Diane Wink Cerumen impaction occurs when increased amounts of hard cerumen either partially or completely occlude the external ear canal. Cerumen is a natural substance that can become dry and immobile and occlude the canal. Although cerumen is an important defense against infection, many think a buildup of earwax is a sign of uncleanliness and make efforts to remove the wax. This can compromise the integrity of the ear’s defenses against infection and actually contribute to cerumen impaction. Ear plugs, hearing aides, ear buds used to listen to music and talk on the phone, and probes such as cotton-tipped swabs used to clean the ear can cause cerumen impaction. The presence of cerumen can also decrease efficacy of hearing aides.1 Clinicians should diagnose cerumen impaction only when an accumulation of cerumen is associated with either or both of the following conditions: patient symptoms and prevention of needed assessment of the ear. An exception is when the patient is elderly or a young child or is cognitively impaired and not able to express symptoms. These individuals are at higher risk for cerumen impaction because they are often unaware of or unable to express any symptoms associated with it. Hearing loss associated with cerumen impaction may further impair cognitive function.1 Cerumen is a soft, yellow, waxy protective substance that is secreted by glands in the external ear canal. It is part of the mechanism that protects the ear canal and tympanic membrane (TM) from dirt and debris. When cerumen is formed relatively close to the TM, it is soft and fluid, colorless, and odorless. As the cerumen moves toward the distal part of the ear canal through the process of mandibular movement, it becomes drier and darker and develops its characteristic odor. If an individual uses a swab to clean the ear canal or another item that obstructs normal movement of the cerumen, the harder cerumen that is not removed or allowed to naturally progress to the outer ear is pushed against the TM. Cotton-tipped swabs can leave fibers from the swab, which then hold the cerumen in a mass. Excessive cerumen production, a narrow ear canal, or obstruction may also predispose a patient to impaction.2 Patients with cerumen impaction typically complain of unilateral or bilateral fullness or hearing loss; otalgia, itching, discomfort, tinnitus, cough, vertigo, and dizziness are also common complaints. Because hearing changes thought to be from cerumen impaction can also be from other causes (e.g., TM rupture) an expanded history to identify such problems should be obtained.1–3 The outer ear should be inspected for size, shape, color, and placement; the lobe, helix, and preauricular and postauricular lymph nodes should be bilaterally palpated. The body temperature and lymph nodes are usually normal. The ear should be inspected by having the patient tip his or her head toward the opposite shoulder. In adults, the pinna is pulled gently up and backward; for young children and infants, the ear is pulled downward. The largest speculum that fits into the ear canal is gently inserted. Cerumen impaction may prevent the speculum from being fully inserted. An impaction appears as a light yellow to dark brown mass that prevents or partially blocks visualization of the TM. Blood in the external ear canal appears as bright red to black and may be liquid or a solid mass. Sanguineous drainage often appears as honey-colored fluid. Whenever a cerumen impaction is noted in one ear, the other ear should be examined as well. No diagnostics are indicated. The primary differential diagnosis is a foreign body in the external ear canal. Perforation of the TM, otitis, middle ear disease, and dysfunction of the eustachian tube can also cause symptoms similar to cerumen impaction. When cerumen removal is needed, first verify if patients have a history of a ruptured TM, tympanostomy tubes, or recent ear surgery. When such history is present, some modes of cerumen removal are contraindicated. Foreign objects such as beans or other vegetable matter tend to swell with the irrigating solution, complicating removal.1,3 • If there is no contraindication to instilling fluid into the ear canal, a commercial ceruminolytic agent (e.g., any brand of carbamide peroxide) or two or three drops of baby oil or mineral oil, liquid docusate sodium, or hydrogen peroxide can be inserted in the affected ear daily for 3 to 5 days. This may resolve the impaction. • If a patient is known to have dry skin in the ear canal, ceruminolytics containing hydrogen peroxide should be avoided because the peroxide can further dry the skin.4 • Although any ceruminolytic agent seems to be better than no treatment at all, there is no evidence that any one particular ceruminolytic is superior to any other.1,5 However, only carbamide peroxide has been approved by the U.S. Food and Drug Administration (FDA) for this use.2 • If the cerumen is deeper in the canal or is not cleared with the ceruminolytic agent and/or curette, irrigation with water or normal saline at body temperature using an ear syringe, a device specifically designed for ear irrigation, or a regular syringe with a flexible catheter can be performed. • The canal should be irrigated until clear unless the patient experiences pain or dizziness. • If the patient is immunocompromised, a sterile solution should be used.1,2 • Pain, injury to the skin of the ear canal with hemorrhage, and acute otitis externa are possible complications after cerumen removal. Patients on anticoagulants are at higher risk for bleeding.1 • The clinical indication for use of antibiotics and topical steroids after removal of a cerumen impaction is determined by the amount of excoriation and other conditions, such as diabetes or an immunocompromised status. • When warranted, hydrocortisone–neomycin sulfate–polymyxin B sulfate (Cortisporin otic solution) or a mixture of white vinegar and rubbing alcohol in the canal every day for 2 or 3 days after the procedure can reduce the risk of otitis externa.1 • Reassess the patient at the conclusion of in-office treatment for cerumen impaction and document resolution of the impaction.1 • If the impaction is not resolved, additional treatment should be prescribed. • If full or partial symptoms persist despite resolution of impaction, clinicians should consider alternative diagnoses and referral to an otolaryngology specialist.1
Cerumen Impaction
Definition and Epidemiology
Pathophysiology
Clinical Presentation
Physical Examination
Diagnostics
Differential Diagnosis
Management
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Cerumen Impaction
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