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Impacted Cerumen

Ear Wax Impaction

Impacted cerumen refers to a condition of excess earwax blocking the external auditory canal. It mainly affects the ability to hear, but may also cause disturbance of equilibrium.


Presentation

Most patients are asymptomatic and IC may be an incidental finding diagnosed during a routine otological examination.

With regards to those patients who do present with manifest IC, partial conductive hearing loss is the most common symptom. Patients may also describe a feeling of fullness or pressure inside their ears. Otalgia and pruritus may be noted. Tinnitus has also been associated with IC. Dizziness and vertigo have been described and may result from functional impairment of the vestibular system.

Young children may be unable to provide such a detailed description of discomfort and pain. They may merely touch their ears repeatedly and present feeding and sleeping problems. Parents may note a reduced ability to hear.

About 50% of IC patients present with bilateral symptoms [5].

Rigor
  • (Grade of recommendation: B-, based on lack of rigorous randomization, lack of definition of cerumen impaction, and only one placebo-controlled trial.) No trials recommending one strategy over another exist.[mdedge.com]
  • Only one rigorous review 42 was found that examined the evidence for the best treatment for impacted cerumen.[academic.oup.com]
Collapse
  • Impacted cerumen Inclusion term(s): Wax in ear H61.20 Impacted cerumen, unspecified ear H61.21 Impacted cerumen, right ear H61.22 Impacted cerumen, left ear H61.23 Impacted cerumen, bilateral H61.3 Acquired stenosis of external ear canal Inclusion term(s): Collapse[icd10coded.com]
Cough
  • Impacted cerumen can cause earaches, temporary hearing loss, ringing in the ear (tinnitus), coughing, or a feeling that the ear is full or plugged. It also can increase the risk of an outer ear infection.[kidshealth.org]
  • Complications of irrigation include otitis externa, perforation, canal trauma, pain, cough, tinnitus, vertigo, otitis media, treatment failure, and time consumption. 9 Harm done by wax softeners is minimal.[mdedge.com]
  • Impacted earwax can cause symptoms like ear pain, itching, feeling of fullness in the ear, ringing in the ear (tinnitus), hearing loss, discharge coming from the ear, odor coming from the ear, cough, and/or change in hearing aid function.[sciencedaily.com]
Heart Failure
  • Failure and Transplantation Cardiology Nita Ahuja MD, MBA Gastrointestinal Surgical Oncology, General Surgery, Minimally Invasive Surgery, Sarcoma and Connective Tissue Surgical Oncology Paul Aiello MD Radiology, Diagnostic Radiology Joseph Akar MD,[yalemedicine.org]
Skin Lesion
  • The presence of cerumen may, however, significantly diminish the risk of an ear infection in case of skin lesions within the external auditory canal.[symptoma.com]
Osteophyte
  • This is not necessarily a congenital condition since space-occupying processes like hyperkeratosis, inflammatory swelling, osteophytes, tumors and a variety of other pathologies may secondarily restrict the lumen of the external acoustic meatus.[symptoma.com]
Tinnitus
  • Tinnitus (ringing in the ears) is the sensation of hearing ringing, buzzing, hissing, chirping, whistling, or other sound in your ear. This can be intermittent or continuous, and can vary in loudness. 3. Feeling of fullness in the ear 4.[info.earwaxmd.com]
  • A feeling of fullness in the ear Pain in the ear Difficulty hearing, which may continue to worsen Ringing in the ear ( tinnitus ) A feeling of itchiness in the ear Discharge from the ear Odor coming from the ear Dizziness Cleveland Clinic News & More[my.clevelandclinic.org]
  • Impacted cerumen can cause earaches, temporary hearing loss, ringing in the ear (tinnitus), coughing, or a feeling that the ear is full or plugged. It also can increase the risk of an outer ear infection.[kidshealth.org]
  • If the patient’s ear wax is cleared, ensure that the symptoms (tinnitus, hearing loss, or otalgia) are resolved. If not, think of another diagnosis. Roland PS, et al. Clinical practice guideline: cerumen impaction.[hippoed.com]
  • Symptoms & Types Symptoms include: Itching Pain Hearing Loss Tinnitus (ringing in the ears) Dizziness A sense of fullness in the ear Diagnosis & Tests The doctor will use an instrument (otoscope) with a light attached to look into the ear canal.[texaschildrens.org]
Otalgia
  • This is, however, not an option if patients suffer from hearing loss or otalgia. Ceruminolytics may also significantly improve the effectivity of irrigation.[symptoma.com]
  • If the patient’s ear wax is cleared, ensure that the symptoms (tinnitus, hearing loss, or otalgia) are resolved. If not, think of another diagnosis. Roland PS, et al. Clinical practice guideline: cerumen impaction.[hippoed.com]
  • Blockage of the ear canal from cerumen can lead to a host of symptoms including: hearing loss, tinnitus, fullness, itching, otalgia, discharge, odor, or cough.[guidelinecentral.com]
  • [PubMed] [Read by QxMD] Tags: Acute Otitis Media ear pain otalgia otitis externa Otitis Media Sean M. Fox I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same.[pedemmorsels.com]
