Otology: Cerumen Impaction and Aural Foreign Bodies.

Cerumen lubricates and protects the external auditory canal, but excess accumulation can lead to ear fullness, itching, otalgia, discharge, hearing loss, and tinnitus. Cerumen should be treated whenever symptoms are present or if it limits diagnosis by preventing a needed otoscopic examination. Clinicians should evaluate for cerumen impaction in those using hearing aids and patients with intellectual disability. Cerumen impaction can be treated with cerumenolytics, ear irrigation, and manual removal with instrumentation. Aural foreign bodies can cause ear fullness, otalgia, discharge, and hearing loss. They are more common in children than adults. The most common type of aural foreign bodies in children is jewelry, followed by paper products, parts of pens or pencils, desk supplies (eg, erasers), BBs or pellets, and earplugs or earphones. In adults, the most common aural foreign bodies are cotton swabs or cotton, followed by hearing aid parts and jewelry or ear accessories. Patients should avoid using cotton tip applicators in the external auditory canal. Alligator forceps, small right angle hooks, and ear irrigation commonly are used to remove aural foreign bodies in an outpatient clinic setting, but the choice depends on the type of foreign body. Soft and irregularly shaped objects can be removed without referral to an otolaryngologist. Patients with hard, spherical, or cylindrical objects should be referred to an otolaryngologist if previous removal attempts have failed or if there is ear trauma to avoid worsening its position in the ear canal.

Cerumenolytics with or without manual extraction for impacted earwax: A network meta-analysis of randomised clinical trials.

BACKGROUND: Many different substances for cerumenolysis have been evaluated in clinical trials. We carried out a systematic review and network meta-analysis to compare their effectiveness. METHODS: Electronic databases were searched for randomised clinical trials conducted in patients with impacted cerumen evaluating cerumenolytics. The primary outcome was the proportion of patients with wax clearance using manual techniques. Rankogram plot was used to assess the "best" cerumenolytic. Odds ratio (OR) with 95% confidence intervals (95% CI) was the effect estimate. RESULTS: Twenty-six studies were included in the systematic review and 25 in the meta-analysis. Sodium bicarbonate (OR: 2.68, 95% CI: 1.2, 6.1) and paradichlorobenzene (OR: 30.9, 95% CI: 5.9, 161.3) were associated with significantly greater proportions of patients with wax clearance following syringing compared to normal saline. Rankogram plot revealed paradichlorobenzene to have the highest probability of being the "best" cerumenolytic. Chlorobutanol was observed to be significantly better than normal saline in adults as well as following single application. Following multiple applications, glycerol, docusate sodium, hydrogen peroxide, oil, paradichlorobenzene, hydrogen peroxide/glycerol and arachis oil/chlorobutanol/paradichlorobenzene were observed with significant cerumenolytic activities. Urea/hydrogen peroxide/glycerol was observed with a significant cerumenolytic activity without the need for further interventions such as syringing/aspiration/suction. CONCLUSION: We observed several cerumenolytics to be effective in the treatment of impacted earwax when accompanied by additional manual techniques such as syringing/aspiration/suction.

Cerumen Impaction: Diagnosis and Management.

Cerumen production is a normal and protective process for the ear canal. However, cerumen should be removed when it causes symptoms (e.g., hearing loss, itching, pain, tinnitus) or prevents assessment of the external auditory canal, the tympanic membrane, or audiovestibular system. Cerumen should also be removed when it limits examination in patients who cannot communicate their symptoms, such as those with dementia or developmental delay, nonverbal patients with behavioral changes, and young children with fever, speech delay, or parental concerns. Patients with coagulopathies, hepatic failure, thrombocytopenia, or hemophilia, and those taking antiplatelet or anticoagulant medications, should be counseled about the increased risk of bleeding in the external auditory canal when cerumen is removed. Effective treatment options include cerumenolytic agents, irrigation with or without cerumenolytic pretreatment, and manual removal. Home irrigation with a bulb syringe may be appropriate for selected adults. Cotton-tipped swabs, ear candling, and olive oil drops or sprays should be avoided. If multiple attempts to remove the impacted cerumen-including a combination of treatments-are ineffective, clinicians should refer the patient to an otolaryngologist. Persistent symptoms despite resolution of the impaction should also prompt further evaluation for an alternative diagnosis.

