Praxis Medical Insights

Initial Assessment and Diagnosis

The American Academy of Otolaryngology-Head and Neck Surgery recommends performing an otoscopic examination to confirm cerumen impaction, and if cerumen is visualized and causing symptoms, treating it; if vertigo persists after successful cerumen removal, the vertigo is not cerumen-related and requires evaluation for other causes 1, 2
Cerumen impaction is diagnosed when cerumen accumulation causes symptoms, such as hearing loss, fullness, tinnitus, or dizziness, or prevents adequate examination of the ear canal/tympanic membrane 1, 3, 4

The American Academy of Otolaryngology-Head and Neck Surgery suggests using water-based cerumenolytics as first-line therapy for confirmed cerumen impaction 4
Carbamide peroxide 6.5% or hydrogen peroxide can be used as cerumenolytic agents, with application for 3-5 days before attempting irrigation 4, 5
Irrigation with body-temperature water can be used as second-line therapy if cerumenolytic alone fails, with success rates ranging from 68-92% 1, 4, 6
Manual removal with curette, forceps, or suction under direct visualization can be used as third-line therapy if irrigation fails or is contraindicated, with success rates approaching 90% 3, 6

After cerumen removal, it is essential to perform two assessments: re-examine the ear canal otoscopically to confirm complete cerumen removal, and ask the patient if vertigo symptoms have resolved 6, 2

Elderly patients have higher rates of cerumen impaction, with a prevalence of 19-65%, and cerumen impaction in elderly is associated with hearing loss and diminished cognitive function 3
Vertigo is rarely the sole symptom of cerumen impaction, and alternative vestibular disorders, such as benign paroxysmal positional vertigo (BPPV), vestibular neuronitis, or Ménière's disease, should be considered 6

Referral to ENT is recommended if multiple treatment attempts are unsuccessful, severe pain or vertigo develops during irrigation, or if the patient lacks equipment/training for manual removal, or if hearing loss persists after cerumen removal, or if vertigo persists after confirmed cerumen clearance 6, 4