Poor access to ear microsuction services

CERUMEN is a wax-like substance that lubricates the external auditory canal (EAC). It is produced in the outer third of the EAC and forms through a mixture of secretions from a number of sebaceous and apocrine glands.¹ It is important for its antibacterial and antifungal properties. Wax impaction is a common presentation in the primary care setting. 

Patients with wax impaction often present with otalgia, itchiness and conductive hearing loss leading to social withdrawal and poor work function.² The first-line treatment for removal of wax is the use of topical cerumenolytics followed by a trial of irrigation (ear-syringing) with the GP.³ Although irrigation, when performed correctly, is considered an effective method of wax removal, one in 1,000 patients experience major complications following irrigation.⁴

In cases with known otological disease such as tympanic membrane perforation, history of mastoidectomy or in cases unresponsive to irrigation, microsuction of the ears is considered. This involves examination of the ear using a binaural microscope (either fixed or loupes) and a fine low-pressure suction device. Suction is performed under direct vision and usually takes only a few minutes to complete. 

Access to ear microsuction services is limited in the Republic of Ireland. At present, waiting times for specialist ear, nose and throat review are currently ranging from 18-36 months. Due to lack of accessibility to microsuction clinics, patients with difficult wax impaction are referred to specialist ear, nose and throat centres, thus adding to waiting list times.

The aim of this audit is to assess the need for access to microsuction services in the primary care setting and identify measures to improve current referral pathways. 

Method and sample

A retrospective audit was completed on the total number of patients attending an acute specialist ear, nose and throat service over the course of one week. The data was collected using patient clinical notes. Data was inputted to a data collection sheet using Microsoft Excel. From the entire patient database a list of patients presenting for microsuction of wax was generated. 

The files of the patients presenting for microsuction of wax were reviewed. The mode of referral, reason for referral, use of cerumenolytics and trial of irrigation with GP was recorded.

Results

Numbers

Total number of patients presenting to an acute ear, nose and throat service in one week was 177 patients.

Total number of patients presenting with wax impaction for microsuction was 47 (26.6%).

Referral sources

• General practitioner referral – 24 (51%)
• Audiology referral – 5 (11%)
• Self-referral – 18 (38%).

Use of cerumenolytics

A total of 18 patients (38%) presenting with wax impaction reported the use of cerumenolytics prior to presenting to the acute ear, nose and throat service. Of these patients, 10 were referred by their GP (56%), two were referred by audiology (11%) and six patients self-referred (33%).

Irrigation

Of the 24 patients referred by their GP only four patients underwent a trial of irrigation (17%). 

The reasons given for incomplete irrigation in these four cases were:

• Incomplete removal of wax following two attempts with both cerumenolytics and irrigation (75%)
• Fear of causing trauma to the tympanic membrane (25%).

The remaining 20 patients referred by their GP did not undergo a trial of irrigation (83%). 

Reasons for not attempting irrigation included:

• Narrow external auditory canal (1%)
• Fear over causing trauma to external auditory canal and tympanic membrane (25%)
• Known pathology, eg. tympanic membrane perforation (1.5%)
• Movement disorder or intellectual impairment (1%)•
• Patient had previous microsuction (1%)
• Practice did not provide an irrigation service (30%).

Discussion

Waiting times for ear, nose and throat specialist review are on average 18-36 months. As a result, patients with chronic conditions are presenting to the emergency department in the hope of expediting review. Wax impaction is a common presentation to acute specialist ear, nose and throat departments, accounting for over a quarter of attendances. It is estimated that GPs see a minimum of two patients per week for ear irrigation.⁴

When irrigation attempts to remove wax fail, GPs are left with little option but to refer to specialist centres. This in turn results in increased waiting times in acute departments and thus has a knock-on effect on outpatient waiting lists due to staffing levels in specialist ear, nose and throat centres. 

The results of this audit also demonstrate a lack of training and fear of irrigation among GPs. The data collected show that approximately one-third of GPs did not offer an irrigation service and one-quarter did not attempt irrigation over fear of causing damage to the external auditory canal and tympanic membrane.

The audit results highlight the lack of support available to GPs in the management of wax impaction. It demonstrates the need for education of GPs and nurse specialists in procedural techniques to manage difficult cases. With effective training the majority of these cases could be managed in the primary care setting, thus reducing referral rates to specialist centres and in turn, reducing waiting list times in specialist ear, nose and throat centres. 

Recommendations

Wax impaction is a common presentation in both the primary care and specialist setting. Access to microsuction services outside specialist centres is limited. The findings from this audit demonstrate that in cases of difficult wax impaction, a GP’s only option is to refer the patient to a specialist centre. Nurse-led wax clinics have proven very successful in the management of wax. However, to date, there are only two ENT clinical nurse specialists in the Republic of Ireland trained in microsuction of ears.

The introduction of a structured training programme for GPs and clinical nurse specialists in common ENT procedural techniques such as microsuctioning would be beneficial in improving management of difficult wax impaction in the community. In addition, structured training would provide community healthcare professionals with the skills necessary to manage many ENT conditions commonly referred to acute services (eg. foreign body impaction, otitis externa and chronic suppurative otitis media). 

It is feasible to set up microsuction services in the primary care setting, staffed by GPs and practice nurses who have been appropriately trained. The resulting increased number of GPs with a special interest in the management of ear, nose and throat conditions in the primary care setting would in turn reduce the number of patients attending acute and outpatient ENT services and lead to an eventual reduction in hospital waiting lists. 

References

1. Alvord L, Farmer BL. Anatomy and Orientation of the Human External Ear. J Am Acad Audiol 1997; 8:383-390
2. Guest JF, Greener MJ, Robinson AC, Smith AF. Impacted cerumen: composition, production, epidemiology and management. QJ Med 2004; 97;477-488
3. Health Service Executive Ireland (www.hse.ie)
4. Bird S. The potential pitfalls of ear syringing. Minimising the risks. Aust Fam Physician 2003 Mar; 32(3):150-151