Ear Wax Management Primary and Community Care Pathway

Issue date: October 2020

Status: Compliance and action

Category: Policy

Title: Ear Wax Management Primary and Community Care Pathway

Date of Review: On-going

For Action by: Health Boards and NHS Trusts

Action required by: 1 October 2021

Sender: Head of Sensory

Welsh Government contact:

Sarah O’Sullivan-Adams Primary Care Directorate

Sarah.o’sullivan-adams@gov.wales

Enclosure(s): None

Ear wax (cerumen) is a common and significant health complaint, specifically significant for people with pre-existing hearing loss as it compounds their communication difficulties.

Unresolved and troublesome ear wax is a relatively easy health condition to address through removal by trained professionals; however, NHS Wales currently has no consistent national pathway for ear wax management in line with NICE guidance (NICE 2016).

A Task and Finish Group was established to ensure all citizens across Wales can access the most appropriate treatment and support for ear wax problems, in line with the Welsh Government’s ‘A Healthier Wales’ plan, the ‘Hearing Framework of Action’ and the new Primary Care Model, underpinned by the principles of prudent healthcare.

The group completed its remit and the following objectives have been met:

1. Determine and report on current service provision across Wales
2. Develop a national integrated pathway for the safe and effective management of ear wax to provide consistent patient outcomes across Wales and ensure:

• equitable access
• efficient and effective use of NHS resources, cost effective and prudent
• consistent seamless management across primary, community and secondary care settings
• self-management where clinically appropriate, empowering people to better manage their own care
• compliance with NICE guidance and Audiology Quality Standards

The Welsh Government launched the Framework of Action for People who are deaf or living with Hearing Loss in May 2017. The Framework commits all stakeholders to work together to improve services and provide high-quality care and support for citizens across Wales. The Hearing Project Board was established to oversee implementation of the recommendations, including development of a national pathway for ear wax management.

Historical treatment: Health boards are responsible for providing ear wax management services. Wax management is not explicitly part of the GP contract - some GP practices have traditionally provided services while others have simply referred all patients with ear wax symptoms to hospital ENT departments.

In recent years, concern has been raised about the procedure used to treat ear wax problems and patient safety. Also, the number of referrals to hospital ENT departments and/or secondary care audiology departments has increased considerably and is not in line with the prudent health care principles underpinning our national plans (‘A Healthier Wales’, ‘Framework of Action’ and new Primary Care Model).

The number of referrals has been increasing year on year, resulting in extended waiting times, which has meant patients with the greatest need are not being seen in the right place, at the right time by the right health professional. In addition, some patients have reported being told by GPs that there is no NHS Wales ear wax management service available and that they should seek private treatment.

Ear wax is produced by the ear as part of its natural process of cleaning and protection and in the majority of cases it does not need to be removed. Sometimes wax can build up in the ear canal and softening agents can be used as part of self-management and then as part of regular maintenance to help prevent further wax.

Experts suggest weekly using two drops of fresh, unused olive oil at room temperature, sodium chloride (salt water) or sodium bicarbonate drops  (1) (NICE 2016).

Sometimes wax can become impacted and cause difficulties. Prevalence of impacted wax increases with age with some studies reporting a prevalence of as high as 34% in those over 65 years of age.

Impacted and/or occluding wax can cause symptoms such as:

• hearing loss – a decrease in hearing sensitivity of typically 20-30dBHL (mild level of hearing loss) if wax is occluding the ear canal
• discomfort
• earache
• feeling of blocked ear
• tinnitus

Often these symptoms and their impact can be significant, particularly for those with pre-existing unmanaged hearing loss where it can compound hearing difficulties. For those using hearing aids, occluding ear wax will impede the passage of amplified sound in the ear canal; often precluding any benefit provided by the device. Also, ear wax can block the hearing aid ear mould or tubing, it can cause acoustic feedback (whistling) and prevent impressions being taken when new ear moulds are needed.

As children’s ear canals are much smaller, wax build up becomes a problem more quickly and they require new ear moulds several times a year as they grow out of them. Occluding earwax also prevents the proper examination of the ear canal and the accurate completion of some diagnostic tests.

In some cases, management of earwax will be more complex (e.g. those with mastoid cavities) and referral to secondary care services may be required. However, this should be a small number of people, with the majority being able to self-manage or have their ear wax managed in primary and community care. There is consensus that certain removal/maintenance methods should not be used (cotton buds, matches etc.) should not be used to try to clear wax from an ear canal. Wax is normally only produced in the outer third of the ear canal, so using these tools forces the wax further down the canal and forms a hard plug against the ear drum. They can also cause trauma to the ear canal and even perforation of the ear drum, thereby also increasing the risk of infection. Ear candling should not be used.

