30 November 2024

The importance of environmentally sustainable practice in healthcare is increasingly recognised, with the UK General Medical Council advising doctors to “Choose sustainable solutions when you’re able to, provided these don’t compromise care standards”[1].
It is estimated that around 2.3 million people each year in the UK require intervention for problems related to earwax[2]. In England, around 330,000 microsuction procedures are performed in the NHS annually[3].
In recent years, there have been concerns around cross-contamination and spread of infection, creating a trend towards single use medical products. A national survey of microsuction practice in the UK showed that 79% of ENT UK members change suction tubing at the end of a clinic session or at the end of the day, but others change may change this more frequently. Over 55% of ENT UK members use gloves and masks routinely in wax removal procedures[4].
Risk of infection from wax microsuction
Wax (cerumen) is a normal biological substance and contains similar bacteria and fungi resident on healthy skin (commensal bacteria). On routine culture this includes Staphylococcus epidermidis, Corynebacterium spp, Staphylococcus aureus, Streptococcus saprophyticum, and Candida albicans[5],[6]. Therefore, coming into contact with healthy wax is comparable to coming into contact with healthy skin (for example through a handshake).
Risk of backflow in low-volume suction tubes is minimal and only happens if:
- The pressure in the tube is higher than the area suctioned, for example, oral cavity with a seal created by the lip around the suction tip.[7],[8],[9]. This is not relevant for wax removal.
- The position of the suction tube is higher than the patient because when suction is turned off gravity may pull the contents in the tube back towards the patient6. Hence, if the suction system is positioned higher than the patient, it is important to ensure the length of suction tube is sufficient to prevent backflow to the patient.
- There is concurrent use of high-volume suction[7].
Whereas there is no specific evidence evaluating risk of cross-contamination from microsuction, the combination of low (near zero) pathogenicity of microorganisms present in healthy wax, and the low risk of backflow in tubing, means the risk of cross-contamination when clearing health wax is negligible.
Personal Protective Equipment
There is no indication to wear gloves or aprons for wax removal. NHS standard infection control precautions recommend glove use only when hands may come into direct contact with blood and/or other body fluids, non-intact skin, or mucous membranes[10] (as a mechanism to reduce the number of pathogens on hands before they are cleaned). Unnecessary use of gloves creates financial and carbon cost[11],[12]. Aprons should only be worn when there is a risk of splash of bodily fluids, so again should not be worn for wax microsuction.
Summary
We recommend that when performing microsuction, the sucker is changed between patients, but the suction tubing and liners only need to be changed once at the end of the day (there is no need to change such equipment between patients or between clinics). There is no indication to wear gloves or aprons during microsuction.
Previous ENT-UK guidance from 2019[13] suggested placing a small piece of silastic tubing between the sucker and main tubing which is changed between patients, suctioning antiseptic solution between every patient, and disposing of suction tubing and liners at the end of each clinic. This is usually unnecessary, and this guidance supersedes this advice. However, if a bodily fluid is suctioned (rather than normal wax), which may for example include infected debris, pus, or blood, then the tubing should be washed through with tap water and/or antiseptic and/or replaced. The reasoned judgment on what to do in such circumstances can be by staff at the point of care, taking account of the potential risk of cross-contamination.
References
- Guest, J.F., Greener, M.J., Robinson, A.C. and Smith, A.F. (2004) Impacted cerumen: composition, production, epidemiology and management. QJM 97(8), 477-488
- Burton L, Bhutta M. 2024. Current UK Practice for Wax Removal: Developing Guidelines towards Safe and Environmentally Sustainable Practice. [Unpublished manuscript]
- Campos A, Arias A, Betancor L, Rodríguez C, Hernández AM, López Aguado D, Sierra A. Study of common aerobic flora of human cerumen. J Laryngol Otol. 1998 Jul;112(7):613-6. doi: 10.1017/s002221510014126x. PMID: 9775288.
- Pata YS, Oztürk C, Akbaş Y, Unal M, Görür K, Ozcan C. Microbiology of cerumen in patients with recurrent otitis externa and cases with open mastoidectomy cavities. J Laryngol Otol. 2004 Apr;118(4):260-2. doi: 10.1258/002221504323011978. PMID: 15117461.
- Mann GLB, Campbell TL, Crawford JJ. Backflow in low-volume suction lines: The impact of pressure changes. J Am Dent Assn 1996;127:611–615
- Barbeau J, ten Bokum L, Gauthier C, Prevost AP. Cross-contamination potential of saliva ejectors used in dentistry. J Hosp Infect 1998;40:303–311.
- Wilson J, Bak A, Loveday HP. Applying human factors and ergonomics to the misuse of nonsterile clinical gloves in acute care. Am J Infect Control. 2017;45(7):779-86
- Loveday HP, Lynam S, Singleton J, Wilson J. Clinical glove use: Healthcare workers’ actions and perceptions. J Hosp Infect. 2014;86(2):110-6. 324.
Download