Cerumen Impaction


Article Author:
Justin Sevy


Article Editor:
Anumeha Singh


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
3/25/2019 10:45:14 PM

Introduction

Production of cerumen (earwax) is a normal and naturally occurring process in humans and many other mammals. It protects the ear from infection and provides a barrier for insects and water. Cerumen is typically expelled from the ear canal spontaneously through natural jaw movement. However, in certain individuals, the self-cleaning mechanism fails, and cerumen can become impacted[1][2]. Cerumen impaction can occlude the canal or press against the tympanic membrane, potentially causing ear discomfort, conductive hearing loss, itching, and tinnitus. Cerumen impaction occurs in up to 6% of the general population, affecting 10% of children and over 30% of the elderly and cognitively impaired populations. It is often seen in those with hearing aids or earplugs, in an external canal occluded by a foreign body, or in people with ear canal anatomic abnormality.[1]

Excessive buildup of cerumen is likely underdiagnosed and undertreated.  In the United States, it leads to 12 million patient visits and eight million cerumen removal procedures each year.  It can interfere with tympanic membrane examination in the clinical setting.  It is diagnosed by direct visualization by a trained provider using an otoscope. [1][3]

Anatomy

Cerumen is made up of shed skin cells and secretions from both the sebaceous and ceruminous glands of the lateral third of the external auditory canal.[1]

Indications

Although excessive accumulation of cerumen is typically asymptomatic, patients should be treated if presenting with hearing loss, ear fullness, pruritus, dizziness, tinnitus, or an earache. Inability to examine an ear due to cerumen impaction is another indication for cerumen removal.

When discovered in the asymptomatic patient, it is not always necessary to treat. It is important to relate to patients that cerumen does not always need to be removed, as cerumen naturally has bacteriocidal, protective, and emollient properties. Observation should be offered as a management strategy if appropriate.

In young children, the elderly, or cognitively impaired individuals, treatment is a reasonable option as they may not be able to verbalize symptoms or are unaware of them.[1][4]

Contraindications

Providers should be wary of patients with certain illnesses (HIV, diabetes mellitus), chronic anticoagulation, or anatomical defects narrowing the canal. In patients with diabetes mellitus, a higher pH is typically present in the cerumen, making superimposed bacterial infections more common. In those with HIV, consider not using tap water to irrigate as there is an association with malignant external otitis. Caution should be exercised with those on chronic anticoagulation as they are at a higher risk for hemorrhage or hematomas.[5]

Use of cerumenolytics (see below) is safe, but contraindications include a perforated tympanic membrane or history of ear surgery including tympanostomy tube placement. Common reactions include local irritation and a rash. With prolonged use, a superinfection may occur.[6]

Technique

When treatment is appropriate, there are three recommended removal methods: cerumenolytic agents, irrigation, and manual removal.[6]

Cerumenolytic agents, also known as ear wax drops, are liquid solutions which help thin, soften, break up, and/or dissolve ear wax. These are typically water- or oil-based drops, with water-based solutions being the most commonly used. Typical ingredients found in water-based cerumenolytics include hydrogen peroxide, acetic acid, docusate sodium, and sodium bicarbonate. Common ingredients in oil based cerumenolytics include peanut, olive, and almond oil.  Most drops are available over the counter. Typically, up to five drops are used at a time one to two times daily for three to seven days. They can be either used by themselves or in conjunction with a procedure such as an ear irrigation.

A commonly prescribed cerumenolytic is carbamide peroxide (brand name Debrox or Murine ear wax removal). Five to 10 drops are placed twice daily for up to four days. The drops work by releasing oxygen to soften and remove ear wax and also have a weak antibacterial effect.

Irrigation is another method to safely and effectively remove unwanted cerumen. Several irrigation methods may be used in the clinical setting. Commonly, warm water alone or a 50/50 mix of water and hydrogen peroxide is inserted into a syringe and discharged into the ear canal with a basin underneath. Another option is a standard oral jet irrigator, with or without a modified tip. Although these methods are inexpensive, if not done properly they can potentially cause trauma, including perforation of the tympanic membrane. To mitigate the risk, an ear irrigator tip can be used. There are electronic irrigators available as well; however, there are no controlled trials to compare the different irrigation methods.

Manual removal is the final method recommended by the American Academy of Otolaryngology-Head and Neck Surgery for removal of unwanted cerumen. Manual removal often requires specialized instrumentation for better visualization, such as a binocular microscope or a handheld speculum. The removal device involves a metal or plastic loop or spoon, curette, or alligator forceps. Some products have illuminated tips to help visualize during the procedure.  Advantages of this method are a decreased risk for infection because the ear canal is not exposed to moisture. It does, however, pose a small risk of perforation and local trauma, especially if the patient is uncooperative. This method also requires more clinical skill.

