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Primary Health Care Services Date of last review 2009

Community Health Centre Clinical Practice Guidelines for Primary Care Nurses Cerumen Impaction Presentation: Excessive accumulation of cerumen forming a solid mass in the external auditory canal. Purpose: To safely soften and remove impacted cerumen. Definition: Cerumen is the yellow-brown waxy substance found in the ear canal that can obstruct the view of the tympanic membrane and cause decreased hearing and dizziness. Etiology: Ear wax accumulates because of excess production or poor migration out of the external auditory canal. Ear canal skin is generated on the tympanic membrane and then migrates laterally out the ear canal. Impacted cerumen can be the result of cotton swabs / Q-tips pushing it back into the ear and the use of hearing aids. Signs and Symptoms: tinnitus (ringing in ears) earache (otalgia) a feeling of fullness in the ears itching decreased hearing obstruction of the auditory canal by cerumen dizziness buzzing sounds Assessment: History: time of onset how long have symptoms persisted? vertigo/balance disturbance patient recently been swimming

previous episodes / recurrent problem? medications and allergies earache tinnitus itching decreased hearing previous ear issues / past ear surgery. cleaning habits occupational history (exposure to dust etc)

Physical assessment: vital signs inspection of external ear canal Note: Irrigation should not be used to remove cerumen if the patient's eardrum is ruptured or missing; if the patient has a history of chronic otitis media or a myringotomy; or if the patient has hearing in only one ear. Intervention: place the patient in a sitting position complete the assessment initiate the clinical pathways Referral to Physician: ear trauma suspected perforation of the tympanic membrane discharge from ear tubes in ear , previous ear surgery, chronic ear disease, hx of TM perforation; pain scale > 7/10 vertigo/balance disturbance unsuccessful irrigation previous surgery on affected ear redness or edema within the external ear canal severe headache that is a new problem for the patient if complication develops during irrigation /unsuccessful irrigation <12 yrs of age ear pain caustic substances in the ear patient has hearing in one ear only Follow-up: If treatment was successful, discharge the patient and instruct to return if symptoms recur or other new symptoms develop.

FRAMEWORK FOR DECISION-MAKING

Identification of client with cerumen impaction

Any of the following identified?

ear trauma suspected perforation of the tympanic membrane discharge from ear tubes in ear , previous ear surgery, chronic ear disease pain scale > 7/10 vertigo/balance disturbance unsuccessful irrigation previous surgery on affected ear redness or edema severe headache that is a new problem for the patient complication develops during irrigation /unsuccessful irrigation <12 yrs of age ear pain caustic substances in the ear Patient has hearing in one ear only

Yes

No

Refer to Physician

Initiate Clinical Pathway

NURSES PRACTICE GUIDELINES Cerumen Impaction Signs and Symptoms: tinnitus earache a feeling of fullness in the ears itching decreased hearing obstruction of the auditory canal by cerumen dizziness buzzing sounds pain____/10 Assessment: Symptoms time of onset______________________________________________________ duration of symptoms_______________________________________________ vertigo/balance disturbance patient recently been swimming previous episodes / recurrent problem___________________________________ medications and allergies_____________________________________________ earache_______L_______R tinnitus itching decreased hearing_______L_________R previous ear issues / past ear surgery.___________________________________ cleaning habits_____________________________________________________ occupational history (exposure to dust etc)_______________________________ Physical assessment: vital signs BP__________Pulse____________SatO2_________________ inspection of external ear canal_________________________________________ Intervention complete the assessment initiate the clinical pathways Referral to Physician: Yes________No_________ Reason: ear trauma suspected perforation of the tympanic membrane discharge from ear tubes in ear , previous ear surgery, chronic ear disease, hx of TM perforation; pain scale > 7/10 vertigo/balance disturbance unsuccessful irrigation

previous surgery on affected ear redness or edema within the external ear canal severe headache that is a new problem for the patient if complication develops during irrigation /unsuccessful irrigation <12 yrs of age ear pain caustic substances in the ear patient has hearing in one ear only

Follow-up: If treatment was successful, discharge the patient and instruct To return if symptoms recur or other new symptoms develop.

Signature____________________________________________________

Date__________

Cerumen Impaction Adult Patient, aged 12 and over

DISCHARGE INSTRUCTIONS/PATIENT INFORMATION If you have been instructed to put mineral oil/olive oil into your blocked ear (s) 1. To place the drops, tilt your head on the opposite side of the affected ear and place 2 to 3 drops of mineral oil or olive oil inside your ear, keep your head tilted for 5 minutes to help dissolve the wax. Plug your ear with a cotton ball. 2. Repeat procedure 3-4 times a day for 3 days. 3. Follow-up in 3 days. 4. Return if signs of discharge, buzzing in the ears, and pain . If your ear (s) have been flushed with water 1. Watch for signs of dizziness, buzzing in the ear, pain or discharge from the ear. If any of these problems occur, return to the Community Health Centre. 2. Avoid using cotton swabs to clean your ears. They tend to push earwax in to your ears. Clean your ears with your finger wrapped in a soft cloth.

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REFERENCES

Buccino, K.(2003). eMedicine consumer health. Foreign body, Ear. Retrieved May 13,.2004 from http://www.emedicinehealth.com/fulltext/13983.htm Budassi Sheehy, S. & Pisaricik Lenehan, G. (1999). Manual of emergency care (5th ed.). St. Louis: Mosby, Inc. Frey, R .J (December, 2002). HealthAtoZ. Cerumen impaction. Retrieved July 29, 200 from http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/health atoz/Atoz/ency/cerumen_impaction.jsp Grand Manan Hospital (2003 April). Clinical practice guidelines for primary care nurses.Cerumen Impaction. Grand Manan Hospital: AHSC. Mayo Clinic Staff (21 November 2003). Mayoclinic.com. Earwax blockage. Retrieved May 13, 2004 from http://www.mayoclinic.com/invoke.cfm?id=DS00052