What is the management of impacted cerumen?

Management of Impacted Cerumen

Impacted cerumen should be treated with cerumenolytic agents, irrigation, or manual removal when it causes symptoms (hearing loss, pain, fullness, tinnitus, itching) or prevents necessary examination of the ear canal or tympanic membrane. 1

Definition and When to Treat

• Cerumen impaction is defined as an accumulation of cerumen that causes symptoms OR prevents assessment of the ear, even if the canal is not completely obstructed. 1
• Do NOT routinely treat asymptomatic cerumen when the ear can be adequately examined. 1
• Special populations who cannot express symptoms (young children, cognitively impaired patients) require prompt evaluation and intervention even without verbal complaints. 1
• Hearing aid users should be examined for cerumen during healthcare encounters, as impaction is common in this population. 1

Pre-Treatment Assessment

Before attempting removal, assess for modifying factors that change your approach: 1

• Tympanic membrane perforation or tympanostomy tubes (contraindication to irrigation) 1, 2
• Prior ear surgery (contraindication to irrigation) 2
• Diabetes mellitus (higher risk of malignant otitis externa with irrigation) 1, 2
• Immunocompromised state (increased infection risk) 1
• Anticoagulant therapy or bleeding disorders (increased bleeding risk with manual removal) 1, 3
• Ear canal stenosis or exostoses (may require specialist referral) 1

Treatment Options (All Are Acceptable First-Line Approaches)

Option 1: Cerumenolytic Agents

• May use water, saline, or commercial cerumenolytic agents (carbamide peroxide, hydrogen peroxide, oil-based, or non-water/non-oil agents). 1, 4
• No agent is superior to others—saline or water is as effective as commercial preparations. 4
• For adults and children >12 years: Apply 5-10 drops twice daily for up to 4 days, keeping head tilted or placing cotton in ear for several minutes. 5, 6
• Children <12 years: Consult a physician before use. 5, 6
• Cerumenolytics should not be used in children <3 years. 7

Option 2: Irrigation

• Technique: Use body-temperature water directed at the ear canal wall, NOT directly at the tympanic membrane. 2, 4
• Pre-treatment with cerumenolytics for 3-5 days may improve success rates (68-92% effective). 1, 2, 4
• Success rates: 68-92% for irrigation alone, but lacks direct visualization during removal. 1

Absolute contraindications to irrigation: 2, 4

• Tympanic membrane perforation or tympanostomy tubes
• Previous ear surgery
• Active ear infection
• Narrow or stenotic ear canals
• Diabetes (use extreme caution due to malignant otitis externa risk)

Complications (occur in 38% but usually self-limiting): Pain, ear canal injury, otitis externa, tinnitus, vertigo, tympanic membrane perforation (0.2% of cases). 2

Option 3: Manual Removal with Instrumentation

• Technique: Use curette, probe, hook, forceps, or suction under direct visualization (headlight, otoscope, or microscope). 1
• Success rates: ~90% with binocular microscope visualization; lower with handheld otoscope. 1
• Preferred when irrigation is contraindicated or in patients with modifying risk factors. 1

Post-Treatment Evaluation (MANDATORY)

You MUST perform two assessments after treatment: 1

1. Otoscopic examination to confirm cerumen removal and assess for complications (perforation, bleeding, trauma)
2. Patient symptom assessment to document resolution

If impaction is not resolved: Use an alternative treatment strategy or combination approach (e.g., cerumenolytic followed by irrigation or manual removal). 1

If symptoms persist despite complete cerumen removal: Evaluate for alternative diagnoses including sensorineural hearing loss, otitis media, eustachian tube dysfunction, cholesteatoma, or temporomandibular joint syndrome. 1

When to Refer to Otolaryngology

Refer immediately if: 1

• Initial treatment attempts are unsuccessful after trying combination approaches
• Complications occur during removal (perforation, severe pain, bleeding)
• Patient cannot tolerate further removal attempts
• You lack specialized equipment (binocular microscope, microsuction) or training
• Persistent symptoms after documented complete removal

What NOT to Do

• Never use ear candling—it is ineffective and contraindicated. 1
• Avoid cotton-tipped swabs for cerumen removal—they push wax deeper and risk canal/tympanic membrane injury. 7, 4, 3
• Do not irrigate if tympanic membrane integrity is uncertain or contraindications exist. 2

Documentation Requirements

Document in the medical record: 1

• Pre-treatment otoscopic findings
• Treatment method used
• Post-treatment otoscopic examination results
• Patient symptom resolution status
• Any complications encountered