Task and Finish Group findings show patients need and appreciate direct and clear language in the advice they receive on management (including self-management) of medical conditions. Information leaflets and promotional material to support people to make the right choices related to ear wax self -management and direct them to access the correct services is important.

Provision of ear wax management services across Wales is patchy; with no clear pathway, training requirements or service specification. There are areas of good practice in ear wax management already being delivered in some health board cluster areas in line with the principles of prudent healthcare that could be rolled out across Wales in line with our national plans.

Incidence of Ear Wax in the Population of Wales

Scoping studies found as part of the development of the Advanced Practice Audiology in primary care that 3% of the population present with ear wax each year. This equates to approximately 96,000 patient appointments in primary care across Wales each year.

The Wax Management Task and Finish Group agreed:

1. Ear wax management to be delivered in a primary and community care setting, in line with the nationally agreed service specification, standard operating procedures and training standards, led by Advanced Audiology Practitioners and delivered by trained healthcare professionals.
2. The Audiology Heads of Service Group to agree and lead on discussion and implementation of points 3-9 below.
3.  Roll out of a national wax management patient pathway.
4.  Commission a national wax management training programme; to include microsuction and/or manual removal using a probe.
5. The new wax management pathway will complement roll out of ‘first point of contact’ access to audiology services in primary care, for patients presenting with hearing problems, tinnitus, and specific balance problems.
6. Develop national advice for ear wax self-management.
7. Health boards will now implement, monitor and review the new pathway and service models in their respective cluster areas.
8. Continue discussion with health professionals to raise awareness e.g. give pharmacists access to training and promotion of wax self-management.
9. Progress centralised national procurement of equipment in one health board.

The recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Committee’s experience and opinion of what constitutes good practice. The NICE pathway for hearing loss in adults recommends that primary or community care services should offer to remove ear wax if the ear wax is contributing to hearing loss or other symptoms, or needs to be removed in order to examine the ear to take an impression of the ear canal.

1. For adults and children over 4 years of age: Self-management using olive oil drops for seven days.

Exceptions:

• patients who have a known outer or middle ear condition that is being managed or requires management by ENT/AVM services should not self-manage. Patient to be referred to appropriate health professional e.g. Practice Nurse, ENT, AVM, GP or Advanced Practice Audiologist
   
• children 0-4 years of age should not self-manage. Parent should refer child to GP/ Advanced nurse practitioner/ Advanced Practice Audiologist. If earwax is confirmed problematic, consider referral to ENT or paediatric audiology for ear wax management. If no earwax, consider referral to ENT/ AVM/ paediatric audiology for further investigation.

2. If ear wax symptoms are not resolved:

• adults should self-refer to ear wax management service
• for children 11 years of age and older, parent refers child to ear wax management service - Referral may also be made by GP practice staff (triage) or GP if picked up in course of appointment for other condition
• for children 5-10 years of age, parent refers child to ear wax management service with specialist skills appropriate for the management of children
• patients of all ages with complex needs (e.g. learning disability, dementia, anxiety) may require onward referral to ear wax management service with specialist/advanced skills appropriate for the management of people with complex needs.

3. If ear wax symptoms are resolved, patients are provided with ongoing self-management advice.
4. For patients of ages: if problematic ear wax is still present, and/or symptoms are not resolved and/or abnormalities are detected, consider referral to:

• GP if earwax removed but there is discomfort/ear ache, blocked ear or abnormal ear on examination
• Paediatric Audiology if earwax removed but hearing loss and/or tinnitus
• ENT or Paediatric Audiology if unresolved ear wax

Notes on Ear Wax Management Pathway

Patients presenting with problematic ear wax symptoms may experience:

• discomfort / ear ache
• blocked ear (self-reported or clinician observed)
• hearing loss
• Tinnitus

Patients without the above ear symptoms but who report problematic earwax are to be provided with info on self-management, including ongoing self-management. Advice is from:

• leaflets/ website
• Choose Well advice at pharmacies
• NHS Direct 0845 4647
• public health information to include advice NOT to use cotton buds or similar inside ear

The exclusions for self-management are:

• have sudden onset or rapid worsening of hearing (NICE Guidance NG98)
• patients with significant pain and/or discharge from ear
• patients with known ear drum perforations and/or discharge from the ear

These groups of patients should contact their general practice.

(1) Advice from Andrew Evans, Chief Pharmaceutical Officer, is that there is little evidence to suggest which type of oil is more effective, or whether salt water is better than a solution of bicarbonate of soda. His comments on self-management: “We have found that using ear drops may help to remove the ear wax. It is not clear whether one type of drop is any better than another, or whether drops containing active ingredients are any better than plain water or saline.” His comments on ear drops that may be obtained on prescription, should ear wax management be added to the Common Ailments Scheme: “When determining the choice of ear drop to prescribe, prescribers should choose the product with the lowest NHS acquisition cost unless there are compelling patient reasons”