Cerumen removal: Comparison of cerumenolytic agents and effect on cognition among the elderly

https://doi.org/10.1016/j.archger.2010.03.025Get rights and content

Abstract

Cerumen impaction may affect hearing and decrease hearing acuity, thus decreasing cognitive functions among the elderly. The objective of this study was to compare the safety and the efficacy of three cerumenolytic agents and to assess the effect of cerumen removal on cognition. Thirty eight elderly subjects (mean age: 78 years, total 76 ears) were treated with either Auro®, Cerumol® or the newer CleanEars®, and the change in the degree of ear canal occlusion was examined after a week. In addition, a change in cognition following cerumen removal was evaluated using Raven's standard progressive matrices (RSPM) test. There was no difference regarding the eventual degree of occlusion between the three treatment groups. Only in the CleanEars® group a complete resolution of obstruction in both ears was achieved. A statistically significant difference between the RSPM score before and after the removal of cerumen was found. Using CleanEars® is as effective and safe as other agents and may be advantageous due to its spray application. Removal of cerumen significantly improves the well-being of elderly patients.

Introduction

Cerumen is part of the external ear defense mechanisms against foreign bodies and infectious agents. It is a combination of epithelial cells, dust, foreign bodies as well as the secretions of the sebaceous glands and apocrine glands. Cerumen lubricates and cleans the ear canal. The lubrication is the effect of lipids, found in high concentration in the sebum, produced by the sebaceous glands. The cleaning function of cerumen is the result of constant migration of the cerumen towards the outer part of the external auditory canal. On its way out, foreign materials adhere to the cerumen and thus are prevented from plugging the ear or reaching the tympanic membrane (McCarter et al., 2007).

Cerumen impaction is a common problem encountered by the general physician, the family physician and the otolaryngologist almost every day. Some 2–6% of the general population in the United Kingdom suffers from cerumen impaction at any given time which suggests a prevalence of 6–18 million individuals in the United States (Roland et al., 2008). It has been estimated that each week 150,000 cerumen removals take place in the United States (Grossan, 1998). Cerumen impaction has important clinical implications on the general well-being of the patient and might cause hearing loss, pain, itching, tinnitus, vertigo, external otitis and even chronic cough (Roeser, 1997). It is also more common among the elderly and in patients with cognitive impairments, with up to 65% of patients over 65 years old having cerumen impaction (Grossan, 1998).

Cerumen impaction may affect hearing (Lewis-Cullinan and Janken, 1990) and decrease hearing acuity by 40–45 dB (Meador, 1995). Such hearing impairment among the elderly causes difficulties in communication, social isolation, depression and even physical immobility (Jones et al., 1984, Murlow et al., 1990). Moreover, decreased hearing in old age, either gradual or acute, is perceived by the patients or their caregivers as a natural, almost expected, phenomenon, which does not merit examination or intervention. Thus old people with reversible deafness, as caused by cerumen impaction, may not reach intervention for a very long period of time (Arlinger, 2003).

Older people tend to have hearing impairments not only due to presbycusis (that is, high-frequency hearing loss caused by aging processes in the cochlea and the cochlear nerve) but also due to the effects of aging on the brain temporal processing (Pichora-Fuller and Souza, 2003). These two cause reduced hearing ability both in quiet and in noisy environment and can cause a significant impairment in the ability of the elderly people to communicate with his or her surroundings. In addition to that, cognitive impairments have their effect on hearing capabilities among the elderly (Martin and Jerger, 2005). These effects may explain the fact that, despite adequate amplification of sound, some elderly patients with hearing loss do not seem to benefit from hearing aids, especially in everyday life, and not in quiet environment.

Cognitive function was also found to be decreased in individuals with hearing loss (Uhlmann et al., 1989). In one small study both hearing and cognition (as measured by the mini-mental state examination = MMSE) were improved after elimination of cerumen impaction (Moore et al., 2002). Improvement of hearing ability may actually improve intelligence: use of cochlear implant in children brings their IQ scores to that of normal healthy children (Wu et al., 2008).

Removal of cerumen from the external auditory canal can be accomplished using physical methods, chemical methods (cerumenolysis) or any combination of them. The physical removal of cerumen using loop, suction, irrigation or forceps is a common procedure done by the physician. However, it is time consuming and might end up with complications, such as lacerations of the external auditory canal, pain, infection, vertigo, tinnitus and tympanic membrane perforation. Performing this procedure by an inexperienced physician might lead to high rate of complications (Grossan, 1998).

Cerumenolytic products act by softening the cerumen and lubricating the canal, thus facilitating cerumen removal from the ear canal or by disintegrating the cerumen. Over the years, a large number of agents have been proposed and tested, including tap water, olive oil, hydrogen peroxide, acetic acid, sodium bicarbonate and other commercially available products. None of these agents was found to be effective in totally dissolving the cerumen (Browning, 2002, Burton and Doree, 2003). No particular cerumenolytic agent was found to be more effective than any other (Roland et al., 2008).

In the present report CleanEars®, Auro® and Cerumol® were compared to each other in their cerumenolytic effects. CleanEars® (Naveh Pharma, Israel) is a new spray-applied cerumenolytic solution which is composed of mineral oil (paraffin), squalane and spiramint oil. CleanEars® provides combined mode of action, namely cerumenolysis along with lubrication. The spray administration may also assist in deeper penetration of the substance to the cerumen layers.

