12-phase flow (12)

1. 1FRAME
   Frame cerumen as a SELF-CLEANING physiologic secretion that is "impaction" ONLY when it is symptomatic or prevents a needed assessment (AAO-HNS 2017 KAS 2 Schwartz Otolaryngol HNS 2017 PMID 28045591). Asymptomatic, examinable wax is NOT treated (KAS 4). Audiometry, SSNHL steroid pathways, otitis-externa antimicrobials, BPPV repositioning, foreign-body/cholesteatoma surgery are recognised then routed OUT by engine_id.
   advance: cerumen-impaction scope confirmed; out-of-scope concerns (SSNHL/OE/BPPV/surgical) routed by engine_id
2. 2ENTRY
   Recognise the symptomatic entry (hearing loss/fullness/otalgia/tinnitus/cough/vertigo with visible wax) vs the prevents-needed-exam entry vs the surveillance entries (hearing-aid users — KAS 6; cannot-self-report children/cognitively-impaired — KAS 5). Establish that the threshold to intervene at all is met.
   inputs: symptomatic_or_prevents_exam
   advance: impaction definition satisfied (symptomatic OR prevents assessment); asymptomatic examinable wax exits without treatment
3. 3CONTEXT
   Otoscopy of canal + visible TM, then capture the AAO-HNS KAS 3 management modifiers that govern modality choice: known/suspected TM perforation, patent tympanostomy tube, prior ear surgery, only-hearing ear, active otitis externa, diabetes, immunocompromise. This phase builds the modality-selection and contraindication map.
   inputs: otoscopy_canal_and_tm, tm_perforation_known_or_suspected, tympanostomy_tube_present, prior_ear_surgery, only_hearing_ear, active_otitis_externa, diabetes, immunocompromise
   actions: workup.vertigo
   advance: otoscopy done; KAS 3 modifier set captured; irrigation eligibility determined
4. 4RED_FLAGS
   Screen for the not-just-wax red flags that change the engine entirely: a sudden (≤72 h) hearing loss out of proportion to the visible wax / persisting after partial clearance (route ent.sudden-sensorineural-hearing-loss.core.v1 — an otologic emergency); otorrhea / pain out of proportion / granulation in a diabetic-immunocompromised host (necrotizing OE — route ent.otitis-externa.core.v1); foreign body / blood / unilateral mass; persistent severe vertigo. These are recognised here and routed OUT, not managed here.
   inputs: hearing_loss_persisting_after_clearance
   actions: workup.ssnhl, calc.qsofa
   advance: not-just-wax red flags screened; SSNHL/necrotizing-OE/vestibular concerns routed by engine_id if present
5. 5INITIAL_WORKUP
   Cerumen impaction is a CLINICAL otoscopic diagnosis — no routine labs/imaging (KAS 2). Tuning-fork (Weber/Rinne) to confirm a conductive pattern consistent with obstruction. Targeted baseline labs ONLY when a modifier/route-out is in play: CBC/CMP/inflammation + frailty/eGFR if necrotizing-OE is suspected in a diabetic/immunocompromised host before route-out, or pre-procedural assessment in the frail/anticoagulated.
   inputs: otoscopy_canal_and_tm
   actions: panel.cbc, panel.cmp, panel.inflammation, calc.clinical_frailty_scale
   advance: otoscopic diagnosis recorded; conductive pattern confirmed; targeted labs only if a route-out is being prepared
6. 6BRANCHING_WORKUP
   Modality decision tree by KAS 3 modifiers: intact TM + no modifier → any of cerumenolytic / irrigation / manual; perforation OR tube OR prior surgery OR only-hearing ear OR active OE → NO irrigation, manual removal under direct vision (curette/microsuction) by an appropriately trained clinician; diabetic/immunocompromised → prefer non-irrigation; anticoagulated → atraumatic softening ± irrigation/microsuction, avoid blind curettage. If wax cannot be cleared safely in-office → ENT/microsuction referral (KAS 10).
