What is the recommended method for cerumen (ear wax) removal in pediatric patients?

From the Guidelines

For pediatric ear wax removal, manual removal by a competent healthcare professional using appropriate instrumentation and visualization is the recommended approach, as it allows for direct visualization of the external auditory canal and does not expose the ear to moisture. This method is often quicker and more effective than other methods, and it is particularly preferred in patients with abnormal otologic findings 1. The use of a handheld speculum or otoscope, a headlamp or head mirror, or the binocular microscope can provide adequate visualization, while instruments such as a metal or plastic curette loop or spoon, an alligator or cup forceps, or angulated suction tips can be used for removal 1.

When performing manual removal, it is essential to have adequate illumination, visualization, and competence in performing the procedure. The healthcare professional should also be able to assess when removal of the cerumen impaction is complete. In some cases, the use of cerumenolytic agents during the week prior to the office visit can reduce potential side effects of suction removal, such as pain or vertigo 1.

Some key points to consider when removing ear wax in pediatrics include:

• Using appropriate instrumentation and visualization to minimize the risk of complications
• Avoiding the use of cotton swabs, hairpins, or other objects that can push wax deeper or damage the ear canal or eardrum
• Considering the use of cerumenolytic agents to soften the wax and reduce the risk of side effects
• Being aware of the potential risks and benefits of different removal methods, including manual removal and irrigation

It is also important to note that ear wax is actually protective, containing antimicrobial properties that help prevent infection, so removal is only necessary when excessive buildup causes symptoms like hearing difficulty, discomfort, or interferes with ear examinations 1. If the child has ear tubes, ear pain, discharge, or if home remedies don't work after several days, it is recommended to consult a pediatrician for further evaluation and treatment.

From the FDA Drug Label

Directions FOR USE IN THE EAR ONLY. Adults and children over 12 years of age: Tilt head sideways and place 5 to 10 drops into ear Tip of applicator should not enter ear canal Keep drops in ear for several minutes by keeping head tilted or placing cotton in the ear Use twice daily for up to 4 days if needed, or as directed by a doctor Any wax remaining after treatment may be removed by gently flusing the ear with warm water, using a soft rubber bulb ear syringe Children under 12 years:consult a doctor

For children over 12 years, ear wax can be removed by:

• Tiltting the head sideways and placing 5 to 10 drops of hydrogen peroxide into the ear
• Keeping the drops in the ear for several minutes
• Using the drops twice daily for up to 4 days if needed
• Removing any remaining wax by gently flushing the ear with warm water using a soft rubber bulb ear syringe For children under 12 years, it is recommended to consult a doctor 2

From the Research

Removing Ear Wax in Pediatrics

• Ear wax, also known as cerumen, is a normal bodily secretion that can become a problem when it obstructs the ear canal 3.
• Symptoms attributed to wax, such as deafness and pain, are common reasons for patients to present to primary care with ear trouble 3.
• The use of ear drops is one method to encourage the removal of ear wax, with various types of liquids available, including oil-based and water-based compounds 3.

Types of Ear Drops

• Oil-based treatments, such as triethanolamine polypeptide and almond oil, have been used to remove ear wax 3.
• Water-based treatments, such as docusate sodium and carbamide peroxide, have also been used 3.
• A study found that sodium bicarbonate was an effective cerumenolytic, with a 10% solution being the most effective 4.
• Another study found that a mixture of glycerine, hydrogen peroxide, and sodium bicarbonate was effective in removing ear wax in children 5.

Efficacy of Ear Drops

• A study found that active treatment with ear drops resulted in a higher proportion of ears with complete clearance of ear wax compared to no treatment 3.
• However, there was no evidence to show that one type of active treatment was more effective than another 3.
• A network meta-analysis found that sodium bicarbonate and paradichlorobenzene were associated with significantly greater proportions of patients with wax clearance following syringing compared to normal saline 6.

Considerations for Pediatrics

• A study found that the use of a mixture of glycerine, hydrogen peroxide, and sodium bicarbonate eased pain for the patient and made the removal procedure more comfortable for the physician 5.
• The study also found that this mixture was effective in removing ear wax in children, with a high removal coefficient 5.
• It is essential to consider the safety and efficacy of ear drops in pediatric patients, as well as the potential for adverse effects, such as discomfort, irritation, or pain 3.