What is the best treatment approach for a patient with an impacted right ear, potentially caused by excessive earwax, and presenting with discomfort and hearing loss?

Treatment of Impacted Right Ear

For a patient with cerumen impaction causing discomfort and hearing loss, initiate treatment with water-based cerumenolytic drops (such as hydrogen peroxide, saline, or sodium bicarbonate) for 3-5 days, followed by irrigation with body-temperature water if impaction persists, and reserve manual removal for cases where irrigation fails or is contraindicated. 1

Initial Assessment: Rule Out Contraindications First

Before starting any treatment, you must identify absolute contraindications that would make standard therapy dangerous 1:

• Perforated tympanic membrane - contraindication to both irrigation and most cerumenolytics 1, 2
• History of ear surgery (unless cleared by ENT) - the tympanic membrane may be thinned or vulnerable 1
• Tympanostomy tubes in place - absolute contraindication 1
• Active otitis externa or ear infection - avoid cerumenolytics and irrigation 1
• Ear canal stenosis or exostoses - can trap water after irrigation 1

Also assess for modifying factors requiring extra caution: anticoagulant therapy, immunocompromised state, diabetes mellitus, or prior head/neck radiation 1.

Step 1: Cerumenolytic Drops (First-Line Treatment)

No specific cerumenolytic agent is superior to plain water or saline - this is supported by Cochrane review evidence 1. Choose any of these water-based options 1:

• Hydrogen peroxide (carbamide peroxide)
• Saline solution (lowest risk of skin reactions)
• Sodium bicarbonate 10% solution (most effective for wax disintegration in lab studies)
• Docusate sodium
• Acetic acid solution
• Plain tap water

Dosing for hydrogen peroxide (adults and children >12 years): Tilt head sideways, place 5-10 drops in affected ear, keep drops in ear for several minutes, use twice daily for up to 4 days 3.

Do not use in children under 3 years, and children under 12 should consult a physician first 1.

Oil-based alternatives (olive oil, almond oil, mineral oil) can be used if water-based agents aren't tolerated, though they only lubricate rather than disintegrate wax 1.

Step 2: Irrigation (If Drops Alone Fail)

The most cost-effective protocol is cerumenolytic followed by self-irrigation at home 1. This combination is more effective than either treatment alone 1.

Critical irrigation technique details:

• Use body-temperature water (37°C/98.6°F) to avoid caloric effects causing vertigo 1
• Plain water or saline is as effective as commercial products 1
• Use a large syringe with controlled, steady pressure 1
• The procedure should not take more than 30 minutes 4

Expected outcomes and risks:

• Hearing improvement of 5-10 dB in most patients 1
• Tympanic membrane perforation occurs in approximately 0.2% of irrigations 1
• Overall complications requiring specialist referral occur in only 1 in 1000 cases 1
• Minor adverse effects include pain, otitis externa, and canal trauma 1

Step 3: Manual Removal (If Irrigation Fails)

Manual removal with curette, forceps, or suction achieves approximately 90% success rates 2. This requires specialized equipment and training 1. The procedure takes only a few minutes and doesn't require anesthesia 4.

Refer to otolaryngology if multiple treatment attempts are unsuccessful or you lack the specialized equipment/training for manual removal 1.

Post-Treatment Assessment

After removing the impaction 1, 2:

• Document resolution of the impaction with otoscopic re-examination
• Reassess symptoms - hearing loss, discomfort, and tinnitus should resolve
• If symptoms persist despite confirmed removal, evaluate for alternative diagnoses: sensorineural hearing loss, otosclerosis, cholesteatoma, otitis media, medication side effects, head/neck tumors, TMJ syndrome, or eustachian tube dysfunction 2

Critical Pitfalls to Avoid

Strongly advise patients against 4, 1:

• Cotton-tipped swabs - can push cerumen deeper, cause canal laceration, TM perforation, or ossicular dislocation
• Ear candling/coning - no evidence of efficacy and can cause serious injury including burns, ear canal occlusion, and TM perforation
• Home oral jet irrigators - lack safety and efficacy research

Prevention of Recurrence

Recurrent earwax impaction occurs in 66.1% of cases 5, often due to wrong perception and preventable self-ear cleaning practices 5. Educate patients that cerumen is a normal protective secretion, not "dirt," and instruct them to avoid inserting objects into the ear canal 1.