Extracción de la cera de los oídos / Extraction of wax from the ear

A través de cuatro artículos sucesivos pretendemos mostrar los procedimientos que consideramos de mayor utilidad para el diagnóstico y el seguimiento de la otitis media serosa (OMS) por parte de Pediatría de Atención Primaria. En este primero, expondremos la que, a nuestro juicio, es la manera más eficaz de limpiar la cera del oído de un niño. Las conclusiones aportadas conjugan las recomendaciones ofrecidas por las principales guías sobre extracción de cera del oído y las de la revisión bibliográfica efectuada, con la experiencia de un equipo de pediatras y de otorrinolaringólogos de la misma área de salud. Alrededor de un 50% de niños requieren limpiar de cera sus oídos a fin de realizar una correcta otoscopia. Para ello podemos utilizar la instilación de cerumenolíticos, la irrigación, la extracción manual o cualquier combinación. No existe evidencia en la bibliografía de que un procedimiento sea mejor que otro. Conclusiones: tras aplicar las diferentes técnicas de limpieza, consideramos que, si la cera es externa y el conducto auditivo permeable, la mejor manera de eliminarla es mediante el uso de curetas o porta-algodones, pero si la cera es más profunda o está impactada, el método elegido será el lavado con irrigación de agua templada, para lo que un cerumenolítico aplicado previamente es de gran ayuda. Aconsejamos realizar dicha irrigación con una jeringa de 20 cc y un catéter intravenoso Abocat® del 14-16, a fin de evitar riesgos (AU)

Through four successive articles we aim to show the procedures we consider to be most useful for the diagnosis and follow-up of otitis media with effusion (OME) by Primary care Pediatrics. In the first one, we expose what we believe is the best way to clean wax from the ear of a child. The conclusions provided combine the recommendations offered by the main guides on extraction of wax from the ear and the literature review carried out, with the experience of a team of pediatricians and otolaryngologists from the same Healthcare Area. Around 50% of children require clean wax from their ears in order to perform a correct otoscopy. To do this we can use the instillation of cerumenolytics, irrigation, manual removal, or any combination. There is no evidence in the literature that a procedure is better than another one. Conclusions: after applying different cleaning techniques, we believe that if the wax is external and the ear canal permeable, the best way to remove it is by the use of blunt ear curettes or applicator with triangular tip, but if the wax is deeper or is impacted, the better choice will be washing with warm water irrigation, in this case, the previous application of a cerumenolytic will be of great help. We advise to perform such irrigation with a syringe of 20 cc and an intravenous catheter Abocat® 14-16, in order to avoid risks (AU)

Bacterial contamination of commercial ear cleaners following routine home use.

Ear cleaning solutions are designed for repeated use, which raises the possibility for bacterial contamination leading to recurrent or persistent infectious otitis. The purpose of this study was to investigate the prevalence of bacterial contamination of commercial ear cleaners following routine home use in dogs and to describe the characteristics that are associated with contamination. Used ear cleaner bottles and information regarding their use were obtained from canine owners visiting veterinary dermatologists. Both the bottle applicator tips and the solution contents were cultured for aerobic bacteria. Bacterial contamination was present on 10% of the bottle tips and in 2% of the solutions. Isolated bacteria included Staphylococcus pseudintermedius, Bacillus spp., coagulase-negative Staphylococcus spp., Micrococcus spp. and Burkholderia cepacia. The contamination rate was significantly higher on the applicator tips than in the solutions (P = 0.0076). The applicator tip contamination rate was significantly higher in expired samples (17%) than in-date samples (4%; P = 0.0277). The bottle sizes were significantly larger for the samples with contaminated applicator tips compared with noncontaminated tips (P = 0.0455). The contamination rate was significantly higher when Tris-EDTA was an ingredient. Cleanliness of the bottle, contact with the ear canal and infection status of the ear at time of culture had no bearing on the contamination rate. In summary, with routine home use of commercial ear cleaners, pathogenic bacterial contamination is of minor concern. This concern may increase when expired products or larger bottles of ear cleaner are used and when Tris-EDTA is an ingredient.

Acute otitis media: From diagnosis to prevention. Summary of the Italian guideline.

Acute otitis media (AOM) is the most common disease occurring in infants and children and has major medical, social and economic effects. If we consider the Italian pediatric population and the incidence rates in different age ranges it can be calculated that almost one million cases of AOM are diagnosed in Italy every year. Various attempts have been made internationally to clarify the most appropriate ways in which AOM should be managed. In Italy, this has been done at local or regional level but there have so far been no national initiatives. The objective of this guideline is to provide recommendations to pediatricians, general practitioners and otolaryngologists involved in the clinical management of acute otitis media in healthy children aged 2 months to 12 years. After a systematic review and grading of evidences from the literature, the document was drafted by a multidisciplinary panel with identified key clinical questions related to diagnosis, treatment of the acute episode, management of complications and prevention.