In a 50‑year‑old man with bilateral cerumen impaction who has experienced throbbing pain for one day in only one ear, what is the most likely cause and what is the appropriate initial management?

Unilateral Ear Pain with Bilateral Cerumen Impaction

The throbbing pain in only one ear despite bilateral cerumen impaction indicates a complication or alternative diagnosis rather than simple cerumen impaction, and requires immediate otoscopic examination to assess for otitis externa, tympanic membrane perforation, or ear canal trauma. 1

Why Pain in Only One Ear is a Red Flag

• Ear pain is not a typical symptom of uncomplicated cerumen impaction alone and mandates further evaluation for complications or alternative diagnoses 1
• While cerumen impaction can cause symptoms including otalgia, the unilateral nature of throbbing pain with bilateral impaction strongly suggests an additional pathologic process in the symptomatic ear 2
• The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that pain, drainage, or bleeding are not symptoms of cerumen impaction itself and indicate complications requiring assessment 1

Most Likely Diagnoses to Consider

Otitis Externa (Most Common)

• Otitis externa is characterized by inflammation or infection of the external auditory canal and is a known complication of cerumen impaction 1
• The throbbing quality of pain for one day is consistent with acute otitis externa, which presents as painful cellulitis of the external auditory canal with erythema and edema 3
• Cerumen impaction can trap moisture and debris, creating an environment conducive to bacterial infection in the affected ear 4

Occult Otitis Media

• Otitis media may be masked by cerumen and should be considered in the differential diagnosis 1
• The most common diagnosis related to otalgia in adults is acute otitis media, characterized by an erythematous, bulging, and cloudy tympanic membrane 3

Trauma or Perforation

• Tympanic membrane perforation or ear canal laceration may have occurred from prior self-cleaning attempts or trauma 1
• These complications can cause significant unilateral pain even in the presence of bilateral cerumen 2

Immediate Management Algorithm

Step 1: Otoscopic Examination (Mandatory)

• Document the ear canal and tympanic membrane status for both patient safety and medicolegal purposes 1
• Specifically assess for:
  • Canal skin integrity and signs of erythema or edema suggesting otitis externa 1
  • Tympanic membrane perforation 1
  • Degree of cerumen impaction in both ears 1
  • Presence of drainage or bleeding 1

Step 2: Pain Management

• For mild to moderate pain: Use acetaminophen or NSAIDs (ibuprofen) as first-line agents 1
• For severe pain: Consider opioid-containing analgesics (oxycodone, hydrocodone) for 48-72 hours with limited doses 1

Step 3: Treatment Based on Findings

If Otitis Externa is Diagnosed:

• Use topical antibiotic drops with or without steroids as primary treatment 1
• Fluoroquinolone drops (ofloxacin or ciprofloxacin-dexamethasone) are preferred 1, 5
• Ciprofloxacin otic solution 0.2% should be instilled into the affected ear twice daily for 7 days 5
• Remove cerumen from the affected ear to allow medication penetration and resolve the underlying impaction 1

If Tympanic Membrane Perforation is Found:

• Avoid ototoxic drops and alcohol-containing solutions 1
• Refer immediately to otolaryngology for specialized management 1
• Mechanical removal of cerumen is the preferred technique when the ear drum is not intact 2

If Only Cerumen Impaction Without Complications:

• This scenario is unlikely given the unilateral throbbing pain, but if examination is normal, consider alternative removal methods (manual removal if irrigation was attempted, or vice versa) 1
• Consider cerumenolytic agents to soften wax before repeat attempt 1, 6

Critical Pitfalls to Avoid

• Do not assume pain is normal after or during cerumen impaction – persistent or severe pain indicates a complication or alternative diagnosis 1
• Do not use topical anesthetic drops without follow-up examination within 48 hours, as they may mask progression of underlying disease 1
• Do not ignore persistent symptoms even if the ear canal appears clear after cerumen removal, as alternative diagnoses must be considered 1
• Avoid irrigation if tympanic membrane perforation is suspected or confirmed, as this can cause infection, pain, ototoxic hearing loss, or caloric-induced vertigo 2

When to Refer to Otolaryngology

Immediate referral is indicated if: 1

• Tympanic membrane perforation is identified
• Complications from removal procedure occur
• Pain persists beyond 48-72 hours despite appropriate treatment
• Multiple unsuccessful removal attempts have been made
• Patient has history of ear surgery or known tympanic membrane abnormalities

Special Considerations for This Patient

• In a 50-year-old male, consider secondary otalgia from temporomandibular joint syndrome or dental infections if examination reveals no ear pathology, as secondary otalgia is more common in adults 4
• If the patient has diabetes or is immunocompromised, extra vigilance is required as these patients are at higher risk for necrotizing external otitis after irrigation 1
• Document whether the patient attempted self-removal with cotton swabs or other objects, as this increases risk of canal trauma 2, 6