Cerumen impaction

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Cerumen impaction is a buildup of cerumen in the external auditory canal (EAC) that is symptomatic and/or prevents clinical evaluation of the auditory canal, tympanic membrane (TM), or the audiovestibular system. While anyone can develop cerumen impaction, risk factors include anatomical ear abnormalities, regular insertion of objects into the ear canal (including hearing aids), dermatological conditions (e.g., eczema, seborrheic dermatosis), and susceptible populations (i.e., young children, individuals with cognitive impairment, and older adults). Symptoms include localized ear discomfort, audiovestibular symptoms, and, in some individuals, nonspecific symptoms such as speech delay and behavioral changes. Cerumen removal is indicated for all individuals with cerumen impaction. Treatment options include manual cerumen removal, EAC irrigation, and cerumenolytics; all options are equally effective and may be used alone or in combination. Individuals should be assessed for risk factors for cerumen removal complications, with management tailored accordingly. Prevention involves patient education on ear hygiene; in individuals with recurrent cerumen impaction, cerumen removal regimens may be considered.

The migration of cerumen from the tympanic membrane toward and out of the entrance of the external auditory canal (EAC) is impaired. ^[2][3]

• Anatomical abnormalities of the external auditory canal (e.g., ear canal stenosis)
• Regular use of foreign objects in the ear canal, e.g. :
  • Hearing aids
  • Earbud headphones ^[5]
  • Cotton-tipped swabs or bobby pins for cleaning or scratching
• Certain dermatological conditions (e.g., eczema, seborrheic dermatosis)
• Individuals who are unable to recognize or effectively communicate symptoms of cerumen impaction, such as:
  • Older adults, especially those living in long-term care facilities ^[2][4]
  • Young children ^[2][4]
  • Individuals with cognitive impairment ^[2][4]

• Localized symptoms
  • Ear discomfort: feeling of fullness, itching, pain
  • Otorrhea
  • Odor
• Hearing loss: conductive hearing loss, decreased hearing aid performance ^[2]
• Nonspecific symptoms (more common in patients who are unable to communicate)
  • Speech delay
  • Behavioral changes
  • Cognitive decline ^[2]
• Cough ^[6]
• Vestibular symptoms (uncommon): tinnitus, vertigo
• Findings on otoscopy: tightly packed cerumen in the outer ear canal that partially or completely obstructs visualization of the auditory canal and/or TM.

Cerumen impaction should be considered in individuals presenting with hearing loss and/or cognitive decline. ^[2]

• Cerumen impaction is a clinical diagnosis based on the presence of tightly packed cerumen in the EAC on otoscopy and ≥ 1 of the following: ^[2][3][4]
  • Associated symptoms
  • Need for cerumen removal to assess the auditory canal, TM, and/or the audiovestibular system

Other conditions that could occlude the external auditory canal and/or cause hearing loss or otalgia include: ^[2]

• Foreign body in the ear
• Ear barotrauma
• Acute otitis media, otitis externa
• Serous otitis media
• Cholesteatoma

The differential diagnoses listed here are not exhaustive.

General principles ^[2][3][4]

• Indications for referral to Otolaryngology for management:
  • Need for sedation
  • Risk factors for cerumen removal complications
  • Unsuccessful attempts at cerumen removal
• Cerumen removal methods: Any of the following may be used alone or in combination unless there are contraindications for specific cerumen removal methods.
  • Ear canal irrigation (at home or in-office)
  • Cerumenolytics (at home or in-office)
  • Manual cerumen removal (office use only)
• Tailor initial management based on:
  • Risk factors for cerumen removal complications
  • Available resources and provider experience
  • Patient preference
• Ear candling, olive oil drops, cotton-tipped swabs, and at-home use of jet irrigators are not recommended for cerumen removal.

Cerumen removal is not indicated for asymptomatic cerumen accumulation that does not prevent assessment of the EAC, TM, or audiovestibular apparatus. Prophylactic removal of nonimpacted cerumen may be considered in individuals who have difficulty expressing or describing symptoms. ^[2][3]

Cerumenolytic agents and EAC irrigation are contraindicated in individuals who may have a nonintact TM.

Risk factors for cerumen removal complications ^[2][4]

In individuals with these conditions, select the most appropriate method of cerumen removal and/or refer the patient to otolaryngology.

• Nonintact TM
• Anatomical abnormalities of the EAC, e.g.:
  • Bony exostosis
  • Ear canal stenosis
• Increased risk of bleeding, e.g.:
  • Bleeding disorders
  • Hepatic failure
  • Anticoagulant use
• Increased risk of infection, e.g.:
  • Diabetes mellitus
  • Immunocompromised status
  • Current ear infection
• History of head and neck radiation

Cerumenolytic agents ^[2][4]

Can be used alone or in combination with EAC irrigation or manual removal of cerumen.

