SUMMARY 

Cerumen, colloquially referred to as “earwax,” is a naturally occurring substance that plays an important role in protecting and lubricating the external auditory canal. Unfortunately, it is also the most common cause of ear canal obstruction, leading to 12 million PCP visits annually with 8 million in office ear wax removals performed each year. Cerumen impaction is more common, and also more often undiagnosed, in the elderly and patients with cognitive impairment, further compounding age related hearing loss.  

DEFINITIONS  

Cerumen 

A mixture of hydrophobic glandular secretions from the outer ear canal mixed with sloughed squamous epithelial cells. Generally expelled via a self-cleaning mechanism assisted by jaw movement. 

Cerumen Impaction  

An accumulation of cerumen that causes symptoms or hinders examination of the middle and inner ear. Does not have to have a total obstruction of the ear canal to be considered an impaction.  

PRESENTATION AND DIAGNOSIS  

• Most often cerumen accumulation is asymptomatic and needs no intervention unless it prevents examination of the middle and inner ear  
• Diagnosis of cerumen impaction can be made when an accumulation of cerumen is seen on exam in addition to: 
  • Associated symptoms AND/OR 
  • Inability to preform necessary ear exam (including auditory and vestibular testing) 
• Occurs in: 
  • 1 in 20 adults  
  • 1 in 3 older adults (> 65 years) 
• Symptomatic patients may report: Otalgia | Hearing loss | Tinnitus | Ear fullness | Itching | Discharge | Odor | Cough | Vertigo | Hearing aid malfunction or feedback  
• Hearing loss does not occur until cross sectional area of the ear canal is reduced by ≥ 80%  
• Exam will demonstrate cerumen in the ear canal on otoscopic exam 
  • Cerumen may vary in color from white to red to black depending on its composition  
  • Cerumen may also vary in texture from solid (likely more chronic) to liquid  
• Otoscopic exam should be performed, regardless of presence of symptoms, in the following cases: 
  • Patients with hearing aids  
  • Patients with cognitive impairment  

PATIENT HISTORY 

• Clinician should also obtain history that alter management and may require referral to ENT provider including:  
  • Medications in use: Anticoagulation | Immunosuppression  
  • Diabetes mellitus: The pH of diabetic cerumen is significantly higher and may facilitate the growth of pathogens | Consider using ear drops to acidify the ear canal post irrigation 
  • Coagulopathy: Method of cerumen removal should minimize risks of abrasions or bruising  
  • Immunocompromised state: Irrigation with tap water implicated in development of malignant otitis externa in these patients  
  • Prior radiation therapy to the head and neck: Radiation can thin epithelium and alter cerumen production resulting in drier cerumen that requires delicate debridement | May be harder to heal following injury predisposing to osteoradionecrosis of the ear canal and temporal bone 
  • Ear canal stenosis: Limits visualization and increases the likelihood of trauma 
  • Exostoses: Limits visualization and increases the likelihood of trauma 
  • Nonintact tympanic membrane: When suspected irrigation is contraindicated and manual removal techniques should be utilized  
  • Current otitis externa: Irrigation should be avoided  

THERAPY  

• The following therapies can be combined in the same visit to produce results (e.g., resolution of symptoms or visualization of the middle ear)  
• No evidence that any method below is superior to another and decision on method should depend on provider and patient preferences  
• Following treatment clinicians should document resolution of impaction 
  • If unresolved clinician should proceed with additional treatment  
  • If impaction appears resolved but symptoms persist than alternative diagnosis should be considered  
• If management is unsuccessful patient should be referred to another provider with expertise or equipment for cerumen removal (e.g., ENT providers) 

Cerumenolytic agents 

• Wax softening agents  
• Used to disperse and soften the cerumen  
• Often used in combination prior to attempting irrigation or manual removal  
• No evidence to show difference in effectiveness between different cerumenolytic drops  
  • Different agents include: Water based (e.g., saline solution, colace, hydrogen peroxide) | Oil based (e.g., mineral oil, olive oil) | Non water or oil based (e.g., debrox)  
• Can be done at home  
• Typically instill several drops once or twice daily for 3 to 5 days 

Irrigation 

• Involves flushing the wax out by a jet of warm water 
• Water should ideally be at body temperature to reduce risk of vertigo  
• Should not take more than 30 minutes 
• Can be done at home  

Manual removal  

• Methods include: Curette | Probe | Hook | Forceps | Suction under direct visualization  
• Generally safe but can abrade or irritate the ear canal  
• Must be done in office by a clinician  

NOTE: Ear candling and cotton tip swabs are NOT recommended methods of cerumen removal and are associated with adverse events (e.g., ear canal trauma, exacerbation of impaction) 

COMPLICATIONS  

• Adverse events are rare and include: Tympanic membrane perforation| Ear canal laceration Infection of the ear | Bleeding | Hearing loss | Otitis externa | Pain | Vertigo | Syncope 
• Risk with using suction device includes loud noise resulting in tinnitus or hearing loss  
• Complications occur at a rate of about 1 in 1000 ear irrigation 
• If complication occurs consider referral to ENT provider  

PREVENTING RECURRENCE  

Who needs prevention? 

• Prevention methods are only recommended for certain patient populations  
  • > 65 years old 
  • People with hearing aids 
  • Patients with a history of excessive earwax 

Cerumenolytic agents 

• Patients should not irrigate or try cerumenolytic agents if they have a history of ear surgery or perforated eardrum 
• Otherwise over the counter agents may be used prophylactically for those with a history of cerumen impaction  

Education 

• Patients should be reassured that earwax is normal and natural, and should not be removed in the absence of impaction as defined above 
• Patients with a history of cerumen impaction should still undergo repeat otoscopic exam if new or recurrent symptoms occur 
  • Otitis externa and otitis media symptoms may mimic cerumen impaction and can be distinguished with otoscopic exam  

Hygiene  

• Patient should be counseled on not inserting ANY foreign objects into the ear canal (e.g., cotton tipped swabs, metal probes)  
  • Can exacerbate or causes cerumen impaction  
  • Associated with risks such as: Skin abrasions | Eardrum perforation | Dislocation of inner ear bones 
• Sage advice: Never put anything smaller than your elbow in your ear! 

Hearing aid users  

• Hearing aid users should have otoscopic exams every 3 to 6 months 
• Wax trap should be routinely cleaned and replaced every 3 months (or whenever hearing aid is not working)  
• Behind the ear hearing aids should have the ear mold removed and cleaned each night  
  • Use mild soapy solution (NO alcohols | Solvents | Oils)  
  • Dry with soft cloth or cotton ball  
• Behind the ear hearing aids that do not have detachable ear molds should be wiped with a damp cloth and brushed with a soft toothbrush to remove wax and debris  

KEY POINTS 

• Cerumen is a naturally occurring substance that can accumulate in certain patients causing symptoms such as hearing loss and ear pain  
• Management and removal of impacted cerumen can result in improved quality of life and resolution of symptoms  
• Method used to remove cerumen depends on clinician and patient preference  
• Patients should be educated on proper ear care including avoiding inserting all  

Learn More – Primary Sources  

American Academy of Otolaryngology—Head and Neck Surgery Foundation Clinical Practice Guideline from : Earwax (Cerumen Impaction)