Production of cerumen (earwax) is a normal and naturally occurring process in humans and many other mammals. It protects the ear from infection and provides a barrier for insects and water. Cerumen is typically expelled from the ear canal spontaneously through natural jaw movement. However, in certain individuals, the self-cleaning mechanism fails, and cerumen can become impacted. Cerumen impaction can occlude the canal or press against the tympanic membrane, potentially causing ear discomfort, conductive hearing loss, itching, and tinnitus. Cerumen impaction occurs in up to 6% of the general population, affecting 10% of children and over 30% of the elderly and cognitively impaired populations. It is often seen in those with hearing aids or earplugs, in an external canal occluded by a foreign body, or in people with ear canal anatomic abnormality.
Excessive buildup of cerumen is likely underdiagnosed and undertreated. In the United States, it leads to 12 million patient visits and eight million cerumen removal procedures each year. It can interfere with tympanic membrane examination in the clinical setting. It is diagnosed by direct visualization by a trained provider using an otoscope. 
Cerumen is made up of shed skin cells and secretions from both the sebaceous and ceruminous glands of the lateral third of the external auditory canal.
Although excessive accumulation of cerumen is typically asymptomatic, patients should be treated if presenting with hearing loss, ear fullness, pruritus, dizziness, tinnitus, or an earache. Inability to examine an ear due to cerumen impaction is another indication for cerumen removal.
When discovered in the asymptomatic patient, it is not always necessary to treat. It is important to relate to patients that cerumen does not always need to be removed, as cerumen naturally has bacteriocidal, protective, and emollient properties. Observation should be offered as a management strategy if appropriate.
Providers should be wary of patients with certain illnesses (HIV, diabetes mellitus), chronic anticoagulation, or anatomical defects narrowing the canal. In patients with diabetes mellitus, a higher pH is typically present in the cerumen, making superimposed bacterial infections more common. In those with HIV, consider not using tap water to irrigate as there is an association with malignant external otitis. Caution should be exercised with those on chronic anticoagulation as they are at a higher risk for hemorrhage or hematomas.
Use of cerumenolytics (see below) is safe, but contraindications include a perforated tympanic membrane or history of ear surgery including tympanostomy tube placement. Common reactions include local irritation and a rash. With prolonged use, a superinfection may occur.
When treatment is appropriate, there are three recommended removal methods: cerumenolytic agents, irrigation, and manual removal.
Cerumenolytic agents, also known as ear wax drops, are liquid solutions which help thin, soften, break up, and/or dissolve ear wax. These are typically water- or oil-based drops, with water-based solutions being the most commonly used. Typical ingredients found in water-based cerumenolytics include hydrogen peroxide, acetic acid, docusate sodium, and sodium bicarbonate. Common ingredients in oil based cerumenolytics include peanut, olive, and almond oil. Most drops are available over the counter. Typically, up to five drops are used at a time one to two times daily for three to seven days. They can be either used by themselves or in conjunction with a procedure such as an ear irrigation.
A commonly prescribed cerumenolytic is carbamide peroxide (brand name Debrox or Murine ear wax removal). Five to 10 drops are placed twice daily for up to four days. The drops work by releasing oxygen to soften and remove ear wax and also have a weak antibacterial effect.
Irrigation is another method to safely and effectively remove unwanted cerumen. Several irrigation methods may be used in the clinical setting. Commonly, warm water alone or a 50/50 mix of water and hydrogen peroxide is inserted into a syringe and discharged into the ear canal with a basin underneath. Another option is a standard oral jet irrigator, with or without a modified tip. Although these methods are inexpensive, if not done properly they can potentially cause trauma, including perforation of the tympanic membrane. To mitigate the risk, an ear irrigator tip can be used. There are electronic irrigators available as well; however, there are no controlled trials to compare the different irrigation methods.
Manual removal is the final method recommended by the American Academy of Otolaryngology-Head and Neck Surgery for removal of unwanted cerumen. Manual removal often requires specialized instrumentation for better visualization, such as a binocular microscope or a handheld speculum. The removal device involves a metal or plastic loop or spoon, curette, or alligator forceps. Some products have illuminated tips to help visualize during the procedure. Advantages of this method are a decreased risk for infection because the ear canal is not exposed to moisture. It does, however, pose a small risk of perforation and local trauma, especially if the patient is uncooperative. This method also requires more clinical skill.
To prevent further accumulation of cerumen in patients with recurrent symptoms greater than one per year, patients may apply mineral oil to the external canal 10 to 20 minutes weekly. Patients with hearing aids should remove them for eight hours a day to reduce cerumen buildup.
There are other over-the-counter devices to remove cerumen that physicians recommend. Cotton swabs are commonly used but should be avoided, as they may worsen the impaction or cause a perforation of the tympanic membrane. Another common home remedy is ear candling. This involves a hollow tube coated in beeswax. One end is inserted into the ear canal, and the other is ignited. It is marketed to have a "chimney effect," created by the pull of air from the ignited candle. This procedure is strongly recommended against by the United States Food and Drug Administration as it is ineffective and has the potential for injury.
It is important to ensure other diagnoses are not missed in patients being treated for cerumen impaction. As mentioned, common complaints of these patients include ear pain, tinnitus, and dizziness. Once cerumen is cleared, and the patient is seen for a follow-up visit, it is important to rule out diagnoses such as otitis media, otosclerosis, sensorineural hearing loss, temporomandibular joint syndrome, and upper respiratory tract infections, among others. When done correctly and successful, it results in immediate symptom relief and patient satisfaction.
Cerumen impaction is often challenging to treat. It is uncomfortable for the patient and often difficult for the clinician and nurse working together to remove the impaction. The healthcare team must work in a coordinated fashion to obtain satisfactory results and avoid complications such as iatrogenic perforation. [Level V]
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