From the Guidelines
I recommend performing ear irrigation to address the patient's right ear clogged sensation due to likely cerumen impaction, given his history of previous impactions. Before irrigation, I would examine the ear canal with an otoscope to confirm the presence of cerumen and ensure there's no contraindication such as tympanic membrane perforation, as suggested by the clinical practice guideline update on earwax (cerumen impaction) 1. For the irrigation, I would use body-temperature water (37°C) with a gentle irrigation system, directing the stream along the superior wall of the ear canal to avoid direct pressure on the tympanic membrane. After irrigation, I would re-examine to confirm removal of the cerumen and dry the canal.
Regarding his Astelin (azelastine) nasal spray request, I would refill this medication at the standard dose of 1-2 sprays per nostril twice daily, as it is an effective treatment for allergic rhinitis symptoms, including nasal congestion, as stated in the practice parameter for the diagnosis and management of rhinitis 1. I would also educate the patient on preventive measures for cerumen impaction, including avoiding cotton swabs and considering periodic use of over-the-counter cerumen softening drops (such as carbamide peroxide 6.5%) once weekly if he experiences frequent impactions. The ear irrigation works by using water pressure to dislodge and flush out accumulated earwax, while Astelin helps manage his nasal congestion through its antihistamine properties that reduce nasal inflammation.
Key considerations in managing cerumen impaction include:
- Assessing the patient for modifying factors that may influence treatment, such as anticoagulant therapy or immunocompromised state 1
- Using appropriate interventions, which may include cerumenolytic agents, irrigation, or manual removal requiring instrumentation 1
- Educating the patient on control measures to prevent future impactions, as recommended in the clinical practice guideline update on earwax (cerumen impaction) 1
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Presentation
The patient is an 88-year-old male presenting with a clogged sensation in his right ear for 2 days. He has a history of cerumen impactions and is requesting ear irrigation. He also denies any pain, shortness of breath, sore throat, or difficulty swallowing.
Request for Ear Irrigation
- The patient's request for ear irrigation is consistent with the management of cerumen impaction, as stated in 2 and 3.
- Effective treatment options for cerumen impaction include cerumenolytic agents, irrigation with or without cerumenolytic pretreatment, and manual removal, as noted in 2.
- Home irrigation with a bulb syringe may be appropriate for selected adults, as mentioned in 2.
Considerations for Ear Irrigation
- Patients with coagulopathies, hepatic failure, thrombocytopenia, or hemophilia, and those taking antiplatelet or anticoagulant medications, should be counseled about the increased risk of bleeding in the external auditory canal when cerumen is removed, as stated in 2.
- The use of cotton-tipped swabs, ear candling, and olive oil drops or sprays should be avoided, as noted in 2 and 3.
Refill Request for Astelin Nasal Spray
- The patient's request for a refill on his Astelin nasal spray for nasal congestion is a separate issue from the ear irrigation request.
- There is no direct evidence in the provided studies to address the refill request, but it may be considered in the context of the patient's overall medical history and current symptoms.