Method

• Instill 1–3 mL (i.e., 20–60 drops) into the affected ear canal to soften and/or dissolve cerumen.
• In-office: Place in the EAC ∼ 15 minutes prior to otic lavage and/or manual removal.
• At home: Instill several drops once or twice a day for at least 3–15 days and then return for reexamination. ^[2]

Contraindications ^[2]

• Children < 3 years of age
• Possibility of a nonintact TM
• Current otitis externa
• Allergy to any ingredient in the cerumenolytic agent

Agents

All cerumenolytic agents (including water) are equally effective. ^[2][4]

• Saline or water ^[4]
• Docusate sodium (off-label)
• 3% hydrogen peroxide (off-label)
• 10% sodium bicarbonate (off-label)
• 2.5% acetic acid (off-label)

Possible complications ^[2]

• Contact dermatitis (see “Irritant vs. allergic contact dermatitis”)
• Otitis externa
• Dizziness
• Temporary hearing loss

Ear canal irrigation ^[2][4]

• Can be performed in the office by a health care provider or at home by the patient or caregiver
• Consider using a cerumenolytic agent 15 minutes before irrigation. ^[7]

Avoid jet irrigators for at-home irrigation as they could potentially damage the TM. ^[2][4]

Method

Water or saline that is close to body temperature is used to flush cerumen out of the EAC using a syringe (manual irrigation) or an electronic irrigator.

• Straighten the EAC by gently pulling the external ear in an upward and backward direction.
• An assistant holds a receptacle (e.g., a kidney tray) under the patient's ear to catch the irrigant.
• Gently instill the irrigant in the EAC, directing the fluid stream toward the wall of the EAC rather than toward the TM; limit irrigation to < 30 minutes.
• Perform an otoscopy to ensure cerumen clearance and assess for complications.
• After irrigation, consider instilling hydrogen peroxide or acetic acid in the EAC to reduce the risk of infection (e.g., in individuals with diabetes). ^[2][3][4]

Avoid using cold or warm irrigation fluids, as this may trigger caloric nystagmus and vertigo. ^[2]

In individuals with diabetes, avoid using tap water for irrigation as it may increase the risk of malignant otitis externa. ^[2]

Contraindications

• Possibility of a nonintact TM
• Prior ear surgery that may have weakened the TM
• Current otitis externa or ear canal dermatitis
• Increased risk of infection
• Unilateral deafness
• Anatomical abnormalities of the ear canal

If an intact tympanic membrane cannot be verified, do not irrigate the ear canal. ^[2]

Potential complications

• TM ruptured (rare)
• Vertigo
• Ear canal injury
• Otalgia
• Otitis externa

Manual cerumen removal ^[2][4]

Should be performed in the office performed by a trained health care provider

Method

• Consider using a cerumenolytic agent 15 minutes before manual removal.
• An instrument (e.g., curette, forceps, angulated suction tip) is inserted into the ear canal to physically remove cerumen. ^[8]
• Use an external light source to directly visualize the ear canal and cerumen during removal. ^[2]

Contraindications

• Increased risk of bleeding (e.g., in patients using anticoagulants or with bleeding disorders)
• Prior head or neck radiation
• Anatomical abnormalities of the ear canal

Potential complications

• Pain
• Bleeding
• Ear canal injury

Reassessment and further management ^[2][4]

• After each attempt at cerumen removal:
  • Perform an otoscopic examination to ensure successful cerumen removal and assess the EAC and TM for any procedure-related complications.
  • Reassess symptoms.
• Further management
  • Unsuccessful removal: Consider other cerumen removal methods and/or refer to otolaryngology.
  • Successful cerumen removal with persistent symptoms: Consider alternative diagnoses.
  • Successful cerumen removal with complete symptom resolution: Discuss cerumen impaction prevention strategies with the patient.

Prevention of recurrence ^[2][4]

Recurrent cerumen impaction may be prevented with any of the following measures: ^[2]

• Scheduled examination and cleaning of the EAC by a health care professional; especially in individuals with hearing aids
• Consider the following in individuals with risk factors for cerumen impaction:
  • Prophylactic use of over-the-counter (e.g., 6.5% carbamide peroxide ) or prescribed cerumenolytic agents ^[4]
  • Self-irrigation: e.g., once weekly with or without alcohol or hydrogen peroxide drops

Advise against ear candling, olive oil drops, cotton-tipped swabs, and home use of jet irrigators as they are ineffective and can increase the risk of injury. ^[2]

• Reassure individuals that cerumen production and removal is a normal physiological process.
• Routine cleaning of the EAC is unnecessary; scheduled cleaning may be considered in individuals with risk factors for cerumen impaction.
• Instruct all individuals to:
  • Avoid placing foreign objects, including cotton swabs, inside the ear canal.
  • Avoid at-home cerumenolytic drops and ear irrigation if there is a possibility of a nonintact TM.
  • Clean the outer ear if cerumen is visible but avoid aggressively cleaning the auditory canal.
  • Contact a health care professional if severe symptoms occur (e.g., bleeding, hearing loss).
• For early identification of cerumen accumulation in individuals using hearing aids, recommend:
  • Regular ear examinations every 3 or 6 months
  • An office evaluation if hearing aid performance decreases