Cerumen impaction removal may not be considered an emergent procedure in the emergency department, but this omnipresent natural phenomenon will bring patients, from infants to the elderly, to your department at all hours of the day and night because loss of hearing is a foreign and uncomfortable sensation.
Cerumen impaction can cause complete hearing loss, pain, dizziness, chronic cough, and even infection. Patients who attempt to remove cerumen at home can end up with otitis externa or otitis media and even tympanic membrane trauma. The cerumen can block visualization of the tympanic membrane so TM rupture or ear infections could be missed. We are going to help you sort through the approaches and tools you need to treat this ailment quickly.
Cerumen impaction in a 55-year-old man with chronic cerumen impactions and otitis media and externa cause by sinus cancer. Photos by M. Roberts.
Cerumen impaction is present in approximately 10 percent of children, five percent of healthy adults, and about 57 percent of older patients in nursing homes, as well as up to 36 percent of patients with intellectual disabilities. (J Am Acad Audiol. 1997;8:391; https://bit.ly/336Ov0p.) Higher-risk populations will have chronic issues and visit your department frequently. Anyone, however, is at risk of complications of cerumen impaction, and those with hearing aids, who swim, or who use ear plugs are at higher risk.
At times, a foreign body may even be the cause of impaction because cerumen will form around the object to help push it out of the canal. It is not uncommon that patients will be unaware of a long-term foreign body in the ear, especially children. Finding something may be a surprise to them, and this must always be on the differential. Otitis externa or media can be treated once identified. See our prior blog on this at https://bit.ly/2ZHgQJM.
Foreign material removed from an impaction in the ear of a patient with acute bacterial otitis externa. Photo by M. Roberts.
The best way to initially treat cerumen impaction is to examine both ears and take a thorough history. If the canal appears blocked with cerumen, there are medications (cerumenolytics such as acetic acid, Cerumenex, Debrox, Colace, hydrogen peroxide, and saline solution) that can be instilled to soften the wax. These are still only 40 percent effective. (Br J Gen Pract. 2004;54:862; https://bit.ly/3idtHdP.) Using cerumenolytics in combination with gentle saline or warm tap water irrigation may be more effective. Several studies suggest that using cerumenolytics at least 15-30 minutes before irrigation may be of greater value if kept in the ear for 24 hours or more. (Aust Fam Physician. 2005;34:303.) Manual impaction removal with metal or plastic loop spoons alone can be effective, but is painful and can be dangerous.
If you choose the cerumenolytic and irrigation approach, you can use a plastic catheter (such as that from an IV needle) at the end of a 10 mL syringe with tap water that is warmed to room temperature. Cold water can cause a caloric-reflex response and should be avoided.
A cone-like device is used to precisely remove impaction. Photo by M Roberts.
What you may not know is that manual impaction removal is best completed by using a cone-like device inserted gently into the ear. A small metal cone can be gently placed in the ear to protect the canal during ear wax removal. It also helps the provider to visualize the cerumen and gently scrape out the material safely. It can also help prevent the spoon or extractor device from going too far into the canal because it can be used a marker of depth when inserted. When the cone is used, the wax will gently slide off into the cone and out of the ear, especially if the ear has been pretreated with a cerumenolytic 15-30 minutes before the procedure.
Watch a video of cerumen removal.
Irrigation v. Manual Removal v. Cerumenolytics
The 2017 guidelines from the American Academy of Otolaryngology-Head and Neck Surgery for managing cerumen impaction include removing cerumen in symptomatic patients (pain, redness, discharge, pruritis, hearing loss, fullness) as well as older patients and those with mental illness or intellectual disability. (Otolaryngol Head Neck Surg. 2017;156[1_suppl]:S1; https://bit.ly/3lWciJ3.) Patients who are asymptotic should not have routine cleaning in the ED. They may clear the impaction on their own.
Some families may swear that olive oil, grapeseed oil, or Vaseline is the best cerumenolytic to remove ear wax. Some providers may only have certain cerumenolytics in stock. In any event, a softening agent of any kind is better than none at all. Keep in mind that some cerumenolytics may cause localized reactions such as redness, rash, pruritis, or generalized irritation. (Otolaryngol Head Neck Surg. 2017;156[1_suppl]:S1; https://bit.ly/3lWciJ3.) If patients have had cerumen impaction in the past, it may be helpful to ask them what they have used for treatment.
The literature comparing the effectiveness of cerumenolytic agents, irrigation, and manual removal is limited. Systematic reviews have not found superiority of one method over the other. (Otolaryngol Head Neck Surg. 2017;156[1_suppl]:S1; https://bit.ly/3lWciJ3.) Direct visualization and experience can make this procedure more successful. Manual removal is not always easy, and can be painful and injure the canal.
A systematic review of 10 randomized trials of 11 cerumenolytics found that cerumenolytics were better than no treatment, but there was no significant difference in the efficacy of different types of drops. (Cochrane Database Syst Rev. 2018;7:CD012171; https://bit.ly/3iaLNNv.) Water and saline solutions were also used and found to be similarly effective compared with cerumenolytics. Research on certain cerumenolytics shows that mineral oils may cause less irritation and drying compared with hydrogen peroxide or acetic acid. Patients with dryness or excessive exfoliation of the ear canal skin should avoid preparations containing hydrogen peroxide because it can exacerbate cerumen accumulation. Consider mineral oil and liquid docusate sodium in these patients. (UpToDate. https://bit.ly/3bBVEtk.)
Martha Weighs In:
- Candling is dangerous. Instruct patients to avoid this practice. The U.S. Food and Drug Administration and various practice guidelines recommend that patients avoid ear candles for cerumen removal.
- Cold water irrigation is just cruel and a good way to get slapped.
- Do not sedate a child to remove ear wax, and consider ENT in house or referral the next day.
- Make an attempt to remove the wax, if possible, and refer to ENT for more difficult cases.
Jim Weighs In:
- Liquid Colace, placed in the canal for 20-30 minutes prior to irrigation, seems to work well.
- Manual wax removal can be painful and injure the canal. Best to try irrigation first.
- Irrigation with warm tap water using an 18-gauge IV catheter is usually effective, but it may take numerous irrigations. Don't give up too quickly.
- It is rather common for the patient to develop otitis externa after a complicated wax removal. A few days of a topical antibiotic solution in the canal is often prescribed.
- Do not irrigate if you are concerned about TM rupture.