Cerumen Impaction: (Earwax Blockage)

Presentation

The patient may complain of “wax in the ear,” a “stuffed-up” sensation, pain, itching, decreased hearing, tinnitus, dizziness, hearing aid malfunction, ear drainage, or ear odor. Symptoms may be sudden in onset if the patient put a cotton-tipped applicator down the ear canal or placed something like mineral oil into the ear canal in an attempt to soften the wax. On physical examination, there is often dark brown, thick, dry, or pasty cerumen, frequently packed down against the eardrum (where it does not occur normally), obscuring visualization of the ear canal and the tympanic membrane.

What to Do

• When excessive cerumen causes symptoms such as those listed or prevents examination of the canal and tympanic membrane, it should be removed. Also consider removing in patients who are unable to report symptoms, such as small children and cognitively impaired patients.

• There are three options for cerumen removal: (1) cerumenolytic agents, (2) irrigation, and (3) manual removal. These methods may be used alone or in combination.

• There is no clear evidence in the literature that one method of removing cerumen impaction is superior, thus the treatment method used should depend on the available resources, experience of the treating clinician, potential harms based on the specific patient, and shared decision making.

• Irrigation and manual removal can increase risk of infection in immunocompromised or diabetic patients. Canal trauma can lead to hemorrhage or hematoma in patients on anticoagulants.

• Cerumenolytics and irrigation should be avoided if tympanic membrane (TM) injury is suspected or tympanostomy tubes are in place.

• Approximately 1/1000 irrigations has a complication. Complications include canal laceration, pain, dizziness, vertigo, syncope, TM perforation, bleeding, transient hearing loss, and subsequent development of otitis externa.

• For difficult cases or patients with known or suspected TM perforation, consider referral to an otolaryngologist (ENT), who has access to a microscope with better visualization and fine tools to delicately remove wax.