What is the recommended approach for examining and treating ear cerumen (earwax) impaction?

Examination and Treatment of Ear Cerumen

Examination Approach

Perform otoscopy using a handheld otoscope, speculum, or binocular microscope to visualize the ear canal and tympanic membrane, diagnosing cerumen impaction only when the accumulation causes symptoms or prevents necessary assessment of the ear. 1

When to Diagnose Impaction

• Diagnose cerumen impaction when accumulation on otoscopy is associated with symptoms (hearing loss, fullness, tinnitus, pain) OR prevents needed examination of the ear canal/tympanic membrane 1
• Do NOT diagnose impaction in asymptomatic patients whose ears can be adequately examined 1
• Even partial occlusion qualifies as impaction if it causes symptoms or prevents audiologic testing, caloric testing, or middle ear assessment 1

Special Populations Requiring Examination

• Examine hearing aid users for cerumen during every healthcare encounter - 60-70% of hearing aid repairs result from cerumen damage 1
• Promptly evaluate patients who cannot express symptoms: young children, cognitively impaired adults, elderly with dementia 1
• In older patients (>65 years), 35% have impaction blocking tympanic membrane visualization, often improving hearing 10-15 dB after removal 1

Pre-Treatment Risk Assessment

Before selecting a removal method, assess for these modifying factors by history and physical examination: 1

• Tympanic membrane perforation or tympanostomy tubes - contraindication to irrigation and most cerumenolytics 1, 2
• Prior ear surgery (tympanoplasty, mastoidectomy) - avoid irrigation 3
• Anticoagulant therapy - increased bleeding risk with manual removal 1
• Diabetes mellitus - higher risk of malignant otitis externa with irrigation 2, 4
• Immunocompromised state - increased infection risk 1
• Ear canal stenosis or exostoses - may require specialized equipment 1
• Current otitis externa - avoid irrigation 1

Treatment Approach

Treat confirmed cerumen impaction with cerumenolytic agents, irrigation, or manual removal with instrumentation - these three methods are equally acceptable first-line options. 1

Treatment Options

1. Cerumenolytic Agents

• Use hydrogen peroxide or carbamide peroxide: tilt head sideways, place 5-10 drops in ear, keep in for several minutes, use twice daily for up to 4 days 5, 6
• Pre-treatment with cerumenolytics for 3-5 days before irrigation improves success rates to 68-92% 2
• Water or saline solution also functions as a cerumenolytic 1

2. Irrigation

• Direct body-temperature water at the ear canal WALL, not directly at the tympanic membrane 2
• Success rate: 65-90% depending on technique 1
• Absolute contraindications: perforated tympanic membrane, tympanostomy tubes, prior ear surgery, current ear infection, narrow/stenotic canals 2, 4
• Minor complications occur in 38% but are usually self-limiting; perforation risk is 0.2% 2

3. Manual Removal with Instrumentation

• Use binocular microscope with curette, forceps, right-angled hook, or suction (French size 3,5,7) under direct visualization 1
• Success rate: ~90% with proper visualization 2
• Preferred method when: tympanic membrane perforation suspected, irrigation contraindicated, exostoses present, or patient preference 1
• Advantages: quicker, direct visualization, no moisture exposure 1

Post-Treatment Assessment

Perform two mandatory assessments after treatment: 1

1. Otoscopic examination - document complete resolution of impaction
2. Patient symptom assessment - confirm symptom resolution

If impaction persists: Use additional treatment (repeat initial method or try alternative approach) 1

If symptoms persist despite clearing impaction: Evaluate for alternative diagnoses (otitis media, otitis externa, sudden sensorineural hearing loss) 1

When to Refer

Refer to otolaryngology or clinician with specialized equipment if: 1, 2

• Initial treatment attempts unsuccessful
• Complications occur during removal
• Patient cannot tolerate further removal attempts
• Specialized equipment needed (binocular microscope, microsuction) 2

Critical Safety Points

Absolute Contraindications

• NEVER use ear candling - no evidence of benefit and causes serious harm including burns, canal obstruction, and tympanic membrane perforation 1, 2
• NEVER irrigate with: perforated tympanic membrane, tympanostomy tubes, prior ear surgery, current infection 2, 4

Common Pitfalls to Avoid

• Do not treat asymptomatic cerumen when adequate examination is possible 1
• Do not use cotton-tipped swabs - they push wax deeper 2
• Do not assume pain is from cerumen - assess for infection or other pathology first 1
• In diabetic patients using irrigation, promptly evaluate any post-procedure ear discharge or pain 2

Prevention Counseling

• Educate patients on proper ear hygiene when cerumen accumulation is present 1
• Consider prophylactic topical emollient treatment weekly for recurrent impaction (reduces recurrence from 61% to 23%) 7