Cerumen Impaction Management

Diagnosis and Symptoms

• Cerumen impaction is diagnosed when an accumulation of cerumen is associated with symptoms, prevents needed assessment of the ear, or both conditions are present, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1
• Symptoms of impaction may include hearing loss, feeling of fullness in the ear, itching, pain, tinnitus, odor or drainage, and cough, affecting various populations, including children and patients with hearing aids 1

Recommendations for Manual Removal

• The American Academy of Otolaryngology-Head and Neck Surgery recommends manual removal under direct visualization by a trained clinician for persistent impaction, which requires appropriate instrumentation, special skills and training, and child cooperation, particularly challenging in pediatric populations 2
• Manual removal should be performed by clinicians experienced in ear care, and oral jet irrigators should not be used for home treatment 2
• Manual removal should be performed under direct visualization with appropriate instrumentation (curette, forceps, or suction), and gentle techniques, such as removing cerumen in small pieces, are essential 1, 2

Treatment Options

• The American Academy of Otolaryngology-Head and Neck Surgery recommends a three-step process for managing impacted ear wax: using cerumenolytic agents to soften the wax, followed by irrigation if needed, and manual removal by a clinician for persistent cases or when irrigation is contraindicated 1
• Water-based cerumenolytic agents (e.g., hydrogen peroxide, sodium bicarbonate solution) are recommended as first-line treatments for softening and disintegrating impacted earwax, with success rates ranging from 5-22% 1
• Irrigation with body temperature water or saline using a soft rubber bulb ear syringe has success rates of 68-92% as a second-line treatment, and is recommended after cerumenolytic application 1

Contraindications and Precautions

• Irrigation is contraindicated when the tympanic membrane is not intact, the patient has a history of ear surgery, or the patient has ear canal stenosis/exostoses, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 1
• Avoid using cotton-tipped swabs for cerumen removal, as they can push wax deeper into the canal, cause trauma to the ear canal, and lead to complications, including infection 1
• Ear candling is not recommended for treating or preventing cerumen impaction, due to the risk of complications and lack of efficacy 1

Special Populations

• Elderly and cognitively impaired individuals have a higher prevalence of cerumen impaction (19-65% in those >65 years) and may not be able to express symptoms, requiring prompt evaluation and regular ear examinations every 3-6 months 1, 2
• Hearing aid users should have regular otoscopy to detect cerumen, and monthly application of carbamide peroxide drops followed by gentle irrigation may be beneficial for prevention in those prone to impaction 3, 1

Complications and Referral

• Potential complications of cerumen impaction treatment include infection, bleeding, dizziness, pain, and tympanic membrane perforation, emphasizing the need for careful removal techniques and patient education 1
• Refer patients to an otolaryngologist when initial management is unsuccessful, symptoms persist despite resolution of impaction, or there is suspicion of underlying ear pathology, such as hyperacusis or acute otitis externa (AOE) 1, 4
• Diagnosis of AOE after cerumen removal is based on tenderness of the tragus, pinna, or both, ear canal erythema and edema, possible otorrhea, and pain that may be intensified by jaw motion, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 4
• Topical antimicrobial therapy with fluoroquinolones (such as ciprofloxacin 0.2% or ofloxacin 0.3%) should be administered twice daily for 7 days as first-line treatment for AOE, with consideration of the following common pathogens:

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Prevention

• Regular ear examinations every 3-6 months and patient education on avoiding cotton swabs or other objects in the ear canal can help prevent future impactions, with emphasis on proper ear hygiene and the use of topical emollients to reduce recurrence rates 2, 1, 3
• The use of topical emollients has been shown to reduce the recurrence of cerumen impaction, with weekly use resulting in a reduced recurrence rate of 23% vs 61% in the control group 2, 1, 3