Management of Cerumen Impaction
The next step in treating cerumen impaction is to use cerumenolytic agents (such as hydrogen peroxide, saline, or water-based drops) for 5 days, followed by irrigation if needed, or proceed directly to manual removal with instrumentation if you have the training and equipment. 1, 2
Initial Assessment Before Treatment
Before initiating treatment, you must assess for modifying factors that change your management approach: 1
- Anticoagulant therapy - increases bleeding risk during removal 1
- Immunocompromised state 1
- Diabetes mellitus 1
- Prior radiation therapy to head and neck 1
- Ear canal stenosis or exostoses 1
- Nonintact tympanic membrane - this is an absolute contraindication to irrigation and most cerumenolytics 1
- History of ear surgery - requires otolaryngologist clearance before using drops or irrigation 1
Treatment Options (Choose Based on Clinical Scenario)
Option 1: Cerumenolytic Agents
Water-based preparations are preferred due to lower risk of local skin reactions compared to oil-based products: 1, 2
- Hydrogen peroxide - apply 5-10 drops twice daily for up to 4 days 3
- Saline solution - equally effective as commercial products with minimal adverse effects 1, 2
- Plain water - as effective as specially formulated products 2
- Sodium bicarbonate solution 2
- Docusate sodium 2
Application technique: Tilt head sideways, instill drops, keep in ear for several minutes by maintaining head tilt or placing cotton in ear 3
Option 2: Irrigation
Irrigation can be performed with or without cerumenolytic pretreatment: 2
- Water must be at body temperature to avoid caloric stimulation and dizziness 2
- Use a large syringe for manual irrigation 2
- Most cost-effective approach: cerumenolytic followed by self-irrigation at home 1, 2
Absolute contraindications to irrigation: 1, 2
- Perforated tympanic membrane
- History of ear surgery (unless cleared by ENT)
- Ear canal stenosis
Option 3: Manual Removal with Instrumentation
This requires specialized equipment and training but is appropriate when: 1
- Irrigation is contraindicated
- Other methods have failed
- Immediate removal is needed
When to Stop and Reassess
Stop treatment and seek further evaluation if: 3
- Treatment needed for more than 4 days 3
- Excessive earwax remains after treatment 3
- Patient develops ear pain, drainage, or bleeding (these are NOT symptoms of simple cerumen impaction) 1
- Dizziness occurs during irrigation 4
Post-Treatment Assessment
You must document resolution of impaction after treatment: 1, 2
- If impaction persists, use additional treatment or combination of methods 1, 2
- If symptoms persist despite clearing the impaction, evaluate for alternative diagnoses such as otitis media, otitis externa, or sudden sensorineural hearing loss 1
When to Refer to Otolaryngology
- Multiple treatment attempts (including combination therapy) are unsuccessful 1, 5
- You lack specialized equipment or training for manual removal 1, 2
- Severe pain develops during treatment 4
- Hearing loss persists after cerumen removal 4
- Patient has retained foreign body 1
- Speech-delayed or developmentally delayed child with persistent hearing loss 1
What NOT to Do
Strongly contraindicated interventions: 1
- Ear candling - no evidence of benefit and can cause serious injury including burns and tympanic membrane perforation 1
- Cotton-tipped swabs or other objects - can cause canal laceration, tympanic membrane perforation, or ossicular dislocation 1
Common Pitfalls to Avoid
- Do not treat asymptomatic cerumen that doesn't prevent examination - it's a normal protective mechanism 1
- Do not overlook patients who cannot express symptoms (young children, cognitively impaired, nonverbal patients) - they require proactive assessment 1
- Do not forget to check hearing aid users for cerumen during routine visits 1
- Do not assume symptoms are from cerumen - otitis media, otitis externa, and sudden hearing loss can masquerade as impaction 1