   inputs: tm_perforation_known_or_suspected, tympanostomy_tube_present, prior_ear_surgery, only_hearing_ear, active_otitis_externa
   actions: workup.vertigo
   advance: a safe modality selected for the modifier profile, OR ENT/microsuction referral initiated
7. 7DIFFERENTIAL
   Terminal differential with named pivots — wax is over-diagnosed: cerumen impaction (wax visibly obstructing + conductive Weber-toward-affected + symptom relief on clearance pivot) vs otitis externa (canal edema/tenderness/otorrhea + tragal pain pivot — route ent.otitis-externa.core.v1) vs otitis media (bulging/retracted TM + URI + middle-ear effusion pivot) vs foreign body (history + discrete object not waxy debris pivot) vs cholesteatoma (retraction-pocket keratin/foul otorrhea/persistent unilateral pivot — surgical, route ENT) vs sudden SNHL (sensorineural pattern, Weber-AWAY, loss out of proportion / persisting post-clearance pivot — route ent.sudden-sensorineural-hearing-loss.core.v1) vs sensorineural presbycusis (bilateral symmetric high-frequency, gradual, no obstruction pivot)
   advance: single best diagnosis selected; not-just-wax look-alikes excluded or routed by engine_id
8. 8RISK_STRATIFICATION
   Stratify the host and the difficulty: necrotizing-OE-risk host (diabetic/immunocompromised + canal inflammation) is the severe end and routes OUT; frailty / cognitive impairment (cannot tolerate or report — KAS 5) lowers the threshold for specialist/microsuction; anticoagulated + hard impaction predicts a higher bleeding/trauma risk for blind curettage; recurrent/narrow/exostotic canal predicts in-office failure → earlier referral. qSOFA/NEWS2 only if a routed-out infective process is systemically unwell.
   inputs: diabetes, immunocompromise, anticoagulant_or_antiplatelet
   actions: calc.clinical_frailty_scale, calc.news2, calc.qsofa, calc.ckd_epi_2021
   advance: host risk + procedural-difficulty tier assigned; route-out vs in-office vs referral path set
9. 9TREATMENT
   AAO-HNS KAS 7 — treat with ≥1 appropriate modality: (1) cerumenolytic agents [water/saline-based; oil-based (olive/almond); or active cerumenolytic — carbamide peroxide, docusate sodium, hydrogen peroxide otic] — drops > no treatment (Cochrane Aaron/Burton 2018 RR 4.09 PMID 30043448) but no class superiority; (2) irrigation/ear-syringing, typically after softening, ONLY if no irrigation contraindication; (3) manual removal under direct vision (curette/microsuction) — the modality of choice when irrigation is contraindicated. Do NOT recommend ear candling (KAS 8 — ineffective and harmful). Anticoagulated → atraumatic technique. Re-examine and document resolution at the end of in-office treatment (KAS 9).
   inputs: anticoagulant_or_antiplatelet
   advance: an appropriate modality (matched to the contraindication profile) delivered; resolution re-checked and documented
10. 10DISPOSITION
    Most cerumen impaction is cleared in a single outpatient visit. If impaction not resolved → repeat/alternative modality; if first-line management is unsuccessful → refer to a clinician with specialized equipment/training (microsuction/binocular microscopy) (KAS 10). If symptoms persist despite documented resolution → exit the wax pathway and route by engine_id (SSNHL / OE / vertigo). Necrotizing-OE-risk and SSNHL cases route OUT regardless of wax clearance.
    inputs: hearing_loss_persisting_after_clearance
    advance: disposition documented; unresolved → referral (KAS 10); persistent-symptom and route-out cases routed by engine_id
11. 11MONITORING
    KAS 9 — at the conclusion of in-office treatment assess and DOCUMENT resolution of impaction (canal/TM now seen). If impaction not resolved, use additional treatment. If full/partial symptoms persist DESPITE resolution, evaluate for an alternative diagnosis: persistent hearing loss → audiometry / SSNHL pathway; otorrhea/pain → otitis externa/media; persistent vertigo → vestibular workup. The response-to-clearance is the key diagnostic test of treatment.
    inputs: hearing_loss_persisting_after_clearance, otorrhea_or_pain_after_clearance, vertigo_persisting_after_clearance
    actions: workup.ssnhl, workup.vertigo, workup.acute_headache
    advance: resolution documented; persistent symptoms triaged to the correct sibling engine; no silent re-treatment of a non-wax symptom
12. 12FOLLOWUP
    Primary-prevention counselling (KAS 1): do NOT use cotton buds / self-instrumentation (pushes wax in, perforation risk); leave self-cleaning ears alone; appropriate control measures (periodic softening/irrigation, scheduled microsuction) for recurrent impactors and hearing-aid users; explicit advice AGAINST ear candling (KAS 8). Recurrent/narrow/exostotic-canal patients and cognitively-impaired/hearing-aid populations get a scheduled surveillance + clearance plan and ENT linkage; close-loop any routed-out audiometry/SSNHL/OE/vestibular result.
    inputs: cotton_bud_or_self_instrumentation_use, recurrent_impaction_or_narrow_canal
    advance: prevention counselling delivered; surveillance/recurrence plan documented; routed-out results closed-loop