Continuing Education Activity

Production of cerumen (earwax) is a normal and naturally occurring process. It protects the ear from infection and provides a barrier to insects and water. Cerumen is typically expelled from the ear canal spontaneously via natural jaw movement. However, in certain individuals, this self-cleaning mechanism fails, and cerumen can become impacted. This activity describes the pathophysiology of cerumen impaction, reviews the technique involved in cerumen removal, and highlights the interprofessional team's role in managing affected patients.

Objectives:

• Describe the pathophysiology of cerumen impaction.
• Summarize the technique involved in cerumen removal.
• Outline the complications associated with the removal of cerumen.
• Explain the role of the interprofessional team in improving outcomes for patients with cerumen impaction.

Introduction

Production of cerumen (earwax) is a normal process in humans and many other mammals. Cerumen moisturizes the skin of the external auditory canal and protects it from infection, providing a barrier for insects and water. Cerumen is typically expelled from the ear canal spontaneously through natural jaw movement. However, in certain individuals, the self-cleaning mechanism fails, and cerumen can become impacted.[1][2] Cerumen impaction can occlude the canal or press against the tympanic membrane, potentially causing ear discomfort, conductive hearing loss, itching. Cerumen impaction occurs in up to 6% of the general population, affecting 10% of children and greater than 30% of the elderly and cognitively impaired. It is often seen in patients who routinely wear hearing aids or earplugs or patients with exostoses or anatomic abnormalities of the external ear canal.[1]

Excessive buildup of cerumen is likely underdiagnosed and undertreated.  In the United States, it leads to 12 million patient visits and eight million cerumen removal procedures each year.  It can interfere with tympanic membrane examination as well as audiometry and hearing aid fitting. It is diagnosed by direct visualization by a trained provider using an otoscope.[1][3]

Anatomy and Physiology

Cerumen is made up of shed skin cells and secretions from both the sebaceous and ceruminous glands of the lateral third of the external auditory canal.[1]

Indications

Although the excessive accumulation of cerumen is typically asymptomatic, patients should be treated if they present with hearing loss, ear fullness, pruritus, dizziness, tinnitus, or otalgia. The inability to examine an ear due to cerumen impaction is another indication for cerumen removal.

When discovered in the asymptomatic patient, it is not always necessary to treat. It is important to relate to patients that cerumen does not always need to be removed, as cerumen naturally has bacteriocidal, protective, and emollient properties. Observation should be offered as a management strategy if appropriate.

In young children, the elderly, or cognitively impaired individuals, treatment is a reasonable option as they may not be able to verbalize symptoms or are unaware of them, significantly worsening their quality of life.[1][4][5]

Contraindications

There are no absolute contraindications to cerumen removal. Physicians should exercise caution in patients with certain immunosuppressive illnesses (HIV, diabetes mellitus), chronic anticoagulation, or anatomical defects narrowing the canal as they may be prone to complications from manual removal. In patients with diabetes mellitus, a higher pH is typically present in the cerumen, making superimposed bacterial infections potentially common. Immunosuppressed patients (diabetes mellitus, HIV, other malignancy) are at higher risk of infection after even minor trauma, so meticulous atraumatic technique should be used in removal. Additionally, this population is at higher risk for malignant otitis externa, which can mimic cerumen impaction or aural polyp to the inexperienced examiner. Caution should be exercised in chronically anticoagulated patients as they are at a higher risk for hemorrhage or hematomas. Irrigation should not be utilized as a method for cerumen removal unless the tympanic membrane can be visualized first to rule out perforation.[6][7]

Use of cerumenolytics (see below) is safe, but contraindications include a perforated tympanic membrane or a history of ear surgery, including tympanostomy tube placement. Common reactions include local irritation and a rash. With prolonged use, a superinfection may occur.[8]

Technique

When treatment is appropriate, there are three recommended removal methods: cerumenolytic agents, irrigation, and manual removal.[8]

Cerumenolytic agents are liquid solutions that help thin, soften, break up, and/or dissolve ear wax. These are typically water- or oil-based compounds, with water-based solutions being the most commonly used. Typical ingredients found in water-based cerumenolytics include hydrogen peroxide, acetic acid, docusate sodium, and sodium bicarbonate. Common ingredients in oil-based cerumenolytics include peanut, olive, and almond oil.  Most drops are available over the counter. Typically, up to five drops are used per dose one to two times daily for three to seven days.

A commonly prescribed cerumenolytic is carbamide peroxide. Five to 10 drops are placed twice daily for up to four days. The drops work by releasing oxygen to soften and encourage spontaneous extrusion of cerumen and also have a weak antibacterial effect.

Irrigation is another method to safely and effectively remove unwanted cerumen, provided the tympanic membrane can be visualized first. Several irrigation methods may be used in the clinical setting. Commonly, warm water alone or a 50/50 mix of water and hydrogen peroxide is inserted into a syringe and discharged into the ear canal with a basin underneath. Another option is a standard oral jet irrigator, with or without a modified tip. Although these methods are inexpensive and generally safe, they can be potential causes of trauma, including perforation of the tympanic membrane. There are electronic irrigators available as well; however, there are no controlled trials to compare the different irrigation methods.

Manual removal is the final method recommended by the American Academy of Otolaryngology-Head and Neck Surgery for the removal of unwanted cerumen. Manual removal often requires specialized instrumentation for better visualization, such as a binocular microscope and a handheld speculum. The removal device involves a metal or plastic loop or spoon, curette, or alligator forceps. Some products have illuminated tips to help visualize during the procedure.  The advantages of this method are a decreased risk of infection because the ear canal is not exposed to moisture. However, it does pose a small risk of perforation and local trauma, especially if the patient is uncooperative. This method also requires more clinical skills and greater cooperation from the patient.

To prevent further accumulation of cerumen in patients with recurrent symptoms greater than one per year, patients may apply mineral oil to the external canal 10 to 20 minutes weekly. Patients with hearing aids should remove them for eight hours a day to reduce cerumen buildup.[9][10]

Complications

There are other over-the-counter devices to remove cerumen that physicians do not recommend. Cotton swabs are commonly used but should be avoided, as they may worsen the impaction or cause a perforation of the tympanic membrane. Another common home remedy is ear candling. This involves a hollow tube coated in beeswax. One end is inserted into the ear canal, and the other is ignited. It is falsely claimed to have a "chimney effect," created by the pull of air from the ignited candle. This procedure is strongly recommended against by the United States Food and Drug Administration as it is ineffective and has the potential for injury.[3][9]

Clinical Significance

It is important to ensure other diagnoses are not falsely-attributed to the cerumen in patients being treated for cerumen impaction. The list of common presenting complaints is long and includes symptoms with many different causes such as otalgia, tinnitus, dizziness, hearing loss, aural fullness, ear itching, or foreign-body sensation. Once cerumen is removed, it is important to rule out diagnoses such as otitis media, otosclerosis, sensorineural hearing loss, temporomandibular joint syndrome, and upper respiratory tract infections, or other causes via further examination and testing if symptoms persist.[1]

Enhancing Healthcare Team Outcomes

Cerumen impaction is rarely challenging to treat but requires a coherent and cooperative patient to be successful. If the patient is unwilling or unable to participate and cooperate in treatment, removing impacted cerumen and otologic examination can be performed under anesthesia. This is typically only necessary in the very young or in those patients whose neurocognitive and neurobehavioral status prevents safe treatment in the office.[11]