What is the recommended treatment for impacted earwax?

Management of Impacted Earwax

For impacted earwax, the recommended treatment is to use cerumenolytic agents (wax-softening drops) for 3-5 days, followed by irrigation if needed, with manual removal by a healthcare provider as a third option when other methods fail. 1

Diagnosis of Cerumen Impaction

Cerumen impaction should be diagnosed when:

• Accumulation of cerumen causes symptoms such as decreased hearing, fullness, tinnitus, or distortion of hearing aid function 1
• Cerumen prevents needed assessment of the ear 1
• Cerumen partially or completely occludes the ear canal, preventing proper audiologic testing 1

Treatment Options

First-Line: Cerumenolytic Agents

• Apply several drops of earwax-softening products once or twice daily for 3-5 days 1
• Options include:
  • Water-based agents: acetic acid, sodium bicarbonate, hydrogen peroxide, sterile saline 1
  • Oil-based agents: almond oil, olive oil, mineral oil 1
  • Non-water, non-oil-based: carbamide peroxide (urea-hydrogen peroxide) 1
• For adults and children over 12 years: tilt head sideways, place 5-10 drops into ear, keep drops in ear for several minutes 2, 3
• For children under 12 years: consult a doctor before using cerumenolytic agents 2, 3

Second-Line: Irrigation

• Indicated when cerumenolytic agents alone are insufficient 1
• Can be performed by healthcare provider or as self-irrigation at home with a bulb syringe 1
• Water should be at body temperature to avoid caloric effects 1
• Should not take more than 30 minutes including preparation time 1
• Any remaining wax after treatment with drops may be removed by gently flushing the ear with warm water using a soft rubber bulb ear syringe 2, 3

Third-Line: Manual Removal

• Performed by a clinician using curette, forceps, or suction 1
• Takes only a few minutes and doesn't require anesthesia 1
• Most appropriate when:
  • Other methods have failed 1
  • Patient has contraindications to irrigation 1
  • Immediate clearance is needed 1

Contraindications and Precautions

Contraindications to Irrigation

• History of tympanic membrane perforation 1, 4
• Presence of tympanostomy tubes 1, 4
• History of ear surgery 1, 4
• Active otitis externa (ear canal infection) 1, 4
• Susceptibility to ear infections 1, 4

Methods to Avoid

• Ear candling/coning should never be used as it is ineffective and potentially dangerous 1
• Cotton-tipped swabs should not be used as they can push wax deeper and potentially cause injury 1, 4
• Avoid probing ears with foreign objects (pens, paper clips, etc.) 1

Prevention of Recurrence

For patients with recurrent cerumen impaction, preventive measures include:

• Topical earwax-softening agents used periodically 1
• Self-irrigation with bulb syringe (shown to reduce recurrence rates from 61% to 23% over 12 months) 1
• Regular checking of the ear canal for cerumen in hearing aid users 1

Potential Complications

• Most complications are minor and include discomfort, irritation, or pain 5
• Rare but more serious complications include tympanic membrane perforation (approximately 0.2% of irrigation cases) 4
• Temporary dizziness may occur, particularly if water temperature differs significantly from body temperature 1

Special Considerations for Children

• No age restrictions for irrigation, though small children may be noncooperative 6, 4
• Cerumenolytic agents are not recommended for children under 3 years 1, 4
• Referral to a specialist is recommended if multiple attempts at removal are unsuccessful 6