Cerumen Impaction

By: Dr. Lusine Mamikonyan

What is cerumen?

Cerumen, also called earwax, is found inside the external auditory canal and is composed of dead skin cells and secretions of ceruminous and sebaceous glands of the ear canal. Its production is a normal physiological process as the cerumen protects the ear from infections, foreign bodies, and insects. In addition, it provides moisture to the skin of the ear canal. In most cases, cerumen is spontaneously removed by jaw movements. However, this self-cleaning mechanism cannot function properly in some individuals, leading to cerumen impaction. This is a common condition for physician visits and affects about 10% of the pediatric population and 30% of elderly and patients with cognitive impairment.

What are the causes of cerumen impaction?

Cerumen impaction occurs when its production exceeds the removal. Increased glandular activity, chronic ear infections, anatomical variations of the ear such as narrow canals, and an increased number of hair follicles in the ear are predisposing factors for earwax blockage. Other potential causes include frequent use of cotton swabs, hearing aids, and swimming plugs.

What are the common symptoms of cerumen impaction?

Cerumen occluding the external ear canal or the tympanic membrane can present with various symptoms, including conductive hearing loss, fullness in the ear, pain, itching, and tinnitus or a ringing sound in the ears. Sometimes, patients with this condition do not present with any symptoms, which is common with little buildup of earwax. Rarely the cerumen can get infected with bacteria or fungus, which will exacerbate the symptoms.

How is cerumen impaction diagnosed?

Patient history and physical examination will help the physician to make the diagnosis. Cerumen impaction is directly visualized by an otoscope or binocular microscope. Sometimes, the physician might require simple hearing tests.

How is cerumen impaction treated?

Cerumen impaction management mainly includes three options: cerumenolytic agents, irrigation, and manual removal.

Cerumenolytic agents are liquid solutions that can be used combined with manual removal with instrumentation and irrigation or used alone. They are topically applied in the external acoustic meatus to soften the cerumen. These agents have several advantages, such as practicality and low risk of mechanical injury. However, they might cause skin irritation or allergic reactions. Patients with tympanic membrane rupture or external ear infection are advised to avoid cerumenolytic agents.

The most commonly used irrigation technique is manual irrigation with a syringe. Warm water alone or combined with hydrogen peroxide is applied in the ear canal. Afterward, the canal should be evaluated for complete clearance or potential injury. Tympanic membrane perforation, tympanometry tubes, and anatomic abnormalities of external acoustic meatus must be excluded before the procedure. Complications due to irrigation include skin injury, pain, and rarely vertigo and tympanic membrane rupture.

Manual earwax removal is done under direct visualization via a binocular microscope or handheld otoscope with a metal or plastic loop, curette, and forceps. This method has some advantages over the other ones, such as low risk of ear infection and tympanic membrane perforation. However, manual removal requires more skills and specific equipment.

How to prevent cerumen impaction?

Instructions on proper ear hygiene can decrease the risk of earwax. People should avoid using cotton swabs or other objects to clean their ears. Individuals with frequent cerumen impaction can use mineral oil from time to time. Maintaining hearing aid hygiene can also prevent earwax blockage.