QUESTION 3. Does the clinical finding of ear wax exclude the finding of otitis media?
- General Paediatrics Department, Birmingham Children’s Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK
- General Paediatrics Department, Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
A 6-year-old boy presented with ear ache and mild fever. The assessing registrar confidently made the assertion that the diagnosis could not be otitis media as he has read that the presence of wax excludes this. You wonder if this is true.
Structured clinical question
In children [population], does the clinical finding of ear wax [intervention] predict the absence of otitis media [outcome]?
Search strategy and outcome
PubMed – advanced search criteria: otitis media, children, ear wax and/or cerumen and diagnosis. Thirty two results were found. The titles and abstracts were reviewed and two relevant studies were found.1 2
Ovid - MEDLINE/EMBASE – advanced search criteria: otitis media, children, ear wax and/or cerumen. Seventeen results were found. The titles and abstracts were reviewed and one relevant study was found (this was the same as the study found in the PubMed search).2
A further search for case reports was unsuccessful. Ovid: MEDLINE/EMBASE database – search terms: otitis media, ear wax and/or cerumen, children and case report.
Searches were carried out in November 2008. See table 3.
Otitis media is a common paediatric condition which is often difficult to diagnose.3 4 Diagnostic features of otitis media include symptoms and findings on otoscopy.5 Presentation can be asymptomatic, particularly in infants.1 5 Findings on otoscopy include middle ear effusion, and opaque, bulging and/or impaired drum mobility.5 The prognosis is good for otitis media, with 80% of children getting better after 3 days without treatment.4 However, there are rare but serious complications which include hearing loss, mastoiditis, meningitis and recurrent attacks.6
The loss of ear wax in otitis media is an appealing notion because it is biologically plausible. Theories suggest that the heat of the inflammatory process involved in otitis media causes the wax in the ear to melt, or that a transudate of serum, containing cerumonilytic properties, may contribute to the breakdown of wax.1
A study conducted in 19831 looked at the appearance of ear wax and the degree to which it obstructed the ear drum and showed that the presence of ear wax does not exclude otitis media. It concluded that “earwax must be removed before a physician can diagnose properly the presence or absence of otitis media”. A further study conducted in 1985 looked at the age prevalence of children with ear wax and the relationship of the amount of wax to otitis media. The results support the assertion that the presence of ear wax may exclude the finding of otitis media and the study concluded that routine removal of ear wax in general practice is not justified. As an additional point, the study conducted in 1985 only included children over the age of 3. Research shows that there is a higher incidence of both otitis media and ear wax in infants.1 3 It is therefore important to include this group in data so that relevant conclusions can be reached that can be used for a paediatric population.
The two studies, which have conflicting conclusions, are the only ones that can be found in the literature which address the relationship between otitis media and ear wax. The study carried out in 1983 by Schwartz et al used a larger population to include infants and therefore has more reliable conclusions. Visualisation of the tympanic membrane can greatly aid in accurately diagnosing otitis media.7 Removal of impacted ear wax using ear drops rather than no treatment has been supported by a recently assessed Cochrane review.8 However, the use of ear drops would not be suitable in an acute problem such as acute otitis media as they often take several days to work. As otitis media is such a common paediatric problem with potentially serious complications,3 4 6 it is important when assessing a patient to take account of the fact that a finding of ear wax does not exclude the finding of otitis media.
Clinical bottom line
There is no evidence to support the assertion that ear wax precludes otitis media. In fact, the presence of ear wax in otitis media is well documented. (Grade B)
For accurate diagnosis of otitis media in children, clinicians ought to consider the acquisition of a skill not currently exercised in normal paediatric practice: the routine removal of wax.
Competing interests None.
Provenance and Peer review Not commissioned; externally peer reviewed.