Pearls of Wisdom: Managing Obstructive Cerumen in the Ear of a 4-Year-Old
Question: Tim is a 4-year-old with low-grade temp and a painful left ear. Your physical examination is within normal limits but limited by cerumen obstruction of the ear canal, so you cannot assess his tympanic membranes.
You are in the midst of another busy day at the office. Tim has had acute otitis media before, and responded well to amoxicillin when treated 3 months ago. He was up for much of the night with irritability and fever. He is not sick, and did eat and drink normally today. He responds playfully when you offer him a toy.
How should you treat this feverish toddler?
- Give azithromycin empirically
- Perform cool water irrigation
- Instill triethanolamine polypeptide
- Instill docusate sodium
What is the correct answer?
(Answer and discussion on next page)
Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).
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Answer: Instill docusate sodium.
It is very tempting to shortcut the diagnostic process for acute otitis media (IAOM). Since Tim has had it before, his ear hurts, and the treatment is simple and usually successful, a variety of forces conspire to make ear canal cleansing seem a progressively more unpleasant choice. Nonetheless, we do need to forge ahead and do whatever is necessary to provide an uncompromised patient evaluation.
Although some 4-year-olds are able to cooperate with ear irrigation, many are not. Instead, it may prove simpler and more efficient to first instill a cerumenolytic into the external canal. The question is which cerumenolytic?
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RELATED CONTENT
Acute Otitis Media: Update on Diagnosis and Treatment
Acute Otitis Media: 6 Steps to Improve Diagnostic Accuracy
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Research
A study performed by Singer et al provides us with an evidence-based answer.1 In this clinical trial, patients over age 1 year presenting to an emergency department with an indication that prompted the need for evaluation of the tympanic membranes.
Head-to-Head Ceruminolytic Trial1
Subjects were randomized to receive either 1 ml of triethanolamine polypeptide (Ceruminex) or 1 ml of docusate sodium (Colace) in the involved ear and then remain recumbent for 10-15 minutes, at which time visualization of the tympanic membrane was again attempted. If unsuccessful, a post-treatment irrigation with lukewarm normal saline was performed and (if needed) repeated once.
Ceruminex vs Colace: Results1
The results: Re-irrigation (ie, after being treated with either docusate sodium or triethanolamine polypeptide drops) found that nearly twice as many patients who had received docusate sodium drops were able to have their tympanic membranes evaluated as those who received triethanolamine polypeptide drops. After irrigation, results with docusate sodium remained statistically superior to triethanolamine polypeptide. There were no significant adverse events in either treatment group.
What’s the “Take Home”?
Even though it is tempting to treat suspected AOM, we must instead perform whatever cleansing mechanism is necessary to get a good look at the tympanic membranes. Although some young children can tolerate extraction of cerumen with a cerumen spoon, it is usually easier to use a cerumenolytic, with irrigation to follow if necessary. Docusate sodium is a superior cerumenolytic to triethanolamine polypeptide.
1. Singer AJ, Sauris E, Viccellio AW, et al. Ceruminolytic effects of docusate sodium: a randomized controlled trial. Ann Emerg Med. 2000;36(3):22