How to treat a patient with plugged ears not caused by earwax (cerumen)?

Treatment of Plugged Ears Not Caused by Earwax

When plugged ears are not due to cerumen impaction, the most common cause is Eustachian tube dysfunction (ETD), and the evidence shows that nasal decongestants are ineffective and should not be used for this condition. 1, 2

Initial Diagnostic Approach

The first critical step is to confirm that cerumen impaction is truly absent by direct otoscopic visualization of the tympanic membrane. 3 You must also differentiate between several distinct causes of ear fullness:

• Eustachian tube dysfunction - characterized by inability to equalize middle ear pressure, often with retracted tympanic membrane or middle ear effusion 1
• Otitis media with effusion - fluid behind an intact tympanic membrane 1
• Acute otitis externa - ear canal inflammation with pain on tragal pressure 4
• Sudden sensorineural hearing loss - requires urgent evaluation 3
• Tympanic membrane perforation - visible defect on examination 5

What NOT to Do

Avoid nasal decongestants (phenylephrine, pseudoephedrine, xylometazoline) for Eustachian tube dysfunction, as multiple studies demonstrate they do not improve ET function and may worsen outcomes. 6, 2

• Topical nasal decongestants showed no improvement in ET opening parameters in controlled studies 2
• Phenylephrine combined with surfactant actually prolonged middle ear effusion resolution compared to surfactant alone (18.67 days vs 10.57 days) 6
• A systematic review found insufficient evidence to recommend any pharmacological intervention for adult ETD 1

Never use ear candling, cotton-tipped swabs, or home oral jet irrigators - these cause harm without benefit and can result in canal laceration, tympanic membrane perforation, or burns. 5, 7

Evidence-Based Treatment Options for Non-Cerumen Plugged Ears

For Eustachian Tube Dysfunction:

• Pressure equalization devices showed short-term improvements in symptoms and middle ear function in single trials, though evidence quality is limited 1
• Autoinflation techniques (Valsalva maneuver, swallowing) may provide temporary relief, though no high-quality evidence supports long-term benefit 1
• Nasal steroids showed no improvement in a single RCT for patients with otitis media with effusion and negative middle ear pressure 1

For Otitis Media with Effusion:

• Watchful waiting is appropriate for most cases, as effusion often resolves spontaneously 1
• Surgical intervention (myringotomy, tympanostomy tubes) may be considered for persistent cases, though this requires specialist referral 1

For Pressure-Related Symptoms (Barotrauma):

• Pressure-regulating earplugs significantly improved subjective symptoms during pressure changes (VAS score 2.19 vs 3.38 without plugs), though they do not improve actual ET function 8
• These devices slow the rate of pressure change in the external auditory canal, providing symptomatic relief 8

When to Refer

Refer to otolaryngology if:

• Multiple treatment attempts fail 5
• Symptoms persist despite appropriate management 5
• Specialized equipment or manual removal techniques are needed 5
• Hearing loss persists after addressing obvious causes 7
• Severe pain, vertigo, or complications develop 7

Critical Contraindications to Remember

Before attempting any intervention, assess for absolute contraindications:

• Tympanic membrane perforation - contraindication to most topical treatments and irrigation 5, 7
• History of ear surgery - requires ENT clearance before any intervention 5, 7
• Tympanostomy tubes in place - contraindication to irrigation and most drops 5
• Active otitis externa - defer treatment until infection resolves 5

Common Pitfalls

• Assuming all ear fullness is cerumen - always visualize the tympanic membrane to confirm diagnosis 3
• Prescribing oral or topical decongestants for ETD - evidence shows these are ineffective and potentially harmful 6, 2
• Failing to identify alternative diagnoses - if symptoms persist despite treatment, evaluate for sensorineural hearing loss, ossicular pathology, or other otologic conditions 7
• Using antihistamine-decongestant combinations - while older literature suggested possible benefit 9, more recent evidence shows no improvement in ET function 1, 2