  • Advise anyone who has had earwax removed to return if they develop otalgia, significant itching of the ear, discharge from the ear or swelling of the external auditory meatus, as this may indicate infection.[patient.info]
Ear Discharge
  • A feeling of fullness in the ear Pain in the ear Difficulty hearing, which may continue to worsen Ringing in the ear ( tinnitus ) A feeling of itchiness in the ear Discharge from the ear Odor coming from the ear Dizziness Cleveland Clinic News & More[my.clevelandclinic.org]
  • PRECAUTIONS: on rare occasions, treatment may cause itching, burning, or increase in ear discharge. Should these symptoms develop after the first few applications of the solution, please discontinue treatment and contact our office.[gulfcoastfacialplastics.com]
  • Advise anyone who has had earwax removed to return if they develop otalgia, significant itching of the ear, discharge from the ear or swelling of the external auditory meatus, as this may indicate infection.[patient.info]
  • First, cerumen is considered potentially infectious when it is contaminated with blood, dried blood, mucous, or ear discharge.[audiologyonline.com]
Hearing Problem
  • Children with a history of impacted cerumen are therefore at greater risk of subsequent hearing problems and of a more permanent nature than those without, notwithstanding the removal of such impacted cerumen.[ncbi.nlm.nih.gov]
  • If the individual still has hearing problems or tinnitus after earwax removal, they may require a hearing loss test to check for other issues.[medicalnewstoday.com]
Ear Fullness
  • DO seek medical evaluation if you have symptoms of hearing loss, ear fullness, and ear pain if you are not certain that they are from cerumen. DO ask your provider about ways that you can treat your cerumen impaction at home.[sciencedaily.com]
  • Trouble hearing Dizziness Ear fullness or a feeling that something is plugging up your ear Itchiness or pain in the ears Ringing in the ears How is cerumen impaction diagnosed? Your healthcare provider will ask about your medical history.[drugs.com]
  • Seek medical evaluation if you have symptoms of hearing loss, ear fullness or ear pain if you are not certain they are from cerumen.[guidelinecentral.com]
  • fullness, pruritus, dizziness, tinnitus, or an earache.[ncbi.nlm.nih.gov]
Dizziness
  • Untreated buildup can lead to hearing loss, irritation, pain in the ear, dizziness, ringing in the ears and other problems. Ear wax can be removed in several ways; some of these methods can be done at home.[my.clevelandclinic.org]
  • Dizziness and vertigo have been described and may result from functional impairment of the vestibular system. Young children may be unable to provide such a detailed description of discomfort and pain.[symptoma.com]
  • Symptoms & Types Symptoms include: Itching Pain Hearing Loss Tinnitus (ringing in the ears) Dizziness A sense of fullness in the ear Diagnosis & Tests The doctor will use an instrument (otoscope) with a light attached to look into the ear canal.[texaschildrens.org]
  • Cotton swabs, hair pins, care keys, toothpicks...these can all injure your ear and may cause a laceration (cut) in the ear canal, a perforation (hole) in the eardrum, and/or dislocation of the hearing bones, leading to hearing loss, dizziness, ringing[sciencedaily.com]
  • (Mild dizziness may occur; this may be avoided by warming the solution to body temperature).[gulfcoastfacialplastics.com]
Vertigo
  • Complications of irrigation include otitis externa, perforation, canal trauma, pain, cough, tinnitus, vertigo, otitis media, treatment failure, and time consumption. 9 Harm done by wax softeners is minimal.[mdedge.com]
  • Vertigo (not all experts believe that wax is a cause of vertigo). Cough (rare and caused by pressure on the auricular branch of the vagus nerve).[patient.info]
  • Irrigation in the presence of a perforated TM may produce caloric effects resulting in vertigo. Mechanical removal of cerumen is the preferred technique in these patients.[aafp.org]
  • Dizziness and vertigo have been described and may result from functional impairment of the vestibular system. Young children may be unable to provide such a detailed description of discomfort and pain.[symptoma.com]
  • Anyone who has had any problems, such as severe vertigo or pain, following previous irrigation should not undergo this procedure again.[medicalnewstoday.com]
Neglect
  • As there are many misconceptions about earwax among the public, health care providers should not neglect patient education opportunities. Patients should be instructed about normal earwax and the self-cleaning nature of the external ear.[aappublications.org]

Workup

IC is diagnosed by means of a standard otological examination. Otoscopic examination of the external acoustic meatus does not allow for visualization of the tympanic membrane because a dense mass of cerumen plugs the ear passage. The skin lining the external auditory canal typically shows signs of inflammation, e.g., erythema and edema. Severity of IC as well as position and properties of the ceruminal mass should be assessed during this examination.

