Ear Wax

Casebank History
1

Where you are:
You are an FY2 in GP surgery.

Who the patient is:
Mrs Nicole Harrop, 29 years old, presented with intermittent ear pain and hearing difficulty for the past month.

What you should do:
Take history and address her concerns.

Data gathering

Doctor: How can I help?
Patient: I have had pain in my ear for the past month.

(P1)
(SOCRATES)
D: Where is it exactly? (site) (which ear?)
P: Right side.
D: What were you doing when it started? (Onset)
P: I was just sitting.
D: What kind of pain? (character)
P: I feel like my ear is blocked (+ve finding)
D: Does it go anywhere? (radiation)
P: No.
D: Is it continuous or comes and go?
P: It comes suddenly and goes on its own.
P: Anything makes your condition better?
P: No.
D: Is there anything that makes it worse?
P: Shower and swimming.
D: Could you please score the pain on a scale of 1 to 10, with 1 being no pain and 10 being the most severe pain you have ever experienced?
(score)
P: 6.
D: How about the other ear?
P: It is fine.
D: Anything else? Are you able to hear?
P: I can’t hear properly with my right ear. (Hearing difficulty +ve finding)
D: Anything else?
P: No.

DDs
D: Any fever? (OM)
P: No.
D: Any discharge from the ear?
P: No.
D: Any vertigo, tinnitus, numbness or tingling in the face? (Cranial nerve involvement)
P: No.
D: Does your ear feel stuffy?
P: Yes. (+ve finding)
D: Do you use cotton buds?
P: Yes (+ve finding)

P2
D: Have you experienced a similar pain before?
P: No.
D: Have you been diagnosed with any medical conditions?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Do you have any allergies from any food or medications?
P: No.
D: Any hospitalisations or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: Any recent travel? (flight)
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: I eat everything, its fine.
D: Do you do physical exercise?
P: I am active.
D: What do you do for a living?
P: Office job.

Examination

  • I would like to check your vitals and examine your ear if that’s OK. I will be using an instrument called an otoscope – an instrument with a light and magnifying glass - to look inside the ear, and I would also like to do hearing tests and balance tests. We will also do some initial investigations.

Provisional diagnosis

  • From my assessment I suspect that you have ear wax build-up in your ear. Sometimes earwax can build up in your ears and block them.
    This can be uncomfortable and annoying, but can usually be treated.

Management

  • Senior.
  • Symptomatic
  • General advice:
  • You cannot prevent earwax. It’s there to protect your ears from dirt and germs.
  • Do not use your fingers or any objects like cotton buds to remove earwax. This will push it in and make it worse.

Medical:

  • Earwax usually falls out on its own. If it does not and blocks your ear, put 2 to 3 drops of medical grade olive or almond oil in your ear twice a day for a few days to soften the wax.
  • It is recommended you use a dropper while lying your head on one side for a few minutes to let the oil work its way through your ear canal(s).
  • You may find it easier to do this first thing in the morning and then just before you go to sleep.
  • Over about 2 weeks, lumps of earwax should fall out of your ear, especially at night when you’re lying down.

If your ears still blocked despite using of the drops, we can do:

  • Ear irrigation: flush the wax out with water.
  • Microsuction: to suck the wax out.
  • These treatments are usually painless. You might have to pay to have them done privately.
  • There’s no evidence that ear candles or ear vacuums get Rid of earwax.

Safety netting

  • Do not use drops if you have a hole in your eardrum (a perforated eardrum).
  • If your symptoms have not cleared after 5 days or your ear is badly blocked and you cannot hear anything (you can get an infection if it has not cleared) come back to us.
2

Where you are:
You are an FY2 Doctor in GP surgery

Who the patient is:
Theresa Scott is a 45-year-old lady who has presented with some complaints

Other information you have about the patient:
None

What you must do:
Assess the patient and discuss management

Patient information:

  • You are a 45 Theresa Scott, a 45-year-old lady who has presented with ear pain
  • Opening sentence: “Doctor, I have earache and I think I have earwax” OR “ Doctor I think I need something for my earwax”?
  • You have had this pain for 3 days
  • Recently you have been well.
  • One of your friends had earwax before, so you also think you have got wax as well.
  • You clean your ears everyday with an earbud.
  • 2 weeks ago you travelled to Spain/Caribbean and you went swimming in the sea.
  • You got a lot of water entering your ear.
  • No fever/No chest pain/No Shortness of breath.
  • You have reduced hearing in the last few days.

Examiner’s prompt

  • Examiner should say ear examination is normal
  • Examiner should give a picture of wax in the ear
  • Aurioscopy
  • BNF

Questions:

  • Why do I have wax?
  • How do I prevent earwax in the future?
  • How often should I clean my ears?
  • How should I clean the ear?

Data gathering

  1. GRIPS
  2. How can I help you?
  3. History of ear pain and wax
  4. Differential Diagnosis
    • AOM
    • Otitis externa
    • Trauma
    • URTI
  5. PMAFTOSA
  6. ICE
  7. Effects of symptoms on patient life
  8. Examinations
    • Observations: All are normal
    • Ear examinations
      • Inspection
      • Temperature
      • Tenderness
    • Otoscope (Auriscopy): The examiner will give you a picture.
    • Tunning fork test.
  9. Explain your examinations findings to the patient.
  10. Diagnosis
    • Wax: Ear wax is formed from sweat and dead cells which are produced in the ear
    • Earwax protects the ear canal, it usually falls off on its own, however if it doesn’t fall off it can Block the ear canal.
    • Blockage of the ear usually occurs if one uses cotton ear buds, this ends up pushing the wax inwards.
    • Swimming can also cause blockage of the ear from ear wax, this happens when water causes the wax to expand and block the ear canal.
    • Some people are just physiologically more prone to produce more earwax.
    • The hearing loss will improve once the wax is removed

Management

  • Ear drops of olive oil for 3 – 5 days, it will dissolve the wax
  • If it does not improve then we can do irrigation
  • Advice about hygiene
  • Cover the ear during swimming
  • Avoid using cotton ear buds
  • Use olive oil or almond oil once a week or every 2 weeks.
  • If the earwax doesn’t come off after ear drops we will try something known as irrigation, we can use eardrops for that

Safety netting

  • High temperature and worsening pain
  • Worsens hearing problem

Concerns:

  • How can I stop this from happening?
    You cannot stop earwax from happening. It is a normal process that prevents the ear.
  • How often do I have to clean the ear?
    You do not have to do it often, but you can try and put eardrops over a week if you notice that you develop earwax too frequently.