Auro® is a FDA-approved drops composed of carbamide peroxide and anhydrous glycerin. Cerumol®, another FDA-approved drops, contains arachis oil (peanut oil), chlorobutanol and dichlorobenzene.

An additional goal of the present study was to assess cognition, as a more comprehensive reflection of quality of life (Nota et al., 2007), using the RSPM. This is a multiple choice test of intelligence, requiring inductive reasoning about abstract geometric patterns. In each test item, the respondent is asked to identify the missing segment required to complete a larger geometric pattern. Many items are in the form of a 3 × 3 or 2 × 2 matrix, giving the test its name. It is a widely used test, first, because it is non-verbal and hence is relatively more culture-free than the standard IQ test or the MMSE and, second, because it correlates well with other measures of intelligence and hence is valid. It appears to cover a broad range of mental abilities, especially abstract intelligence which was found to be impaired in individuals with hearing loss (Oleron, 1950). The test is applied widely and is usable with individuals irrespective of age, sex, nationality, or education. Most importantly, it is a non-threatening and friendly instrument that may be used in the doctor's office without evoking any special surprise. We could not find any studies investigating the relationship between the Raven test and hearing.

Section snippets

Ethics

The study took place at the Rehabilitation Department of a geriatric hospital and was approved by the institutional ethics review board. All subjects signed informed consent.

Study population

Subjects enrolled in the study were well over 18 years old, without any previous ear disease, and none had any ear examination or treatment during the previous 6 months. A total of 41 volunteers were enrolled in the study between February and September 2008. They were chosen after routine screening otoscopy, done in most

Results

Twelve participants were treated with Auro®, 13 participants were treated with Cerumol® and 13 participants were treated with CleanEars®. Altogether 76 ears were examined. There were no statistical differences regarding age, gender and cognitive impairments between the three treatment groups. Table 2, Table 3 summarize the mean degree of occlusion and distribution of occlusion between the three treatment groups before and after the treatment. There were no differences regarding the degree of

Discussion

This is a prospective, blinded study, in which a single investigator examined and evaluated the subjects. Each subject was his own control with regard to both the effect of the cerumenolytic agent on the cerumen and the effect of the removal of the impacted cerumen on the RSPM score.

Conflict of interest statement

None.

Acknowledgements

The support of The Morris Slivka Legacy, to honor the memory of Leo Aryeh Greenberg, is gratefully acknowledged.

References (24)

  • A.M. Moore et al.

    Cerumen, hearing and cognition in the elderly

    J. Am. Med. Dir. Assoc.

    (2002)
  • P.S. Roland et al.

    Clinical practice guideline: cerumen impaction

    Otolaryngol. Head Neck Surg.

    (2008)
  • S. Arlinger

    Negative consequences of uncorrected hearing loss – a review

    Int. J. Audiol.

    (2003)
  • G. Browning

    Wax in ear

    Clin. Evid.

    (2002)
  • M.J. Burton et al.

    Ear drops for the removal of ear wax

    Cochrane Database Syst. Rev.

    (2003)
  • J.R. Chandler

    Partial occlusion of the external auditory meatus: its effect upon air and bone conduction hearing acuity

    Laryngoscope

    (1964)
  • D.M. Chaput de Saintonge et al.

    A clinical comparison of triethanolamine polypeptide oleate-condensate ear drops with olive oil for the removal of impacted wax

    Br. J. Clin. Pract.

    (1973)
  • M. Grossan

    Cerumen removal – current challenges

    Ear Nose Throat J.

    (1998)
  • C. Hand et al.

    The effectiveness of topical preparations for the treatment of earwax: a systematic review

    Br. J. Gen. Prac.

    (2004)
  • D.A. Jones et al.

    Hearing difficulty and its psychological implications for the elderly

    J. Epidemiol. Commun. Health

    (1984)
  • C. Lewis-Cullinan et al.

    Effect of cerumen removal on the hearing ability of geriatric patients

    J. Adv. Nurs.

    (1990)
  • S. Lyndon et al.

    A comparison of the efficacy of two ear drop preparations (‘Audax’ and ‘Earex’) in the softening and removal of impacted ear wax

    Curr. Med. Res. Opin.

    (1992)
  • Cited by (18)

    • Identification of hearing loss among residents with dementia: Perceptions of health care aides

      2014, Geriatric Nursing
      Citation Excerpt :

      In particular, when they knew the resident they were better able to identify the relative contributions of hearing loss and dementia to communication breakdowns and which strategies to use to prevent or repair these breakdowns. By identifying the presence, type, and severity of hearing loss, communication challenges may be mitigated through direct treatments such as removing cerumen from the ear canal39 and effectively employing hearing aids and other assistive listening devices.27 By identifying and reporting hearing loss to the nurse in charge, health care aides can play an important role in supporting and even enhancing residents' communication abilities.

    • Earigate™ for softening ear wax: Is it safe when the eardrum is perforated?

      2014, International Journal of Pediatric Otorhinolaryngology
      Citation Excerpt :

      These products can gain access to the membranous labyrinth by permeating through the round window membrane, which is selectively permeable to chemicals with molecular weights below 1000 kD [14,15]. There are studies, which have considered the usefulness and safety of various wax softeners and ears cleansers [1,3,4,6,10,16,17]. Saline was found to be as effective as other commercially available ear products, such as chlorobutanol and potassium carbonate, in softening ear wax, or even more effective [6].

    • Actual issues of cerumenolysis

      2023, Vestnik Otorinolaringologii
    View all citing articles on Scopus
    View full text