Candida
  • However, the authors also isolated Candida albicans, Pseudomonas aeruginosa, P. stutzeri and S. aureus. Secondly, 21 only 16/164 cerumen samples showed no growth.[academic.oup.com]

Treatment

Removal of cerumen is the treatment of choice in symptomatic patients. Watchful waiting is indicated in the remaining IC patients, since the condition may resolve spontaneously within a few days.

Removal of cerumen should be carried out with utmost care in order to avoid inflicting damage to the external auditory canal or the tympanic membrane. In general, three therapeutic approaches can be distinguished: irrigation, application of ceruminolytics and manual removal [1]. These techniques are frequently combined, i.e., an irrigation with a solution containing ceruminolytics may be more effective than either method alone.

Irrigation

Irrigation may be carried out with saline solution or ceruminolytics, both warmed up to body temperature. Ideally, an irrigation is prepared by applying either of both liquids half an hour before the ear is rinsed. Removal of the ceruminal plug may be largely facilitated after soaking. With regards to the equipment, both ear syringes as well as oral jet irrigators are frequently used. However, the latter should not be utilized without putting on a supplementary ear irrigator tip. Excess pressure largely increases the risk for perforation of the tympanic membrane and other trauma. Many otolaryngologists use improvised irrigation system, which is a valid alternative as long as the physician disposes of the necessary experience to manage it [10].

Irrigation is contraindicated in patients presenting tympanic membrane perforations or that recently underwent surgery to reconstruct this organ.

Application of ceruminolytics

Ceruminolytics alone may resolve up to 40% of IC cases if applied regularly during prolonged periods of time. This is, however, not an option if patients suffer from hearing loss or otalgia. Ceruminolytics may also significantly improve the effectivity of irrigation. Distinct formulations are available, but superiority has not been proven for any particular product.

Similar to what has been stated about irrigation, ceruminolytics are not to be administered in patients that do or did suffer from tympanic membrane perforations.

Manual removal

Manual removal of cerumen is carried out with a curette, forceps, or suction device. It is the method of choice if both irrigation and ceruminolytics are contraindicated or if direct visualization of the procedure is required for any other reason.

Prognosis

IC has generally an excellent prognosis. Many patients presenting this condition remain asymptomatic for years. However, IC is associated with an increased risk of infection, inflammation and hearing loss. In fact, it has been estimated that one out of three children suffering from otitis media also shows IC. Considering the above given epidemiological data, this estimate corresponds to a threefold increase when compared with the general pediatric population.

Complications that may arise from removal of IC are traumas to the external auditory canal or the tympanic membrane, subsequent otalgia, otitis externa or media and further hearing loss.

Etiology

Any pathologic condition interfering with the process of ceruminokinesis may ultimately provoke IC. For instance, anatomic anomalies such as a narrow or abnormally shaped external auditory canal may impede transport of cerumen towards the outer ear. This is not necessarily a congenital condition since space-occupying processes like hyperkeratosis, inflammatory swelling, osteophytes, tumors and a variety of other pathologies may secondarily restrict the lumen of the external acoustic meatus. Similarly, patients who are wearing hearing aids are plugging their ear passage and thus provoke retention of earwax.

Both changes in quality and quantity of cerumen may increase the risk of IC. Ceruminal fluidity decreases with age. While children generally dispose of well-viscous cerumen, earwax is rather dry and brittle in the elderly. An excess production of cerumen may result from dyskeratosis and other dermatological disorders.

Any ineffective attempt to remove cerumen from the external auditory canal may literally result in compaction of earwax in front of the tympanic membrane. Available transport mechanisms cannot clear this dense mass and continuous secretion of new cerumen adds to its volume. Therefore, neither cotton swabs and much less pencils, hair pins or other objects are suitable to clear the ear passage from earwax.

Epidemiology

It has been estimated that 10% of all children and 5% of otherwise healthy adults suffer from IC, although the condition may be asymptomatic in a large share of these patients [4]. The small and narrow external auditory canal of pediatric patients may partially explain the observed high incidence in this age group. With regards to adults and as has been mentioned above, IC is most frequently observed in the elderly. Patients suffering from mental retardation pose another risk group.

