Cerumen Impaction: Diagnosis and Management

 

Am Fam Physician. 2018 Oct 15;98(8):525-529.

  Patient information: See related handout on earwax.

Cerumen production is a normal and protective process for the ear canal. However, cerumen should be removed when it causes symptoms (e.g., hearing loss, itching, pain, tinnitus) or prevents assessment of the external auditory canal, the tympanic membrane, or audiovestibular system. Cerumen should also be removed when it limits examination in patients who cannot communicate their symptoms, such as those with dementia or developmental delay, nonverbal patients with behavioral changes, and young children with fever, speech delay, or parental concerns. Patients with coagulopathies, hepatic failure, thrombocytopenia, or hemophilia, and those taking antiplatelet or anticoagulant medications, should be counseled about the increased risk of bleeding in the external auditory canal when cerumen is removed. Effective treatment options include cerumenolytic agents, irrigation with or without cerumenolytic pretreatment, and manual removal. Home irrigation with a bulb syringe may be appropriate for selected adults. Cotton-tipped swabs, ear candling, and olive oil drops or sprays should be avoided. If multiple attempts to remove the impacted cerumen—including a combination of treatments—are ineffective, clinicians should refer the patient to an otolaryngologist. Persistent symptoms despite resolution of the impaction should also prompt further evaluation for an alternative diagnosis.

Cerumen, or earwax, is a combination of glandular secretions and desquamated epithelial cells that cleans, protects, and lubricates the external auditory canal.1 Cerumen is typically expelled from the ear canal spontaneously via a self-cleaning mechanism that is assisted by jaw movement.2 In some persons, however, this mechanism fails and cerumen becomes impacted. Cerumen impaction is defined as an accumulation of cerumen that causes symptoms or prevents assessment of the ear canal, tympanic membrane, or audiovestibular system; complete obstruction is not required.3 Cerumen impaction is a common reason for consultation with primary care physicians and is present in about 10% of children, 5% of healthy adults, up to 57% of older persons in nursing homes, and one-third of patients with mental retardation.1,46 Cerumen-related procedures accounted for nearly $50 million in Medicare spending in 2012.6

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Cerumen impaction should be treated when it causes symptoms such as hearing loss, itching, pain, or tinnitus, or when it prevents assessment of the external auditory canal, tympanic membrane, or audiovestibular system.

C

3

Cerumen should be removed when it limits examination in patients who cannot communicate their symptoms, such as those with dementia or developmental delay, nonverbal patients with behavioral changes, and young children with fever, speech delay, or parental concerns.

B

3, 810

Irrigation, cerumenolytic agents, and manual removal with instrumentation are effective treatments for cerumen impaction. There is not enough evidence supporting the superiority of one option over another.

B

3, 17, 18

Cotton-tipped swabs, ear candling, and olive oil drops or sprays should not be used to remove cerumen because they are ineffective and have potential adverse effects.

C

3, 20, 27


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Cerumen impaction should be treated when it causes symptoms such as hearing loss, itching, pain, or tinnitus, or when it prevents assessment of the external auditory canal, tympanic membrane, or audiovestibular system.

C

3

Cerumen should be removed when it limits examination in patients who cannot communicate their symptoms, such as those with dementia or developmental delay, nonverbal patients with behavioral changes, and young children with fever, speech delay, or parental concerns.

B

3, 810

Irrigation, cerumenolytic agents, and manual removal with instrumentation are effective treatments for cerumen impaction. There is not enough evidence supporting the superiority of one option over another.

B

3, 17, 18

Cotton-tipped swabs, ear candling, and olive oil drops or sprays should not be used to remove cerumen because they are ineffective and have potential adverse effects.

C

3, 20, 27


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Diagnosis

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The Authors

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CHARLIE MICHAUDET, MD, CAQSM, is an assistant professor in the Department of Community Health and Family Medicine at the University of Florida, Gainesville....

JOHN MALATY, MD, is an associate professor in the Department of Community Health and Family Medicine at the University of Florida and medical director of Family Medicine at Main Street Clinic in Gainesville.

Author disclosure: No relevant financial affiliations.

Address correspondence to John Malaty, MD, University of Florida, 1707 N. Main St., Gainesville, FL 32609 (e-mail: malaty@ufl.edu). Reprints are not available from the authors.

References

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