Does the clinical finding of ear wax exclude the finding of otitis media? n

Date First Published:
June 26, 2004
Last Updated:
January 15, 2010
Report by:
Natasha Ahmad, Ian Wacogne , Specialist Registrars in Paediatrics (General Paediatrics Department, Birmingham Children’s Hospital NHS Foundation Trust)
Three-Part Question:
In [children] does [the clinical finding of ear wax] predict [the absence of otitis media]?
Clinical Scenario:
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.

Search Strategy:
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.

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).
Search Details:
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
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Cerumen removal. How necessary is it to diagnose acute otitis media? Schwartz RH, Rodriguez WJ, McAveney W, et al. 1983 279 children and infants with signs/symptoms of otitis media in an American population over a 10-month period Prospective non-randomised(level 3b) How many children required mechanical removal of ear wax to visualise the tympanic membrane clearlyProportion of children with the requirement for ear wax removal 29% of patients overall required removal of ear wax to visualise the tympanic membrane57% of infants with otitis media required removal of ear wax to visualise most of the eardrum11% of children in the study had aural ear wax with a soft cheesy or semiliquefied consistency The requirement for ear wax removal was inversely proportional to ageThe population of the study is not defined (ie, primary or secondary care)Suggests that ear wax should be removed before a physician can properly diagnose the presence or absence of otitis media
Ear wax and otitis media in children. Fairey A, Freer CB, Machin D. 1985, 207 children aged 3–10, presenting for any reason, in a general practice population in Southampton during December and FebruaryChildren in the group seen in February had wax removed if it was obscuring the tympanic membrane Prospective non-randomised(level 3b) Proportion of children with otitis mediaPrevalence of wax with ageThe relationship of the amount of wax to otitis media 27.5% of children in the study had otitis mediaThere was a gradual decline in the prevalence of wax with ageThe amount of wax insignificantly (p = 0.06) decreased in the presence of otitis mediaAfter removal of significant ear wax only 1 further diagnosis of otitis media was made Infants were not included in the populationThe number of cases who had removal of significant ear wax is not stated in the data providedSuggests that the routine removal of wax in a general practice population is not justified when assessing a child’s ears when otitis media is suspected
Author Commentary:
Conventional wisdom has taught, in paediatrics, that the presence of wax excludes the finding of otitis media. Examination of the literature suggests that this is, in fact, a myth.(Schwartz, Fairey).<br><br>Otitis media is a common paediatric condition which is often difficult to diagnose (O'Neill, Berman). Diagnostic features of otitis media include symptoms and findings on otoscopy (RCPCH). Presentation can be asymptomatic, particularly in infants (Schwartz, RCPCH). Findings on otoscopy include middle ear effusion, and opaque, bulging and/or impaired drum mobility. The prognosis is good for otitis media, with 80% of children getting better after 3 days without treatment (Berman). However, there are rare but serious complications which include hearing loss, mastoiditis, meningitis and recurrent attacks.
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.
References:
  1. Schwartz RH, Rodriguez WJ, McAveney W, et al. . Cerumen removal. How necessary is it to diagnose acute otitis media?
  2. Fairey A, Freer CB, Machin D. . Ear wax and otitis media in children.
  3. O’Neill P. . Clinical evidence: acute otitis media.
  4. Berman S. . Otitis media in children.
  5. RCPCH. . Otitis media in primary care. Summary: an appraisal document. London:
  6. Froom J, Culpepper L, Jacobs M, et al. . Antimicrobials for acute otitis media? A review from the International Primary Care Network.
  7. Rothman R, Owens T, Simel D. . Does this child have acute otitis media?
  8. Burton MJ, Doree CJ. . Ear drops for the removal of ear wax.