?1) otoscope 2) headlamp 3) metal/plastic loops or spoons or curettes 4) alligator forceps 5) suction tips 6) cotton-tipped buds 7) aural suction devices
Regarding mechanical methods, comment on indications?1) prior ear surgery 2) TM perforations 3) immunocompromised states including diabetes mellitus
Regarding mechanical methods, commonet on complications?1) requires special skills 2) requires patient cooperation 3) may cause pain, trauma to the external ear or TM, vertigo
*** SUMMARY = Cerumen impaction is prevalent in all ages, but appears to be more common among what patient groups?1) children (10%) 2) elderly 3) developmentally delayed (more than 1/3)
*** SUMMARY = List 4 treatment options for impacted cerumen?1) manual removal by curettage 2) hooks or forceps 3) irrigation of ear canal 4) using solutions to soften cerumen (cerumenolytics)
*** SUMMARY = is there a cerumenolytic that is superior to another? Unless cerumenolytics are combined with ______, is probably no more effective than no treatment?no; irrigation
*** SUMMARY = Is there any benefit in recommending regullar aural toilet to prevent cerumen accumulation or remove impacted cerumen in the absence of symptoms, even in pts w/ a propensity for impaction?no