Management of Impacted Ear Wax
The most effective approach to managing impacted ear wax involves a three-step process: using cerumenolytic agents to soften the wax, followed by irrigation if needed, and manual removal by a clinician for persistent cases or when irrigation is contraindicated. 1
Diagnosis of Cerumen Impaction
Cerumen impaction should be diagnosed when:
- An accumulation of cerumen is associated with symptoms (pain, fullness, hearing loss, tinnitus, etc.)
- The cerumen prevents needed assessment of the ear
- Or both of the above conditions are present 1
Symptoms of impaction may include:
- Hearing loss (ranging from 5-40 dB depending on occlusion)
- Feeling of fullness in the ear
- Itching
- Pain
- Tinnitus
- Odor or drainage
- Cough 1, 2
Treatment Options
1. Cerumenolytic Agents
First-line treatment for softening and disintegrating impacted earwax 3
Options include:
Administration technique:
2. Irrigation
- Second-line treatment after cerumenolytic application 3
- Success rates range from 68-92% 3
- Use body temperature water or saline with a soft rubber bulb ear syringe 1, 3
- Any wax remaining after cerumenolytic treatment may be removed by gently flushing the ear with warm water 4, 5
3. Manual Removal
- Indicated when:
- Irrigation and cerumenolytics are ineffective
- Patient has contraindications to irrigation (non-intact tympanic membrane, history of ear surgery)
- Visualization is required for diagnosis 1
- Should be performed under direct visualization with appropriate instrumentation (curette, forceps, or suction) 1, 3
- Safest first-line approach for patients with complex medical history 3
Assessment for Modifying Factors
Before treatment, assess for factors that may modify management:
- Anticoagulant therapy
- Immunocompromised state
- Diabetes mellitus
- Prior radiation therapy to head and neck
- Ear canal stenosis or exostoses
- Non-intact tympanic membrane 1, 3
Contraindications
Do not use irrigation when:
Avoid cotton-tipped swabs for cerumen removal:
- Can push wax deeper into the canal
- May cause trauma to the ear canal
- Cotton tips may separate, requiring removal as a foreign body
- Can lead to complications including infection 1
Ear candling is not recommended for treating or preventing cerumen impaction 1
Complications of Treatment
Potential complications include:
- Tympanic membrane perforation (up to 1% of cases with syringing) 7
- Ear canal laceration
- Infection
- Bleeding
- Dizziness
- Pain 1, 7
Prevention of Recurrence
For patients prone to cerumen impaction:
- Regular ear examinations every 3-6 months 3
- Patient education on avoiding insertion of objects into the ear canal 1, 3
- Monthly application of carbamide peroxide drops followed by gentle irrigation may be beneficial 3
- Weekly use of topical emollients has been shown to reduce recurrence rates (23% vs 61% in control group) 3
When to Refer
Refer patients to an otolaryngologist when:
- Initial management is unsuccessful
- Symptoms persist despite resolution of impaction
- There is suspicion of underlying ear pathology
- Patient has complex factors requiring specialized equipment and training 1, 3
Special Populations
- Children under 12 years: Consult a doctor before using cerumenolytic agents 4, 5
- Elderly and cognitively impaired: Higher prevalence of cerumen impaction (19-65% in those >65 years); may not be able to express symptoms; require prompt evaluation 1
- Hearing aid users: Should have regular otoscopy to detect cerumen 1, 3
By following this evidence-based approach to managing impacted ear wax, clinicians can effectively address this common condition while minimizing complications and preventing recurrence.