What is the treatment for impacted cerumen (earwax)?

From the Guidelines

Treatment for impacted cerumen (earwax) should begin with cerumenolytic agents to soften the wax, followed by irrigation or manual removal, as this approach has been shown to be effective in improving symptoms and hearing loss 1. The most recent and highest quality study, a clinical practice guideline update from 2017, supports the use of topical therapy, including cerumenolytic agents, as a first-line treatment for impacted cerumen 1. Key points to consider when treating impacted cerumen include:

• Using over-the-counter cerumenolytic agents, such as mineral oil, baby oil, glycerin, or commercial drops like Debrox or Murine Ear Drops, applied 2-3 times daily for 3-5 days
• Irrigating the ear canal with body-temperature water using a bulb syringe, while pulling the ear upward and backward (for adults) or downward and backward (for children)
• Manual removal by a healthcare provider using specialized tools like a curette or suction for difficult cases
• Avoiding the use of cotton swabs, which can push wax deeper, and ear candling, which is ineffective and potentially dangerous
• Preventing future impactions by limiting ear cleaning to the outer ear only, as the ear canal naturally cleans itself through jaw movements that gradually move wax outward. It is also important to note that patients with ear tubes, perforated eardrums, or diabetes should avoid self-irrigation and seek professional care 1. Additionally, a study from 2008 found that removal of impacted cerumen can improve hearing, and that cerumen impaction is a frequent reversible cause of hearing loss 1. Overall, the goal of treatment is to relieve symptoms, improve hearing, and prevent future impactions, while minimizing the risk of complications.

From the FDA Drug Label

Directions FOR USE IN THE EAR ONLY adults and children over 12 years of age: • tilt head sideways • place 5 to 10 drops into ear • tip of applicator should not enter ear canal • keep drops in ear for several minutes by keeping head tilted or placing cotton in the ear • use twice daily for up to four days if needed, or as directed by a doctor • any wax remaining after treatment may be removed by gently flushing the ear with warm water, using a soft rubber bulb ear syringe Directions FOR USE IN THE EAR ONLY. Adults and children over 12 years of age: Tilt head sideways and place 5 to 10 drops into ear Tip of applicator should not enter ear canal Keep drops in ear for several minutes by keeping head tilted or placing cotton in the ear Use twice daily for up to 4 days if needed, or as directed by a doctor Any wax remaining after treatment may be removed by gently flusing the ear with warm water, using a soft rubber bulb ear syringe The treatment for impacted cerumen (earwax) is to:

• Place 5 to 10 drops of the otic solution (such as carbamide peroxide or hydrogen peroxide) into the ear
• Keep the drops in the ear for several minutes by keeping the head tilted or placing cotton in the ear
• Use the solution twice daily for up to 4 days if needed, or as directed by a doctor 2, 3
• Remove any remaining wax by gently flushing the ear with warm water, using a soft rubber bulb ear syringe Key considerations:
• The treatment is for adults and children over 12 years of age
• Children under 12 years should consult a doctor 2, 3

From the Research

Treatment Options for Impacted Cerumen

The treatment options for impacted cerumen (earwax) include:

• Watchful waiting 4
• Manual removal 4, 5, 6, 7
• The use of ceruminolytic agents 4, 5, 6, 7, 8
• Irrigation with or without ceruminolytic pretreatment 4, 5, 6, 7

Ceruminolytic Agents

Ceruminolytic agents are used to soften the earwax, making it easier to remove. The types of ceruminolytic agents include:

• Oil-based compounds (e.g. olive or almond oil) 8
• Water-based compounds (e.g. sodium bicarbonate or water itself) 8
• Non-water, non-oil-based solutions (e.g. carbamide peroxide) 8

Irrigation

Irrigation can be used to remove the earwax, and can be done with or without ceruminolytic pretreatment. Home irrigation with a bulb syringe may be appropriate for selected adults 5.

Referral to an Otolaryngologist

Referral to an otolaryngologist is indicated if:

• Treatment with a ceruminolytic agent followed by irrigation is ineffective 4, 5
• Manual removal is not possible 4, 5
• The patient develops severe pain or has vertigo during irrigation 4
• Hearing loss is still present after cerumen has been removed 4
• The patient has a hard, spherical, or cylindrical object in the ear canal 6

Avoided Practices

The following practices should be avoided:

• Using cotton swabs or ear candles 4, 5, 6
• Using cotton-tipped swabs in the external auditory canal 6