目的2008年美国耳鼻咽喉头颈外科学会基础耳垢阻塞物临床实践指南的更新为处理耳垢阻塞物提供了基于证据的建议。耳垢嵌塞被定义为引起症状的耳垢积聚,阻止对耳朵的评估,或者两者兼而有之。与先前指南相比的变化包括增加了一名消费者到开发小组;新的证据(3个指南,5系统审查,和6项随机对照试验);增强了有关患者教育和咨询的信息;阐明行动陈述关系的新算法;扩展行动陈述档案以明确地陈述质量改进机会,对证据的信心,故意的模糊,和意见分歧;加强外部审查程序,包括公众意见和期刊同行审查;关于管理耳垢影响的3个新的关键行动声明,重点是初级预防,禁忌干预,以及转诊和协调护理。目的本指南的主要目的是帮助临床医生识别可能从干预中受益的耳垢嵌塞患者,并促进循证管理。该指南的另一个目的是强调特殊人群或具有改变因素的患者的需求和管理选择。该指南适用于所有可能诊断和治疗耳垢嵌塞患者的临床医生。它适用于任何可以识别耳垢嵌塞的环境,监控,或管理。该指南不适用于与以下情况相关的耳垢嵌塞患者:耳道皮肤病;复发性外耳道炎;闭塞性角化病;先前的放射治疗影响耳朵;先前的鼓室成形术/鼓膜成形术,管壁向下乳突切除术,或其他影响耳道的手术。关键行动声明小组强烈建议临床医生应治疗,或者是指可以治疗的临床医生,耳垢嵌塞,定义为与症状相关的耳垢积聚,防止对耳朵进行必要的评估,或者两者兼而有之。小组提出了以下建议:(1)临床医生应解释适当的耳朵卫生,以防止患者积聚耳垢时发生耳垢嵌塞。(2)临床医生应诊断耳垢嵌塞时,如在耳镜检查中看到的,与症状有关,防止对耳朵进行必要的评估,或者两者兼而有之。(3)临床医生应通过病史和/或体格检查评估患有耳垢的患者是否有改变管理的因素,如≥以下1项:抗凝治疗,免疫受损状态,糖尿病,之前对头部和颈部进行放射治疗,耳道狭窄,外生骨,和不完整的鼓膜。(4)临床医生不应常规治疗无症状且耳朵可以充分检查的患者的耳垢。(5)临床医生应确定耳道阻塞的患者可能无法表达症状(幼儿和认知障碍的儿童和成人),他们应该及时评估干预的必要性。(6)临床医生应进行耳镜检查,以检测助听器患者在医疗保健期间是否存在耳垢。(7)临床医生应该治疗,或者是指可以治疗的临床医生,有耳垢嵌塞的患者进行适当的干预,其中可能包括≥1种以下物质:灌溉,或手动删除需要仪器。(8)临床医生应建议不要使用耳光检查来治疗或预防耳垢嵌塞。(9)临床医生应在耳垢嵌塞的办公室治疗结束时评估患者,并记录嵌塞的解决方法。如果影响没有解决,临床医生应该使用额外的治疗。如果尽管嵌塞消退,但全部或部分症状仍然存在,临床医生应评估患者的替代诊断。(10)最后,如果初始管理不成功,临床医生应将患有持续性耳垢嵌塞的患者转介给具有专门设备和培训的临床医生,以清洁和评估耳道和鼓膜。该小组提供了以下选项:(1)临床医生可以使用cerumenolidagent(包括水或盐溶液)在处理耳垢嵌塞。(2)临床医生可以使用灌溉来管理耳垢。(3)临床医生可以在处理耳垢嵌塞时使用需要仪器的手动移除。(4)最后,临床医生可以就控制措施对有耳垢嵌塞或过度耳垢的患者进行教育/咨询。
Objective This update of the 2008 American Academy of Otolaryngology-Head and Neck Surgery Foundation cerumen impaction clinical practice
guideline provides evidence-based recommendations on managing cerumen impaction. Cerumen impaction is defined as an accumulation of cerumen that causes symptoms, prevents assessment of the ear, or both. Changes from the prior
guideline include a consumer added to the development group; new evidence (3
guidelines, 5 systematic reviews, and 6 randomized controlled trials); enhanced information on patient education and counseling; a new algorithm to clarify action statement relationships; expanded action statement profiles to explicitly state quality improvement opportunities, confidence in the evidence, intentional vagueness, and differences of opinion; an enhanced external review process to include public comment and journal peer review; and 3 new key action statements on managing cerumen impaction that focus on primary prevention, contraindicated intervention, and referral and coordination of care. Purpose The primary purpose of this guideline is to help clinicians identify patients with cerumen impaction who may benefit from intervention and to promote evidence-based management. Another purpose of the
guideline is to highlight needs and management options in special populations or in patients who have modifying factors. The
guideline is intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction, and it applies to any setting in which cerumen impaction would be identified, monitored, or managed. The
guideline does not apply to patients with cerumen impaction associated with the following conditions: dermatologic diseases of the ear canal; recurrent otitis externa; keratosis obturans; prior radiation therapy affecting the ear; previous tympanoplasty/myringoplasty, canal wall down mastoidectomy, or other surgery affecting the ear canal. Key Action Statements The panel made a strong recommendation that clinicians should treat, or refer to a clinician who can treat, cerumen impaction, defined as an accumulation of cerumen that is associated with symptoms, prevents needed assessment of the ear, or both. The panel made the following recommendations: (1) Clinicians should explain proper ear hygiene to prevent cerumen impaction when patients have an accumulation of cerumen. (2) Clinicians should diagnose cerumen impaction when an accumulation of cerumen, as seen on otoscopy, is associated with symptoms, prevents needed assessment of the ear, or both. (3) Clinicians should assess the patient with cerumen impaction by history and/or physical examination for factors that modify management, such as ≥1 of the following: anticoagulant therapy, immunocompromised state, diabetes mellitus, prior radiation therapy to the head and neck, ear canal stenosis, exostoses, and nonintact tympanic membrane. (4) Clinicians should not routinely treat cerumen in patients who are asymptomatic and whose ears can be adequately examined. (5) Clinicians should identify patients with obstructing cerumen in the ear canal who may not be able to express symptoms (young children and cognitively impaired children and adults), and they should promptly evaluate the need for intervention. (6) Clinicians should perform otoscopy to detect the presence of cerumen in patients with hearing aids during a health care encounter. (7) Clinicians should treat, or refer to a clinician who can treat, the patient with cerumen impaction with an appropriate intervention, which may include ≥1 of the following: cerumenolytic agents, irrigation, or manual removal requiring instrumentation. (8) Clinicians should recommend against ear candling for treating or preventing cerumen impaction. (9) Clinicians should assess patients at the conclusion of in-office treatment of cerumen impaction and document the resolution of impaction. If the impaction is not resolved, the clinician should use additional treatment. If full or partial symptoms persist despite resolution of impaction, the clinician should evaluate the patient for alternative diagnoses. (10) Finally, if initial management is unsuccessful, clinicians should refer patients with persistent cerumen impaction to clinicians who have specialized equipment and training to clean and evaluate ear canals and tympanic membranes. The panel offered the following as options: (1) Clinicians may use cerumenolytic agents (including water or saline solution) in the management of cerumen impaction. (2) Clinicians may use irrigation in the management of cerumen impaction. (3) Clinicians may use manual removal requiring instrumentation in the management of cerumen impaction. (4) Last, clinicians may educate/counsel patients with cerumen impaction or excessive cerumen regarding control measures.