Accumulation of cerumen producing symptoms or obstructing the canal/TM examination.
Also known as: cerumen impaction, earwax impaction, impacted cerumen
Overview
Accumulation of cerumen that (a) causes symptoms (hearing loss, fullness, pain, tinnitus, itch, cough), (b) prevents needed examination of the ear, or (c) both. Asymptomatic cerumen that does not obstruct evaluation is not 'impaction' and does not require removal.
Epidemiology
Affects ~1 in 10 children, 1 in 20 adults, and >1 in 3 elderly or cognitively impaired patients. Among the most common reasons for primary-care ENT visits.
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Advanced age (drier cerumen, less elastic canal skin)
Use of cotton-tipped applicators (pushes cerumen deeper)
Hearing aid or earplug use
Narrow or hairy canals (more common in men)
Down syndrome, intellectual disability
Prior radiation to ear
Cerumen-producing genotype (wet vs dry cerumen is genetically determined)
Pathophysiology
Cerumen is a mixture of ceruminous gland secretion, sebum, exfoliated keratinocytes, and dust. It is normally extruded laterally via epithelial migration and jaw movement. Mechanical disruption (cotton swabs, devices) or impaired migration (age, dermatologic disease) leads to accumulation, hardening, and impaction.
Clinical presentation
Symptoms
Gradual or sudden hearing loss (often after water exposure swells cerumen)
Sensation of ear fullness or pressure
Tinnitus
Itch, mild discomfort or pain
Reflex cough (Arnold nerve — auricular branch of CN X)
Dizziness (uncommon)
Signs / physical exam
Direct visualization of cerumen filling part or all of the EAC
Inability to visualize the tympanic membrane
Conductive hearing loss on bedside tuning fork tests if canal completely occluded
Differential diagnosis
Otitis externa — Pain on tragal pressure, erythematous canal, debris but not the firm yellow-brown plug of cerumen; topical otic drops
Foreign body — History or visualization of non-cerumen object; common in children
Keratosis obturans — Painful accumulation of desquamated keratin in canal, often bilateral; canal widening; may erode bone
Cholesteatoma — White debris in attic or retraction pocket, often with foul otorrhea; CT and ENT referral
Cerumen removal methods with indications and contraindications.
Treatment
First-line
Ceruminolytic agent — carbamide peroxide 6.5% drops, mineral oil, hydrogen peroxide 3%, or docusate sodium — 3-5 drops BID for 3-5 days
Irrigation with body-temperature water using a syringe or commercial irrigator — direct jet toward posterior canal wall (NOT directly at TM); contraindicated if TM perforation, tube, or h/o ear surgery
Manual removal with curette, hook, or suction under direct visualization — preferred for hard plugs or when irrigation contraindicated
Avoid cotton-tipped applicators and ear candles (no evidence of benefit; risk burns and TM injury)
Second-line / adjunct
ENT referral for: failed primary attempts, suspected TM perforation, prior ear surgery, anticoagulation with high bleeding risk, only-hearing ear, uncooperative patient (microscopy with suction)
Patient education to prevent recurrence: do not insert objects in ear; periodic ceruminolytic in high-risk patients
Complications
TM perforation (irrigation, instrumentation)
External canal abrasion or bleeding
Acute otitis externa following manipulation
Tinnitus or transient vertigo from cold/warm water (caloric stimulation)
Persistent hearing loss if undiagnosed underlying pathology (cholesteatoma, tumor)
PANCE pearls
Use body-temperature water for irrigation — cold or hot water induces caloric vertigo and nystagmus.
Never irrigate if TM perforation, tympanostomy tube, prior tympanoplasty, or h/o radical mastoidectomy is known or suspected.
Patients on anticoagulants are at higher risk of canal bleeding — prefer ceruminolytic and gentle technique.
After removal, ALWAYS visualize the TM — cerumen impaction can mask AOM, perforation, cholesteatoma, or canal tumor.
Routine ear 'cleaning' with cotton swabs causes most impactions — the ear is self-cleaning.
References
AAO-HNS 2017 — Schwartz SR et al. Clinical Practice Guideline (Update): Earwax (Cerumen Impaction). Otolaryngol Head Neck Surg 2017;156(1S):S1-S29
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