Earwax Impaction

Earwax impaction is accumulation of cerumen that blocks the external ear canal, causing symptoms or preventing examination of the eardrum. Cerumen is a normal protective secretion containing keratinocytes, lipids and antimicrobial peptides, and it normally migrates outward on its own. Impaction affects about 2 to 6 percent of the general population, up to 30 percent of older adults and children, and 30 to 40 percent of hearing aid users.

• Risk factors: narrow, hairy or tortuous canal, exostoses, use of cotton buds, hairpins or fingers (pushes wax inward), hearing aids and earbuds, dry skin or eczema, old age, learning disability, previous ear surgery.
• Complications: conductive hearing loss (up to 40 dB), tinnitus, dizziness, reflex cough, ear pain, otitis externa, hearing aid feedback, inability to examine the eardrum. Perforation can follow aggressive removal.

• Reduced hearing, blocked or full feeling, tinnitus, itch, discomfort, dizziness, reflex cough, hearing aid whistling. It often follows a bath or attempted cleaning.
• Otoscopy shows yellow brown to black wax occluding the canal.
• Red flags: discharge, severe pain, bleeding, fever, facial weakness, vertigo with hearing loss, history of perforation, grommets or ear surgery, sudden sensorineural hearing loss, diabetes or immunosuppression with granulation in the canal (malignant otitis externa), a mass or foreign body, unilateral hearing loss that persists after wax removal.

• Clinical, by otoscopy, with or without microscopy.
• Tuning fork tests (Weber lateralises to the blocked ear, Rinne negative in conductive loss) or audiometry if hearing loss persists after clearance.
• Contraindications to irrigation to be checked first: perforated eardrum (current or past), grommets, previous ear surgery, active otitis externa or media, cleft palate, only hearing ear, previous complications from irrigation.
• Differentials: foreign body, otitis externa, middle ear effusion, otosclerosis, cholesteatoma, exostoses, keratosis obturans, tumour, fungal otitis externa.

• Do not remove asymptomatic wax. Avoid cotton buds, hairpins, ear candles (burns, impaction, perforation) and fingers.
• Softening (first line, 3 to 5 days):
  • Olive or almond oil, 2 to 3 drops in the ear 2 to 3 times daily, lying on the side for 5 to 10 minutes afterwards.
  • Sodium bicarbonate 5 percent ear drops, 5 drops twice daily for 5 days (may dry and irritate).
  • Docusate sodium 0.5 percent or carbamide peroxide 6.5 percent drops, 5 drops twice daily for up to 4 days. Avoid with perforation or infection.
  • Many cases resolve with softening alone.
• Removal if softening fails or wax prevents examination:
  • Irrigation with a pressure controlled irrigator using water at body temperature (37 C, since cold or hot water causes vertigo), directing the jet along the posterior canal wall with the pinna pulled up and back in adults (down and back in children). Stop if pain or dizziness occurs.
  • Microsuction under direct vision is preferred when irrigation is contraindicated.
  • Manual removal with a curette, forceps or probe by a trained clinician.
• After removal, examine the eardrum and check hearing. If the canal is traumatised or otitis externa develops, use ciprofloxacin 0.3 percent with dexamethasone 0.1 percent drops, 3 to 4 drops twice daily for 7 days (safe with perforation).
• Prevention: clean the outer ear only with a cloth. People prone to wax can use olive oil drops once or twice weekly. Hearing aid users may need removal every 3 to 12 months.
• Refer to ENT for failed removal, perforation or previous surgery, exostoses, suspected cholesteatoma, sudden hearing loss or severe complications.