To prevent further accumulation of cerumen in patients with recurrent symptoms greater than one per year, patients may apply mineral oil to the external canal 10 to 20 minutes weekly. Patients with hearing aids should remove them for eight hours a day to reduce cerumen buildup.[7][8]

Complications

There are other over-the-counter devices to remove cerumen that physicians recommend. Cotton swabs are commonly used but should be avoided, as they may worsen the impaction or cause a perforation of the tympanic membrane. Another common home remedy is ear candling. This involves a hollow tube coated in beeswax. One end is inserted into the ear canal, and the other is ignited. It is marketed to have a "chimney effect," created by the pull of air from the ignited candle. This procedure is strongly recommended against by the United States Food and Drug Administration as it is ineffective and has the potential for injury.[3][7]

Clinical Significance

It is important to ensure other diagnoses are not missed in patients being treated for cerumen impaction. As mentioned, common complaints of these patients include ear pain, tinnitus, and dizziness. Once cerumen is cleared, and the patient is seen for a follow-up visit, it is important to rule out diagnoses such as otitis media, otosclerosis, sensorineural hearing loss, temporomandibular joint syndrome, and upper respiratory tract infections, among others. When done correctly and successful, it results in immediate symptom relief and patient satisfaction.[1]

Enhancing Healthcare Team Outcomes

Cerumen impaction is often challenging to treat. It is uncomfortable for the patient and often difficult for the clinician and nurse working together to remove the impaction. The healthcare team must work in a coordinated fashion to obtain satisfactory results and avoid complications such as iatrogenic perforation. [Level V]


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Cerumen Impaction - Questions

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On a routine physical exam of a healthy male, you note cerumen occluding most of the left ear canal, but part of the tympanic membrane is visible. The patient denies any symptoms, including hearing loss, dizziness, or pain. What is the best management?



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What is the first step in preparing for irrigation of impacted cerumen?



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What is the most common cause of hearing loss in adults over the age of 65?



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Cerumen is best removed with which of the following?



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What solution is most often used to remove cerumen?



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A healthy 30-year-old patient experiences conductive hearing loss. What is the most likely diagnosis?



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Which of the following is the least likely to cause excessive cerumen accumulation?



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What is the most common problem with the external auditory meatus?



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A 55-year-old male present with conductive hearing loss of the left ear. On otoscopy, the tympanic membrane cannot be visualized due to cerumen impaction. What technique should not be used to remove the cerumen?



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Which of the following is not an approved method of cerumen impaction?



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A student in training presents a patient that complains of loss of ability to hear out of the right ear. They complain of a sensation that they may pass out. They also report a chronic cough. What is the next step?



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Cerumen Impaction - References

References

Michaudet C,Malaty J, Cerumen Impaction: Diagnosis and Management. American family physician. 2018 Oct 15;     [PubMed]
Hauk L, Cerumen Impaction: An Updated Guideline from the AAO-HNSF. American family physician. 2017 Aug 15;     [PubMed]
Schumann JA,Pfleghaar N, Ear Irrigation 2019 Jan;     [PubMed]
Sevy JO,Singh A, Cerumen Impaction 2019 Jan;     [PubMed]
Demir E,Topal S,Atsal G,Erdil M,Coskun ZO,Dursun E, Otologic Findings Based on no Complaints in a Pediatric Examination. International archives of otorhinolaryngology. 2019 Jan;     [PubMed]
Driscoll PV,Ramachandrula A,Drezner DA,Hicks TA,Schaffer SR, Characteristics of cerumen in diabetic patients: a key to understanding malignant external otitis? Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 1993 Oct;     [PubMed]
Schwartz SR,Magit AE,Rosenfeld RM,Ballachanda BB,Hackell JM,Krouse HJ,Lawlor CM,Lin K,Parham K,Stutz DR,Walsh S,Woodson EA,Yanagisawa K,Cunningham ER Jr, Clinical Practice Guideline (Update): Earwax (Cerumen Impaction) Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2017 Jan;     [PubMed]
Roland PS,Smith TL,Schwartz SR,Rosenfeld RM,Ballachanda B,Earll JM,Fayad J,Harlor AD Jr,Hirsch BE,Jones SS,Krouse HJ,Magit A,Nelson C,Stutz DR,Wetmore S, Clinical practice guideline: cerumen impaction. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2008 Sep;     [PubMed]

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