What is the best course of action for an elderly patient experiencing a sensation of ear wax in both ears, despite minimal wax presence, while taking azelastine (antihistamine), Flonase (fluticasone propionate) and Allegra (fexofenadine) for allergies?

Management of Ear Fullness Without Visible Cerumen in Elderly Patient on Nasal Antihistamines and Corticosteroids

The most likely explanation is that her antihistamine and nasal corticosteroid regimen is causing eustachian tube dysfunction or drying of the ear canal, creating a sensation of fullness despite minimal visible cerumen—reassure her, consider reducing antihistamine burden, and evaluate for alternative causes of aural fullness. 1

Diagnostic Approach

Confirm True Absence of Cerumen Impaction

• Visualize the entire tympanic membrane with otoscopy to definitively rule out cerumen impaction, as cerumen does not need to completely occlude the canal to cause symptoms—even partial accumulation can be problematic 1, 2
• Document that the tympanic membrane is fully visible and that symptoms persist despite minimal cerumen 1, 3

Consider Medication-Related Causes

• Antihistamines (azelastine, fexofenadine) can cause drying of mucous membranes and eustachian tube dysfunction, leading to ear fullness sensations without actual wax accumulation 4
• Nasal corticosteroids (Flonase) typically improve eustachian tube function but can occasionally cause local irritation 4
• The combination of multiple antihistamines may be excessive and contributing to her symptoms through anticholinergic drying effects

Differential Diagnosis When Cerumen is Absent

If the tympanic membrane is fully visualized and symptoms persist, consider these alternative diagnoses: 1, 2, 3

• Eustachian tube dysfunction (most likely in this context given medication regimen)
• Sensorineural hearing loss
• Otosclerosis or other ossicular pathology
• Serous otitis media (middle ear effusion)
• Temporomandibular joint syndrome
• Medication side effects (tinnitus, altered auditory perception)
• Cholesteatoma (less likely but serious)

Management Algorithm

Step 1: Medication Adjustment

• Consider reducing antihistamine burden by eliminating redundant therapy—she is on both azelastine (nasal antihistamine) and Allegra (oral antihistamine), which may be excessive 4
• Trial discontinuation of oral fexofenadine while maintaining nasal spray therapy for 1-2 weeks to assess symptom improvement
• Continue Flonase as nasal corticosteroids are generally beneficial for eustachian tube function 4

Step 2: If Minimal Cerumen is Present

• Even minimal cerumen can cause symptoms in elderly patients—consider cerumenolytic treatment if any wax is visible 1, 2
• Water or saline drops are as effective as commercial cerumenolytics and are inexpensive 1, 5
• Apply drops for 5 days, then reassess 5

Step 3: Reassessment After Intervention

• Perform otoscopic re-examination and symptom reassessment after any intervention 1, 2
• Document whether symptoms have resolved, improved, or persisted 1

Step 4: If Symptoms Persist Despite Clear Ear Canals

• Obtain audiometry to evaluate for sensorineural or conductive hearing loss 1, 6
• Consider tympanometry to assess middle ear function and eustachian tube dysfunction 3
• Refer to otolaryngology if symptoms persist after addressing obvious causes, or if hearing loss is documented 1, 3

Common Pitfalls to Avoid

• Do not assume all ear fullness is cerumen—the tympanic membrane must be visualized to confirm diagnosis 1, 3
• Do not irrigate or use cerumenolytics if the tympanic membrane is not fully visible or if perforation is suspected, as this can cause serious complications 1, 7
• Do not recommend cotton-tipped swabs for cleaning, as they push wax deeper and can cause trauma 1, 8
• Do not recommend ear candling under any circumstances—it is ineffective and dangerous, with documented complications including burns, canal occlusion, and tympanic membrane perforation 1
• Do not fail to identify alternative diagnoses if symptoms persist despite confirmed absence of cerumen 1, 2, 3

Patient Education

• Explain that ear fullness can occur without visible wax due to medication effects on mucous membranes and eustachian tube function 4
• Reassure that earwax is protective and most people do not need regular ear cleaning 1
• Advise against inserting any objects into the ear canal 1, 8

When to Refer

Refer to otolaryngology if: 1, 3

• Symptoms persist despite medication adjustment and confirmed clear ear canals
• Hearing loss is documented on audiometry
• Multiple treatment attempts fail
• Tympanic membrane abnormalities are identified
• Patient develops severe pain, vertigo, or other concerning symptoms