A patient with several months of recurrent ear fullness, mild hearing loss, and intermittent balance problems that improve briefly with pressure equalization—should I first try over‑the‑counter carbamide peroxide (Debrox) ear drops or proceed directly to clinician‑performed ear irrigation?

Management of Recurrent Ear Fullness with Mild Hearing Loss and Balance Issues

You should first perform a targeted otoscopic examination to rule out cerumen impaction before considering over-the-counter cerumenolytics or irrigation, because this patient's chronic symptoms (several months), intermittent balance issues, and only momentary relief with pressure equalization strongly suggest Eustachian tube dysfunction rather than simple cerumen impaction. 1, 2

Why This Matters: Alternative Diagnosis First

The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that when cerumen has been adequately removed but symptoms persist, clinicians must consider alternative diagnoses including Eustachian tube dysfunction, sensorineural hearing loss, serous otitis media, or other middle ear disorders. 1

Your patient's presentation is highly suspicious for Eustachian tube dysfunction because:

• Chronic duration (several months) exceeds typical cerumen impaction presentation 1
• Momentary relief with pressure equalization is the hallmark of Eustachian tube dysfunction, not cerumen 2
• Intermittent balance issues suggest middle ear involvement beyond simple canal obstruction 1
• Bilateral "airplane ear" sensation points to pressure equalization problems 2

The Diagnostic Pathway You Should Follow

Step 1: Otoscopic Examination (Immediate)

Perform pneumatic otoscopy to assess for:

• Cerumen impaction (if present, this is easily visualized) 1
• Middle ear effusion (fluid behind the tympanic membrane) 1
• Tympanic membrane mobility and retraction 1

Critical point: If you cannot adequately visualize the tympanic membrane due to cerumen, then proceed with cerumen removal. 1

Step 2: If Cerumen Is Present

The 2017 AAO-HNS guideline provides clear direction:

• Cerumenolytics alone have the lowest success rates for impaction removal 1
• Irrigation success ranges from 68-92% 1
• Combination therapy (cerumenolytic followed by irrigation) is more effective than either alone 1

Therefore: If cerumen impaction is confirmed, use Debrox (carbamide peroxide) for 3-5 days followed by in-office irrigation rather than Debrox alone or irrigation alone. 1, 3

Step 3: If No Cerumen or Symptoms Persist After Removal

You must obtain audiometry because:

• Hearing loss is reported by this patient 1
• The AAO-HNS recommends prompt audiologic examination for persistent symptoms (≥6 months) associated with hearing difficulties 1
• Eustachian tube dysfunction commonly causes conductive hearing loss that requires objective measurement 2

Consider tympanometry and specialized Eustachian tube testing (sonotubometry, tubomanometry) as these have the best diagnostic performance for obstructive Eustachian tube dysfunction. 2

Why Not Start with Debrox Empirically?

This approach has three major problems:

1. Low diagnostic yield: Only 2.1-10% of adults have cerumen impaction in screening studies, though rates are higher in elderly populations 1

2. Delays correct diagnosis: The patient has had symptoms for "several months"—this chronic presentation with balance issues demands investigation for middle ear pathology, not empiric wax treatment 1, 2

3. Poor efficacy as monotherapy: Cerumenolytics alone have lower success rates than combination therapy, and a 2018 Cochrane review found only low-quality evidence that any cerumenolytic is better than no treatment 3

The Balance Issue Changes Everything

Balance problems are not a typical symptom of cerumen impaction but are commonly reported with:

• Middle ear effusion (otitis media with effusion) 1, 4
• Eustachian tube dysfunction 2
• Inner ear involvement 1

The AAO-HNS specifically lists dizziness as a symptom requiring evaluation beyond simple cerumen management. 1

Common Pitfalls to Avoid

Do not assume all ear fullness is wax: The 2017 guideline emphasizes that persistent symptoms after adequate cerumen removal mandate consideration of alternative diagnoses. 1

Do not use cotton swabs for diagnosis or treatment: These are contraindicated and can worsen impaction. 5, 6

Do not delay audiometry in adults with hearing complaints: This represents a quality improvement opportunity according to the AAO-HNS tinnitus guideline, which applies to any patient with hearing concerns. 1

Practical Algorithm for This Patient

1. Today: Perform otoscopy (with pneumatic assessment if possible) 1

   • If cerumen blocks view → prescribe Debrox 5 days, return for irrigation 1, 3
   • If tympanic membrane visible → proceed to Step 2

2. If TM visible or after cerumen removal: Order audiometry 1

   • Document tympanic membrane appearance 1
   • Consider tympanometry 2

3. If hearing loss or abnormal tympanometry: Refer to ENT for Eustachian tube dysfunction evaluation 2

4. If normal exam and testing: Consider trial of nasal steroid for possible Eustachian tube inflammation (though evidence is limited) 1

When to Refer to Otolaryngology

The 2017 guideline states referral is indicated when: 1

• Initial treatment attempts are unsuccessful
• Symptoms persist despite cerumen removal
• Patient has complications or cannot tolerate office procedures
• Specialized equipment (microscopy, microsuction) is needed

Your patient likely needs ENT evaluation regardless given the chronic nature, balance symptoms, and high probability of Eustachian tube dysfunction rather than simple cerumen impaction. 1, 2