What is the appropriate management for dried cerumen in a child's ear when the ear canal is intact and there are no signs of infection?

Management of Dried Cerumen (Earwax) in Pediatric Ears

In a child with dried cerumen and an intact ear canal without infection, treatment is only indicated if the cerumen causes symptoms (hearing loss, fullness, pain) or prevents necessary examination of the tympanic membrane—otherwise, observation is appropriate. 1

When to Treat vs. Observe

Leave the Cerumen Alone If:

• The child has no symptoms (no hearing loss, ear fullness, pain, or tinnitus) 1
• The tympanic membrane can be adequately visualized 1
• No audiologic or vestibular testing is needed 1
• Cerumen serves protective functions with bactericidal and emollient properties 1

Treat the Cerumen If:

• Symptoms are present: hearing loss, fullness, tinnitus, otalgia, or cough 1
• Visualization of the tympanic membrane is needed (e.g., to rule out perforation or middle ear disease) 1
• Audiologic testing is required (audiometry, tympanometry, otoacoustic emissions) 1
• In one study, cerumen removal was necessary in 29% of children to diagnose acute otitis media 1

Assessment Before Removal

Check for modifying factors that change your removal technique: 1

• Tympanic membrane integrity: History of perforation or tympanostomy tubes present? 1
• Ear canal anatomy: Stenosis or exostoses? 1
• Medical conditions: Diabetes, immunocompromised state, anticoagulation therapy? 1

Removal Methods

For Intact Tympanic Membrane:

• Cerumenolytic agents: Carbamide peroxide 5-10 drops twice daily for up to 4 days in children over 12 years 2
• Irrigation: Gentle flushing with warm water using soft rubber bulb syringe after cerumenolytic softening 2
• Manual extraction: Using otoscope with magnification and micro-instrumentation 1

For Non-Intact Tympanic Membrane or Tympanostomy Tubes:

• Mechanical removal is the ONLY safe option 1
• Irrigation is contraindicated due to risk of infection, ototoxic hearing loss, pain, and vertigo from caloric effects 1
• Use binocular microscope with micro-instrumentation for safe removal 1

Common Pitfalls to Avoid

• Do not irrigate if tympanic membrane integrity is uncertain—this can cause middle ear infection, ototoxicity, or vertigo 1
• Do not use cotton swabs or objects smaller than your elbow in the ear—these push cerumen deeper and can injure the canal or perforate the drum 1
• Do not use ear candles—no evidence of efficacy and can cause serious ear damage 1
• Do not overclean ears—excessive cleaning irritates the canal and paradoxically increases impaction risk 1

Parent Education

• Cerumen is normal and protective; it does not always need removal 1
• The ear has a natural "conveyor belt" self-cleaning mechanism where epithelial cells migrate laterally, carrying cerumen and debris outward 1
• Seek medical attention if home remedies fail or if ear pain, drainage, or bleeding develop (these are NOT cerumen symptoms) 1