Practice Guidelines

Diagnosis and Management of Cerumen Impaction



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Am Fam Physician. 2009 Nov 1;80(9):1011-1013.

Guideline source: American Academy of Otolaryngology–Head and Neck Surgery

Literature search described? Yes

Evidence rating system used? Yes

Published source: Otolaryngology–Head and Neck Surgery, September 2008

Available at: http://www.entnet.org/practice/cerumenimpaction.cfm

Endorsed by the AAFP, February 2010. http://www.aafp.org/patient-care/clinical-recommendations/all/endorsed.html

Cerumen, or earwax, is normally expelled from the ear canal by a self-cleaning mechanism assisted by jaw movement. Occasionally this mechanism fails, and accumulation of cerumen can lead to symptoms such as pain, itching, tinnitus, and hearing loss. Cerumen impaction is one of the most common reasons patients seek medical care for ear-related problems. Although excessive cerumen is present in 10 percent of children and more than 30 percent of older and cognitively impaired patients, cerumen impaction is underdiagnosed and likely undertreated.

Diagnosis

Cerumen typically is asymptomatic and does not impair physical examination. Physicians should diagnose impaction only when an accumulation of cerumen is associated with symptoms (e.g., otalgia, tinnitus, vertigo) or prevents necessary assessment of the ear. Total occlusion is not necessary for diagnosis. However, impaction should not be diagnosed unless visualization of the ear canal or the tympanic membrane (TM) is essential.

The use of hearing aids or earplugs may cause stimulation of cerumen glands, leading to excessive cerumen production. Physicians should be aware that patients who use these devices are at high risk of impaction, but examinations more frequent than every three months are not necessary.

Management

It is important for patients to understand that cerumen does not always need to be removed. It acts as a self-cleaning agent with protective, emollient, and bacteriocidal properties. Cerumen generally is removed from the ear canal naturally, so observation over time can be offered as a reasonable management strategy in asymptomatic patients with nonimpacted cerumen.

When cerumen causes symptoms or prevents necessary clinical examination, impaction should be treated. In some cases, treatment may be indicated even if the patient is not symptomatic. Young children and cognitively impaired or older persons are at high risk of cerumen impaction, but may be unaware of or unable to express symptoms. Physicians should evaluate the need for treatment in these patients if the ear canal is obstructed.

TREATMENT OPTIONS

There are three types of interventions for cerumen impaction: irrigation, manual removal, and topical preparations (Table 1). The choice of method depends on the available resources, experience of the physician, and ease with which the canal can be cleared. Combining any of these methods, either simultaneously or at intervals, is also an option.

Table 1.

Therapeutic Options for Cerumen Impaction: Advantages and Disadvantages

Option Advantages Disadvantages and potential complications

Irrigation

Effective

TM perforation; pain; vertigo; EAC trauma; otitis externa; severe audiovestibular loss

Manual removal

Effective

Special skills required; skin laceration; pain; patient cooperation required (especially with children)

Topical preparations

Easy application

Otitis externa; allergic reactions; pain or vertigo if TM is not intact; transient hearing loss

Effective, but no more than saline or water


EAC = external auditory canal; TM = tympanic membrane.

Adapted with permission from Roland PS, Smith TL, Schwartz SR, Rosenfeld RM, Ballachanda B, Earll JM, et al. Clinical practice guideline: cerumen impaction. Otolaryngol Head Neck Surg. 2008;139(3 suppl 2):S11.

Table 1.   Therapeutic Options for Cerumen Impaction: Advantages and Disadvantages

View Table

Table 1.

Therapeutic Options for Cerumen Impaction: Advantages and Disadvantages

Option Advantages Disadvantages and potential complications

Irrigation

Effective

TM perforation; pain; vertigo; EAC trauma; otitis externa; severe audiovestibular loss

Manual removal

Effective

Special skills required; skin laceration; pain; patient cooperation required (especially with children)

Topical preparations

Easy application

Otitis externa; allergic reactions; pain or vertigo if TM is not intact; transient hearing loss

Effective, but no more than saline or water


EAC = external auditory canal; TM = tympanic membrane.

Adapted with permission from Roland PS, Smith TL, Schwartz SR, Rosenfeld RM, Ballachanda B, Earll JM, et al. Clinical practice guideline: cerumen impaction. Otolaryngol Head Neck Surg. 2008;139(3 suppl 2):S11.

A standard oral jet irrigator, with or without a specially modified tip, is commonly used for aural irrigation in the physician's office. Specially designed electronic irrigators are also available, but no evidence supports their use over standard oral jet irrigators. Pretreatment with a topical preparation improves the effectiveness of irrigation, regardless of the type of preparation. Irrigation should not be performed in patients with a history of ear surgery or in those with anatomic abnormalities of the ear canal.

Manual removal of impacted cerumen requires an instrument for visualization (e.g., handheld speculum or otoscope, headlamp, binocular microscope) and one for removal (e.g., metal and plastic loop or spoon, alligator forceps, curette). Soft cerumen can sometimes be removed with cotton wool applied to an applicator or aspirated with a suction tip attached to a negative-pressure pump.

