Web Exclusive - The Simplest Explanation is Often the Best
The Simplest Explanation is Often the Best
Urgent message: Emergency Physicians are trained to rule out the most dangerous, life-threatening diagnosis first. Rarely, this can lead to missing the forest for the trees.
Author: Tracey Quail Davidoff, MD
Author Information: Dr. Davidoff is an urgent care physician at Accelcare Medical Urgent Care and Urgent Care by Lifetime Health in Rochester, New York.
A 23-year-old male graduate student calls the urgent care center asking if he can be seen for dizziness and anxiety. He states he was seen in the emergency room several nights earlier with a diagnosis of panic attack. He is not feeling better and wants to know if you think there is anything you can do for him. As you roll your eyes, the RN answering the phone says, "sure, come on in, we'll see what we can do."
An hour later, the patient charts in. He states he has been having dizziness, including lightheadedness and vertigo off and on for a week and a half, worse in the last 2 days. He feels anxious and says the symptoms are so bothersome, they are making him crazy. He has not been able to work or study.
Several nights ago, he went to the university teaching hospital emergency department (ED), where he says he waited several hours. He reports that they asked him all kinds of neurologic and cardiac questions, did an intensive neurologic exam, including testing for eye movements and gait;finger-to-nose testing; heart exams standing, sitting, and bearing down; listened to blood vessels in his neck; and checked reflexes in his arms and legs. When the exam was done, they did computed tomographic and magnetic resonance imaging of his brain, an electrocardiogram, an echocardiogram, and what sounded like a tilt table test, and he was seen by a neurologist.
After nearly 24 hours of testing in the ED, the patient was told his symptoms were related to anxiety and he was offered a psychiatric consult for anxiety and stress management. He refused, because the wait would be several hours and he just wanted to go home and get some sleep. He was told to follow up with his primary care physician (PCP) in several days, but because thes PCP is in another state, he failed to follow up.
In the days that ensued, the patient’s symptoms got worse. He also developed a sensation of pressure in his head, a spinning sensation, and decreased hearing.
Pertinent Physical Findings
- General: Awake and alert, anxious and frustrated.
- Temp: 37.0
- HR: 90 and regular
- R: 14
- BP: 120X90
Hearing was grossly normal. Pupils were equal, round, and reactive to light, with extra-ocular muscles intact with no nystagmus. Motor exam was non-focal, gait was stable, Romberg test was negative. Examination of the ears showed copious amounts of cerumen protruding from both external ear canals that could be seen without an otoscope. The remainder of the exam was unremarkable.
Cerumen was removed initially with a curette, but because of the shear amount of wax present, irrigation with lukewarm water was used to fully clean out the external ear canals. Both tympanic membranes appeared macerated from prolonged contact with wax, and probably water behind the wax.
The patient's symptoms improved subjectively by 75% to 80%, and his hearing was restored. He stated that no one in the ED had even looked in his ears, and he was left wondering what sort of bill he was going to get for tests that could have easily been avoided.
Cerumen is composed of hair, desquamated epithelial skin, bacteria of normal skin flora, water, and secretions of both sebaceous and cerumenous glands in the lateral 1/3 of the ear canal.1 The ears typically are self-cleaning, as lateral epithelial migration and normal jaw movement allows for removal of cerumen from the ear canal.2 Accumulation of cerumen can cause impaction, which affects up to 6% of the general population. The number is significantly higher in patients with cognitive impairment, such as nursing home residents or the developmentally disabled. Cerumen removal is the most common ear, nose and throat procedure performed in primary care.3
Cerumen accumulation is usually asymptomatic, but some patients may develop any of the following: hearing loss, earache, ear fullness, itchiness, reflex cough, dizziness, including vertigo, and tinnitus.
Removal of cerumen should only be undertaken in patients who are symptomatic, or in cases when it is imperative to see behind the wax.2 There are no studies proving which method of removal is best, although the American Academy of Otolaryngology issued guidelines for the diagnosis and management of cerumen impaction in 2008. The best method of removal depends upon the available resources, the provider's experience, and the patient's level of cooperation. Irrigation with water, manual removal with a curette, and topical preparations are all acceptable. Cerumenolytics should not be used and irrigation should not be performed in patients who are known to have or suspected of having perforation of the tympanic membrane or those with a history of ear canal surgery.2
The use of oral jet irrigators (Waterpik, or similar) is not recommended because of the risk of perforation. Ear candling also is not recommended. Routine use of cotton swabs to clean the ears may increase risk of cerumen impaction, becauses it pushes the cerumen further into the canal.1-3
In patients with recurrent symptomatic cerumen impaction and otherwise normal ears, recurrence may be preventable by placing several drops of mineral or olive oil on a cotton ball in the ear for 10 to 20 minutes once a week. An alternate is to irrigate the ears every 6 to 12 months. More frequent cleaning is not recommended.1
Referral to a specialist is not required except in the case of perforated tympanic membrane, previous ear surgery, purulent or necrotic tissue in the ear, or persistent complaints after the cerumen has been removed.
- Cerumen. www.uptodate.com
- Roland PS, Smith TL, Schwartz SR, et al. Clinical Practice Guideline: Cerumen Impaction. Otolaryngol Head Neck Surg. 2008;139(3 Suppl 2):S1-S21.McCarter DF, Courtney AU, Pollart SM. Cerumen Impaction. Am Fam Physician. 2007;75(10):1523-1528.