What is the recommended treatment for cerumen (earwax) buildup?

Management of Cerumen (Earwax) Buildup

The recommended first-line treatment for cerumen impaction is the use of water-based cerumenolytic agents (such as hydrogen peroxide or sodium bicarbonate solution) followed by gentle irrigation with body temperature water using a soft rubber bulb syringe if needed. 1

Treatment Algorithm

Step 1: Assessment and Identification

• Determine if cerumen removal is necessary:
  • Presence of symptoms (hearing loss, itching, pain, tinnitus)
  • Inability to examine ear canal or tympanic membrane
  • Behavioral changes in nonverbal patients or those with dementia 2

Step 2: First-Line Treatment

• Water-based cerumenolytic agents:
  • Hydrogen peroxide (5-10 drops)
  • Sodium bicarbonate solution
  • Success rates range from 5-22% 1
  • Administration:
    • Tilt head sideways
    • Place 5-10 drops into ear
    • Keep drops in ear for several minutes
    • Use twice daily for up to 4 days 3, 4

Step 3: Second-Line Treatment (if needed)

• Irrigation:
  • Use body temperature water or saline
  • Use soft rubber bulb ear syringe
  • Success rates of 68-92% 1
  • Any wax remaining after cerumenolytic treatment may be removed by gently flushing the ear 3, 4

Step 4: Manual Removal (if needed)

• If irrigation and cerumenolytics fail
• Requires specialized tools and training
• Consider referral to otolaryngologist if multiple attempts are unsuccessful 5

Important Contraindications and Precautions

• Do not use cerumenolytics if:

  • Ear pain is present
  • Ear discharge is present
  • Tympanic membrane perforation
  • History of ear surgery
  • Presence of ear tubes 1

• Do not irrigate if:

  • Perforated tympanic membrane
  • History of ear surgery
  • Active ear infection
  • Ear canal trauma 1

• Special considerations:

  • Children under 12: consult a doctor 3, 4
  • Patients on anticoagulants: increased risk of bleeding 2

What to Avoid

• Cotton-tipped swabs: Can push wax deeper and cause trauma 6, 1
• Ear candling: No validated scientific evidence of efficacy and potentially harmful 6, 1
• Probing with foreign objects (pens, paper clips): Can worsen impaction or cause injury 1
• Alcohol-based solutions: Potential ototoxicity 1

Prevention Strategies

• Monthly application of carbamide peroxide drops followed by gentle irrigation for those prone to impaction 1
• For hearing aid users:
  • Regular ear canal checks every 3-6 months
  • Regular cleaning of hearing aids
  • Replacement of wax traps every 3 months 1
• Weekly use of a topical emollient has shown reduced recurrence of impaction (23% vs 61% in control group) 6, 1

When to Refer to a Specialist

• Failed attempts at cerumen removal
• Complications occur during removal
• Patient cannot tolerate the procedure
• Symptoms persist despite adequate wax removal 1
• Persistent symptoms despite resolution of impaction 2

The American Academy of Otolaryngology-Head and Neck Surgery guidelines emphasize that cerumen is a normal protective substance, but removal is indicated when it causes symptoms or prevents proper examination of the ear 6, 1. The evidence suggests that water-based cerumenolytics followed by irrigation are effective first-line treatments with minimal adverse effects 7.