Earwax Management

Diagnosis and Symptoms

• Dizziness/vertigo is a symptom associated with cerumen impaction, and only 40% to 50% of patients with cerumen impaction and associated dizziness reported improvement after ear lavage, according to the American Academy of Otolaryngology-Head and Neck Surgery, in patients with cerumen impaction 1
• Impacted ear wax can cause pulsatile tinnitus, though it is not the most common cause of this specific type of tinnitus, as reported by the American Academy of Otolaryngology-Head and Neck Surgery 2
• Cerumen impaction can lead to significant hearing loss ranging from 5 to 40 dB depending on the degree of canal occlusion, and complete or partial occlusion of the ear canal can lead to various symptoms including sensation of fullness in the ear, tinnitus (including pulsatile forms), pain or discomfort, itching, odor, drainage, and cough, according to the American Academy of Otolaryngology-Head and Neck Surgery 2

Assessment and Evaluation

• A complete otoscopic examination is necessary to confirm cerumen impaction, and assessment of symptoms including timing of tinnitus onset, character of the tinnitus, and associated symptoms such as hearing loss and ear fullness is crucial, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 2
• The American Academy of Otolaryngology-Head and Neck Surgery recommends assessing for complete occlusion, as hearing acuity typically doesn't diminish until the cross-sectional area of the ear canal is reduced by at least 80%, in patients with cerumen impaction 1
• The American Academy of Otolaryngology-Head and Neck Surgery recommends assessing the character of the tinnitus, including whether it is rhythmic or pulsing with heartbeat, to determine the underlying cause 2

Treatment and Removal

• Cerumen removal can be performed through manual removal under direct visualization, with a success rate of approximately 90%, or irrigation, with a success rate of 68-92%, as reported by the American Academy of Otolaryngology-Head and Neck Surgery 2
• Manual removal by a healthcare provider using a curette, probe, hook, forceps, or suction has a success rate of approximately 90% 2
• Self-irrigation with a bulb syringe using warm water is effective in reducing symptoms and can be used as a first-line treatment for cerumen impaction, after applying a cerumenolytic agent (e.g., carbamide peroxide 6.5%), as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2
• The following table summarizes the types of cerumenolytic agents:

Special Considerations

• Patients with coagulopathies or on anticoagulant therapy require special care during removal to avoid bleeding, according to the American Academy of Otolaryngology-Head and Neck Surgery, in patients with cerumen impaction and coagulopathies or on anticoagulant therapy 2
• Immunocompromised patients may be at higher risk for post-procedure infections, as reported by the American Academy of Otolaryngology-Head and Neck Surgery, in immunocompromised patients with cerumen impaction 2
• Hearing aid users, individuals with narrow or tortuous ear canals, elderly patients, and children are at higher risk for cerumen impaction due to various factors such as overstimulation of cerumen production, impairment of natural self-cleaning mechanisms, and age-related changes in cerumen consistency and ear canal skin 2

Prevention and Complications

• Regular use of cerumenolytic agents can prevent recurrence of cerumen impaction, with a recurrence rate of 23% in patients using regular preventive treatment versus 61% in control groups, as reported by the American Academy of Otolaryngology-Head and Neck Surgery 2
• Preventive measures should be focused on individuals at highest risk for developing cerumen impaction, including elderly individuals, people with cognitive impairment, those with narrowed or anatomically deformed ear canals, individuals with certain dermatologic conditions, and hearing aid users, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 2
• The American Academy of Otolaryngology-Head and Neck Surgery advises against using cerumenolytics or irrigation in patients with ear pain, drainage, or bleeding, history of tympanic membrane perforation, previous ear surgery, or ear tubes, due to increased risk of complications 2
• Potential complications of cerumen removal include tympanic membrane perforation, ear canal laceration, infection, bleeding, worsening hearing loss, otitis externa, pain, dizziness, and syncope, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 2
• Excessive ear wax (cerumen) production is commonly caused by overstimulation of cerumen production from improper cleaning methods, hearing aid use, or anatomical factors that impair the ear's natural cleaning mechanisms, and the American Academy of Otolaryngology-Head and Neck Surgery recommends avoiding the use of cotton-tipped swabs 2