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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).
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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Schwartz 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
Fairey et al, 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

Comment(s)

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).

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.

Clinical 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? Am J Dis Child 1983;137:1064–5.
2. Fairey A, Freer CB, Machin D. Ear wax and otitis media in children. BMJ (Clin Res Ed) 1985;291(6492):387–8.
3. O’Neill P. Clinical evidence: acute otitis media. BMJ 1999;319:833–5.
4. Berman S. Otitis media in children. N Engl J Med 1995;23:1560–5.
5. RCPCH. Otitis media in primary care. Summary: an appraisal document. London: RCPCH, 2003.
6. Froom J, Culpepper L, Jacobs M, et al. Antimicrobials for acute otitis media? A review from the International Primary Care Network. BMJ 1997;315:98–102.
7. Rothman R, Owens T, Simel D. Does this child have acute otitis media? JAMA 2003;290:1633–40.
8. Burton MJ, Doree CJ. Ear drops for the removal of ear wax. Cochrane Database Syst Rev 2003;(3):004326.