From the Guidelines
Impacted cerumen should be treated with cerumenolytic agents, such as water-based or oil-based preparations, as the initial treatment option. The use of cerumenolytic agents is supported by the clinical practice guideline update on earwax (cerumen impaction) published in 2017 1. This guideline reviews the evidence regarding the safety and efficacy of cerumenolytic agents for the treatment of impacted cerumen.
Treatment Options
- Topical therapy can be used to manage cerumen impactions, either as a single therapeutic intervention or in combination with other techniques, including irrigation of the ear canal and manual removal of cerumen.
- Water-based agents, such as carbamide peroxide, can induce hydration and subsequent fragmentation of corneocytes within the cerumen, making them a suitable option for treatment.
- Oil-based preparations, such as mineral oil, can lubricate and soften cerumen without disintegrating it, making them another viable option.
Application and Irrigation
- For home treatment, patients can use over-the-counter cerumenolytics, applying 5-10 drops into the affected ear twice daily for 3-5 days.
- The ear should be kept tilted for 5 minutes after application to allow the solution to penetrate the wax.
- Irrigation can be performed using a bulb syringe with body-temperature water directed at the ear canal wall, not directly at the eardrum.
Clinical Removal
- Healthcare providers may use specialized instruments like curettes or suction under direct visualization for clinical removal.
- Manual removal is particularly appropriate for patients with diabetes, immunocompromised status, or perforated eardrums where irrigation is contraindicated.
- Softening the wax with cerumenolytics before irrigation or manual removal increases success rates.
Prevention
- Patients should avoid using cotton swabs, which can push wax deeper and cause trauma.
- Regular preventive use of cerumenolytics (once weekly) may benefit those with recurrent impactions.
- Treatment is important as impacted cerumen can cause hearing loss, pain, tinnitus, and increase infection risk, ultimately affecting morbidity, mortality, and quality of life.
From the FDA Drug Label
Directions FOR USE IN THE EAR ONLY adults and children over 12 years of age: • tilt head sideways • place 5 to 10 drops into ear • tip of applicator should not enter ear canal • keep drops in ear for several minutes by keeping head tilted or placing cotton in the ear • use twice daily for up to four days if needed, or as directed by a doctor • any wax remaining after treatment may be removed by gently flushing the ear with warm water, using a soft rubber bulb ear syringe Directions FOR USE IN THE EAR ONLY. Adults and children over 12 years of age: Tilt head sideways and place 5 to 10 drops into ear Tip of applicator should not enter ear canal Keep drops in ear for several minutes by keeping head tilted or placing cotton in the ear Use twice daily for up to 4 days if needed, or as directed by a doctor Any wax remaining after treatment may be removed by gently flusing the ear with warm water, using a soft rubber bulb ear syringe The treatment of impacted cerumen involves:
- Placing 5 to 10 drops of carbamide peroxide (OTIC) 2 or hydrogen peroxide (OTIC) 3 into the ear
- Keeping the drops in the ear for several minutes
- Using the treatment twice daily for up to 4 days if needed, or as directed by a doctor
- Removing any remaining wax by gently flushing the ear with warm water, using a soft rubber bulb ear syringe Key considerations:
- The treatment is for adults and children over 12 years of age
- Children under 12 years should consult a doctor
From the Research
Treatment Options for Impacted Cerumen
- Cerumenolytic agents can be used as an effective treatment option for impacted cerumen 4
- Irrigation with or without cerumenolytic pretreatment is also a viable option for removing impacted cerumen 4, 5
- Manual removal can be used if irrigation and cerumenolytics are contraindicated, but may require specialized training to prevent adverse outcomes 5
- Home irrigation with a bulb syringe may be appropriate for selected adults 4
Contraindications and Precautions
- Patients with coagulopathies, hepatic failure, thrombocytopenia, or hemophilia, and those taking antiplatelet or anticoagulant medications, should be counseled about the increased risk of bleeding in the external auditory canal when cerumen is removed 4
- Cotton-tipped swabs, ear candling, and olive oil drops or sprays should be avoided 4