Hearing loss and ear wax

This is a new guideline from NICE on managing hearing loss and ear wax, published in June 2018. Exciting? Well, there are a couple of good bits in here, especially given how common a problem this is. Some top tips that were new for me:

  • Consider an urgent referral to ENT for someone of Chinese or South East Asian origin with hearing loss AND a middle ear infusion, which is not due to an URTI.
  • Consider referring patients with newly diagnosed dementia, or people with learning disabilities for a hearing assessment every 2 years. Also consider referring at diagnosis for people with dementia and on transfer to adult services for people with a learning disability.
  • NICE advises that we should NOT be advising patients to use home syringing kits. See below for more detail on why this is.
  • GP surgeries should be offering irrigation for wax removal, or aural probing.
  • Drops don't have to be used for several days before irrigation. Studies suggest that using drops immediately before irrigation is safe and effective.
  • If irrigation is unsuccessful, then water can be instilled 15 mins before a second attempt, or a 5 day course of drops can be advised.
  • What drops to suggest patients use? NICE advises that any can be used, even hydrogen peroxide, which has gone out of fashion a bit. See below for more detail on this (I know it's a bit trivial, but it always really annoys me that I don't know the evidence base for something we advise on all the time).

Hearing loss and when to refer

Sudden or rapidly worsening hearing loss

Patients should be referred whether it is unilateral or bilateral if it is not explained by external or middle ear problems.

  • Sudden loss (i.e. developed suddenly over 3d or less) in the last 30d – refer immediately (within 24 hrs) to ENT or ED.
  • Sudden loss > 30d ago – refer urgently (within 2w) to ENT or an audiovestibular service.
  • Rapidly worsening loss (ie 4 to 90d) refer urgently (within 2w) to ENT or an audiovestibular service.

Hearing loss with other signs or symptoms

Refer immediately (to be seen within 24 hrs) to ENT if:

  • Acquired unilateral hearing loss AND altered sensation OR facial droop on the same side. NB If stroke is suspected then obviously manage as that.
  • Hearing loss in immunocompromised patients with otalgia AND otorrhoea IF treatment hasn’t worked within 72 hrs (beware malignant otitis externa).

Consider an urgent referral (within 2ww) to ENT if:

  • Chinese or South East Asian origin with hearing loss AND a middle ear effusion, not associated with URTI (nasopharyngeal tumours are more common).

Consider referring patients to ENT or an audiovestibular service if they have:

  • Unilateral or asymmetric hearing loss.
  • Hearing loss that fluctuates and isn’t associated with an URTI.
  • Hyperacusis (that is causing significant distress and interferes with daily activities).
  • Persistent tinnitus that is unilateral, pulsating, distressing or has changed significantly.
  • Vertigo that hasn’t fully resolved or is recurrent.
  • Hearing loss that isn’t age related.

Consider referring patients to ENT, if after the removal of wax, or the treating of infection, they have any of the following:

  • Partial or complete blockage of the ear canal that prevents examination or impression taking.
  • Pain that has lasted more than 1 week, despite treatment.
  • Otorrhoea (not wax) that has not responded to treatment or has recurred.
  • Abnormal appearance of the drum (e.g. inflammation, polyp formation, perforation, abnormal bony or skin growths, swelling of the outer ear, blood in the ear canal).
  • Middle ear effusion that persists after or occurs in the absence of an URTI.

Ear wax

Such a common problem and one which causes a surprising amount of distress and time spent consulting with us. I was particularly interested in this bit as quite a few practices seem to be stopping doing irrigation and advising more self-management.

A note of caution... most of the studies done in this area are on small numbers of people and are of low quality. It can therefore be quite hard to draw robust conclusions.

Ear irrigation vs home syringing

NICE advises that we should be offering irrigation where wax is causing a problem.

Benefits of GP ear irrigation vs home syringing:

  • It is more effective (there are fewer consultations in the following 2 yrs for ear wax).
  • It is more comfortable for patients.
  • It gives better hearing afterwards (by about 10dB).

However, the studies have not been large enough to show whether there are any significant harms from home syringing and it is probably more cost-effective as the benefits of irrigation are small.

NICE advises that we do not suggest home syringing to patients. This is partly because its safety has not been proven. It is also because they felt that in general we advise patients not to insert anything into their ears and yet advising home syringing goes directly against this advice.

Ear drops immediately before irrigation

Traditionally we have advised patients to use drops for at least 5d before irrigation. However there is no high quality research that shows any benefit of using drops for several days before irrigation compared to using them just immediately before irrigation.

Only having to insert drops immediately before irrigation may benefit some groups (e.g. the elderly) who could struggle to insert drops. It may also reduce the number of unsuccessful irrigation attempts, as drops can be inserted immediately before the procedure.

If unsuccessful, evidence suggests that instilling water into the ear and leaving it for 15 mins also improves the chances of success.

Ear drops for wax removal

This is one of those scenarios where drop A is better than drop B in study 1, drop B is better than drop C in study 2 and drop C is better than drop A in study 3, i.e. all a bit of a nonsense.

Olive oil - There weren't any decent studies done that NICE could find on using olive oil on it's own for wax clearance. There is evidence for it's benefit in use before irrigation.

Hydrogen Peroxide - There is some evidence that it can cause irritation and some evidence of increased harm if used before irrigation. However NICE felt that there wasn't enough evidence to give a negative recommendation about it.

So what should we be advising? The evidence does suggest that using drops on their own is effective and that they are effective if used before irrigation. Water, olive oil and sodium bicarbonate all have good evidence for use before irrigation, though sodium bicarbonate doesn't have evidence for any benefit if used only immediately before irrigation. NICE advises that it is difficult to conclude that there is a clear advantage of one drop over another. They suggest considering cost and patient factors when giving advice.

This article first appeared in The Sessional GP magazine.

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