Clinical Cmmissining Grup (CCG) Treatment Plicy NHS Birmingham and Slihull Clinical Cmmissining Grup NHS Sandwell and West Birmingham Clinical Cmmissining Grup DRAFT Plicy fr the Management f Ear Wax 1
Clinical Cmmissining Grup (CCG) Treatment Plicy Dcument Details: Versin: DRAFT v5. Ratified by (name and date f Cmmittee): Treatment Plicy Clinical Develpment Grup 22 nd March 2018 Date issued fr Public Cnsultatin: 14 th May 2018 Equality & Diversity Impact Assessment 13 th April 2018 The CCG plicy has been reviewed and develped by the Treatment Plicies Clinical Develpment Grup in line with the grups guiding principles which are: 1. CCG Cmmissiners require clear evidence f clinical effectiveness befre NHS resurces are invested in the treatment; 2. CCG Cmmissiner require clear evidence f cst effectiveness befre NHS resurces are invested in the treatment; 3. The cst f the treatment fr this patient and thers within any anticipated chrt is a relevant factr; 4. CCG Cmmissiners will cnsider the extent t which the individual r patient grup will gain a benefit frm the treatment; 5. CCG Cmmissiners will balance the needs f each individual against the benefit which culd be gained by alternative investment pssibilities t meet the needs f the cmmunity 6. CCG Cmmissiners will cnsider all relevant natinal standards and take int accunt all prper and authritative guidance; 7. Where a treatment is apprved CCG Cmmissiners will respect patient chice as t where a treatment is delivered; AND 8. All plicy decisin are cnsidered within the wider cnstraints f the CCG s legally respnsibility t remain fiscally respnsible. 2
Clinical Cmmissining Grup (CCG) Treatment Plicy Categry: Restricted Ear Wax Earwax is a nrmal physilgical substance which is a cmbinatin f dead flattened cells, cerumen (a wax-like substance), sebum. The external auditry meatus may als cntain residue frm csmetics and envirnmental dust. Earwax cleans, lubricates, and prtects the lining f the ear canal, trapping dirt and repelling water. Peple are at risk f impacted earwax if they: Have narrw r defrmed ear canals. Have excessive hairs in their ear canals. Have benign bny grwths in the external auditry canal (stemata). Have a dermatlgical disease (psriasis r eczema) f the peri-auricular area r scalp. Prduce hard wax, as this is mre likely t becme impacted. Are elderly (earwax tends t becme drier in lder peple). Have a histry f recurrent impacted wax. Have recurrent titis externa. Have Dwn's syndrme. The mst cmmn symptms caused by impacted earwax are: Cnductive hearing lss. Earache. Tinnitus. Vertig. Other cnditins which shuld be excluded (ruled ut) include: Otitis externa (inflammatin f the auricle r external ear canal due t allergy, infectin, r eczematus cnditins). Freign bdies (particularly in children). 3
Clinical Cmmissining Grup (CCG) Treatment Plicy NICE (2016) recmmends earwax shuld be remved if it is ttally ccluding the ear canal AND ne f the fllwing: The persn is symptmatic (cnductive hearing lss; earache; tinnitus; vertig). The tympanic membrane is bscured by wax but needs t be viewed t establish a diagnsis. The persn wears a hearing aid and an impressin needs t be taken fr a muld, r wax is causing the hearing aid t whistle. Cnsider ear irrigatin using an electrnic irrigatr t remve earwax in adults, prvided there are n cntraindicatins: eardrum perfratin ear infectin Previus ear surgery. When carrying ut ear irrigatin in adults: use pre-treatment wax sfteners, either immediately befre ear irrigatin r fr up t 5 days befrehand if irrigatin is unsuccessful: i. repeat use f wax sfteners r If irrigatin is unsuccessful after the secnd attempt, refer the persn t a specialist ear care service r an ear, nse and thrat service fr remval f earwax. Cnsider micrsuctin r ther methds f earwax remval (such as manual remval using a