Can impacted cerumen (earwax) cause tinnitus?

Does Impacted Cerumen Cause Tinnitus?

Yes, impacted cerumen is a recognized cause of tinnitus and should be treated when this symptom is present. 1

Evidence from Clinical Guidelines

The American Academy of Otolaryngology-Head and Neck Surgery explicitly identifies tinnitus as one of the cardinal symptoms of cerumen impaction in their 2017 clinical practice guideline. 1 The guideline states that patients should understand that symptoms of cerumen impaction include "decreased hearing, fullness, tinnitus, and distortion/changes to hearing aid function." 1

The 2008 guideline similarly lists tinnitus among the symptoms associated with cerumen impaction, alongside hearing loss, fullness, itching, otalgia, discharge, odor, and cough. 1

Clinical Approach to Tinnitus from Cerumen

When a patient presents with tinnitus and you identify cerumen impaction on examination, you should treat the impaction and reassess for symptom resolution. 1

Diagnostic Steps:

• Perform otoscopic examination to identify cerumen accumulation that either causes symptoms or prevents complete visualization of the tympanic membrane 1
• Document the presence of tinnitus as a presenting symptom 1
• Note that cerumen does not need to completely occlude the canal (100%) to cause symptoms—even partial occlusion can be problematic 1

Treatment and Outcome Assessment:

After removing the cerumen impaction, you must perform two critical assessments: 1

1. Otoscopic re-examination to confirm the cerumen has been adequately removed
2. Symptom reassessment to determine if the tinnitus has resolved or improved

If tinnitus persists after confirmed removal of cerumen, you must evaluate for alternative diagnoses including sensorineural hearing loss, otosclerosis, cholesteatoma, otitis media, medication side effects, head and neck tumors, temporomandibular joint syndrome, or eustachian tube dysfunction. 1

Important Clinical Caveats

The Diagnostic Pitfall:

The guideline explicitly warns that symptoms of cerumen impaction—including tinnitus—overlap with many other conditions. 1 This is why post-treatment reassessment is mandatory, not optional. The evidence shows that 10-35% of cerumen removal attempts may be unsuccessful initially, requiring alternative treatment methods. 1

Evidence Quality:

The guideline rates the evidence linking cerumen impaction to symptoms (including tinnitus) as Grade C with respect to signs and symptoms, though the confidence level is rated as high. 1 This reflects that while the association is well-recognized clinically, the quality of studies specifically examining symptom resolution is limited. 1

Conductive Hearing Loss Mechanism:

Cerumen impaction causes tinnitus through conductive hearing loss when the ear canal cross-sectional area is reduced by at least 80%. 1 The hearing loss can range from 5 to 40 dB depending on the degree of occlusion. 1

Treatment Success Rates

Treatment effectiveness ranges from 65% to 90% depending on the method used. 1 Manual removal with microscopic visualization achieves approximately 90% success rates, while irrigation has lower success rates of 68% to 92%. 1 Even with microsuction, nearly 10% of removal attempts are unsuccessful. 1

If initial treatment fails, use combination therapy (cerumenolytic followed by irrigation or manual removal) rather than simply repeating the same unsuccessful method. 1