Cerumen Impaction

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 at a time 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 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 for infection because the ear canal is not exposed to moisture. It does, however, pose a small risk of perforation and local trauma, especially if the patient is uncooperative. This method also requires more clinical skill, and greater cooperation by 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]

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]

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, and 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]

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, removal of 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 treatement in the office.[11]