prbe) fr adults in primary r cmmunity care nly if: the practitiner (such as a cmmunity nurse r audilgist) has training and expertise in using these methds t remve earwax and the crrect equipment is available. D nt ffer adults manual ear syringing t remve earwax. Advise adults nt t remve earwax r clean their ears by inserting small bjects, such as cttn buds, int the ear canal. Explain that this culd damage the ear canal and eardrum, and push the wax further dwn int the ear. Anyne wh has had earwax remved shuld be advised t return if they develp talgia, itching, r discharge frm the ear, r swelling f the external auditry meatus, as this may indicate infectin. 4
Clinical Cmmissining Grup (CCG) Treatment Plicy Referral shuld be arranged t an Ear, Nse, and Thrat specialist if the persn has: A chrnic perfratin f the tympanic membrane. A past histry f ear surgery. A freign bdy in the ear canal. Used ear drps, which have been unsuccessful, and irrigatin is cntraindicated. Had unsuccessful irrigatin. Eczema r psriasis Advice shuld be urgently sught frm an Ear, Nse, and Thrat specialist if: Severe pain, deafness, r vertig ccur during r after irrigatin, r if a perfratin is seen fllwing the prcedure. Infectin is present and the external canal needs t be cleared f wax, debris, and discharge. If the persn cntinues t experience hearing lss after wax remval arrange an audigram. 5
Clinical Cmmissining Grup (CCG) Treatment Plicy Eligibility Criteria: Ear irrigatin as a management ptin fr ear wax shuld be avided whenever pssible. Hwever, ear irrigatin may be carried ut in primary care by a specially qualified clinician in patients ver the age f 6 mnths whm are cncrdant with the prcedure and have a level f understanding required t enable the prcedure t be carried ut safely in the fllwing circumstances: Patient must have used ear drps fr at least 3-5 days befre irrigatin is undertaken AND the patient must have at least ONE f the fllwing symptms which has persisted despite ear drps. If earwax is ttally ccluding the ear canal and any f the fllwing are present: Hearing lss Earache Tinnitus Vertig If the tympanic membrane is bscured by wax but needs t be viewed t establish a diagnsis The persn wears a hearing aid and an impressin needs t be taken fr a muld, r wax is causing the hearing aid t whistle. Referral shuld be arranged t an Ear, Nse, and Thrat specialist if the persn has: A chrnic perfratin f the tympanic membrane. A past histry f ear surgery. A freign bdy in the ear canal. Used ear drps, which have been unsuccessful, and irrigatin is cntraindicated. Had unsuccessful irrigatin. Eczema r psriasis N.B The ear wax remval methds listed belw are NOT cmmissined by the CCG as per NICE recmmendatins: Manual ear syringing Advise peple against inserting anything in the ear as cttn buds, matchsticks, selfirrigatin r self-suctin and hair pins can: Damage the wall f the canal and increase the likelihd f titis externa. 6
Clinical Cmmissining Grup (CCG) Treatment Plicy Cause the wax t becme impacted by pushing it further int the canal. Perfrate the tympanic membrane. Advise that the use f ear candles has n benefit in the management f earwax remval and may result in serius injury. This means (fr patients wh DO NOT meet the abve criteria ) the CCG will nly fund the treatment if an Individual Funding Request (IFR) applicatin prves exceptinal clinical need and that is supprted by the CCG. Please Nte: Nurse Practitiners carrying ut aural care, shuld ensure that they meet the cmpetencies set ut by the RCN (2018) https://www.rcn.rg.uk/prfessinal-develpment/publicatins/pub-004266 Guidance: NICE 2017 Hearing Lss. Hearing Lss in Adults: Diagnsis and Management. (currently in develpment, final dcument due fr release May 2018) NICE. 2016. Clinical Knwledge Summaries: Ear Wax. https://cks.nice.rg.uk/earwax 7