Topical preparations for the treatment of cerumen impaction exist in three forms: water-based; oil-based; and non–water-, non–oil-based agents (Table 2). Water-based ceruminolytics induce hydration and subsequent fragmentation of corneocytes. Oil-based agents, which are not true ceruminolytics, lubricate and soften cerumen but do not disintegrate it. The mechanism by which non–water-, non–oil-based agents work is not known. Studies show that any type of topical agent is superior to no treatment, but there is little evidence that any single agent is superior to another. The use of a ceruminolytic agent improves outcomes when combined with irrigation, but no preparation has been proven superior to another.

Table 2.

Topical Preparations for Treatment of Cerumen Impaction

Preparation Active constituents

Oil-based

Almond oil

Arachis oil

Earex

Arachis oil, almond oil, rectified camphor oil

Mineral oil/liquid petrolatum

Olive oil

Water-based

Acetic acid

Cerumenex

Triethanolamine polypeptideoleate condensate

Colace

Docusate sodium

Hydrogen peroxide

Sodium bicarbonate

Sterile saline solution

Water

Other

Audax

Choline salicylate, glycerine

Debrox

Carbamide peroxide (urea–hydrogen peroxide)


Adapted with permission from Hand C, Harvey I. The effectiveness of topical preparations for the treatment of earwax: a systematic review. Br J Gen Pract. 2004;54(508):862–867.

Table 2.   Topical Preparations for Treatment of Cerumen Impaction

View Table

Table 2.

Topical Preparations for Treatment of Cerumen Impaction

Preparation Active constituents

Oil-based

Almond oil

Arachis oil

Earex

Arachis oil, almond oil, rectified camphor oil

Mineral oil/liquid petrolatum

Olive oil

Water-based

Acetic acid

Cerumenex

Triethanolamine polypeptideoleate condensate

Colace

Docusate sodium

Hydrogen peroxide

Sodium bicarbonate

Sterile saline solution

Water

Other

Audax

Choline salicylate, glycerine

Debrox

Carbamide peroxide (urea–hydrogen peroxide)


Adapted with permission from Hand C, Harvey I. The effectiveness of topical preparations for the treatment of earwax: a systematic review. Br J Gen Pract. 2004;54(508):862–867.

Inappropriate options for treatment of cerumen impaction include the in-home use of oral jet irrigators, cotton swabs, and ear candling. Ear candling is a popular alternative remedy in which one end of a hollow tube of fabric coated with beeswax is inserted into the ear, and the other end is ignited. It is marketed as a way to draw cerumen out of the ear through a “chimney effect” produced by the burning candle. Although no reliable data are available on ear candling, limited research has shown that it is implausible, ineffective, and potentially unsafe, and the U.S. Food and Drug Administration warns against it.

COMPLICATIONS

Physicians should perform a history and physical examination for patients with cerumen impaction to assess for factors that affect treatment, such as ear canal stenosis, nonintact TM, diabetes mellitus, immunocompromise, or anticoagulant therapy.

Anatomic factors, either congenital or acquired, that result in narrowing of the ear canal can affect treatment by limiting visualization and increasing the risk of trauma. A narrow ear canal can make irrigation and manual instrumentation difficult. Narrow ear canals are common in persons with Down syndrome, other craniofacial disorders, or chronic external otitis. Safe and effective irrigation is not always possible in these patients.

A perforated TM limits the options for cerumen removal. Infection, pain, and ototoxic hearing loss are possible, depending on the irrigation solution used. Irrigation in the presence of a perforated TM may produce caloric effects resulting in vertigo. Mechanical removal of cerumen is the preferred technique in these patients.

The pH of cerumen in persons with diabetes is higher than that of persons without the condition. This may facilitate the growth of pathogens. Physicians who use irrigation in these patients must take care to minimize trauma and provide close follow-up; ear drops to acidify the ear canal after irrigation also should be considered.

Irrigation with tap water is associated with malignant external otitis. Because this condition has been reported in patients with AIDS, tap water irrigation also may pose risks in these patients.

Patients on anticoagulant therapy are at higher risk of cutaneous hemorrhage or subcutaneous hematoma. Careful instrumentation is essential to minimize bleeding.

Follow-Up

The symptoms of cerumen impaction overlap with those of several other conditions. Once impaction has been resolved, the patient should be reexamined to determine whether symptoms were in fact caused by cerumen impaction. Impaction is resolved when the ear can be examined without the interference of cerumen and the patient is no longer symptomatic. If the first condition is met but symptoms persist, alternative diagnoses should be considered (Table 3).

Table 3.

Cerumen Impaction: Alternative Diagnoses

Adverse effects of medications

Ear canal skin disorder

Eustachian tube dysfunction

Head and neck tumors

Otitis media

Otosclerosis

Sensorineural hearing loss

Temporomandibular joint syndrome

Upper respiratory tract infection

Table 3.   Cerumen Impaction: Alternative Diagnoses

View Table

Table 3.

Cerumen Impaction: Alternative Diagnoses

Adverse effects of medications

Ear canal skin disorder

Eustachian tube dysfunction

Head and neck tumors

Otitis media

Otosclerosis

Sensorineural hearing loss

Temporomandibular joint syndrome

Upper respiratory tract infection

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.



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