A male-to-female ratio of 1.6 to 1 has been observed in a study comprising more than 200 patients [5].

Sex distribution
Age distribution

Pathophysiology

The external auditory canal is lined with modified skin that nevertheless contains all characteristic appendages, i.e., hairs, sebaceous and sweat glands. Local sweat glands are particularly wide merocrine glands and are called ceruminal glands. Sebaceous glands, in contrast, are holocrine glands that open into hair follicles. Both sebaceous and ceruminal glands contribute to cerumen production. Earwax mainly consists of saturated and unsaturated long-chain fatty acids, alcohols, squalene and cholesterol [6].

Not only skin appendages but also skin layers found in the external acoustic meatus correspond to those of other regions of the body. Thus, cells originating from the basal layer of the epidermis pass through multiple phases of differentiation until being shed from the stratum corneum. However, they are not cleared as easily from skin surface and become part of the cerumen instead. It has been estimated that keratin accounts for more than half of the total weight of cerumen. But removal of keratin and cellular debris is only one of those functions fulfilled by cerumen.

Cerumen poses both a mechanical and chemical barrier against infection and infestation of the ear. Ceruminokinesis, i.e., the constant but barely noticeable outward flow of cerumen, transports keratin, debris, dust and other foreign bodies that may have entered the external auditory canal towards the outer ear. Furthermore, cerumen has antibacterial and antimycotic properties: Its pH is slightly acidic and cerumen contains lysozyme, an antibacterial hydrolase also contained in saliva, lacrimal fluid and nasal secretion. Although genetic variations between distinct types of cerumen have been described a long time ago, more recent studies could not find significant differences regarding incidence rates of otitis externa and ceruminal bactericidal activity [7] [8]. The presence of cerumen may, however, significantly diminish the risk of an ear infection in case of skin lesions within the external auditory canal. Of note, microbial evolution brought forth bacterial strains, mainly Staphylococcus spp. and Bacillus spp., able to survive in cerumen and utilize its components for growth and replication [9].

Prevention

One of the main risk factors for IC is the ineffective attempt to remove cerumen from the external auditory canal inserting cotton swabs, hair pins, keys or other not suitable objects. This generally results in compaction of cerumen in the depth of the external ear. Patients should be advised against such behavior. Removal of cerumen should only be carried out by trained health care professionals.

Patients with an increased risk of IC may use ceruminolytics to prevent this condition.

Summary

The external auditory canal, also called external acoustic meatus, extends from the outer ear to the tympanic membrane and is therefore considered to be part of the external ear. The auditory ossicles (malleus, incus and stapes) are located within the middle ear and thus medial to the tympanic membrane. Finally, cochlea and vestibular system compose the inner ear. Here, mechanical stimuli originating from sound waves and body posture changes are translated into nervous signals.

A variety of mechanical and chemical barriers avoids damage to the sensitive parts of middle and inner ear. One of those barriers is cerumen produced in the external auditory canal. The latter is lined with skin that, similar to other areas of the body, contains sebaceous glands and sweat glands. However, due to anatomical and physiological modifications, local sweat glands are designated ceruminal glands. Both sebaceous and ceruminal glands contribute to cerumen production [1]. Furthermore, desquamated epithelial cells, hairs, debris and dust may constitute more or less physiological parts of cerumen.

Cerumen, as produced by sebaceous and ceruminal glands, is a yellowish, viscous liquid. Its properties change with time, dehydration and retention of debris and dust, as mentioned above: It loses fluidity, becomes darker, harder and brittle. It should nevertheless be transported towards the outer ear and be cleared from the external auditory canal by means of a process called ceruminokinesis, i.e., cerumen transport stimulated by masticatory movements. However, any condition interfering with ceruminokinesis prolongs the time of retention of cerumen inside the external auditory canal, promotes further hardening until finally, the ceruminal plug cannot be removed by any means. This condition is referred to as impacted cerumen (IC).

IC is a very common condition and has been estimated to affect about 5% of the population. The widely spread habit of trying to remove cerumen with cotton swabs, pencils or otherwise unsuitable objects increases the risk of IC [2]. It may be an incidental finding in asymptomatic patients, but the pathology may also cause significant hearing impairment, otalgia and dizziness and have patients present to the emergency room [3]. Thus, general practitioners, otolaryngologist and those professionals attending in emergency departments should all dispose of detailed knowledge regarding treatment options for IC.

Patient Information

External, middle and inner ear are the three main parts of the human ear. The external auditory canal is part of the external ear and extends from the outer ear to the tympanic membrane. It is lined by modified skin that disposes of hair follicles, hairs, sebaceous and sweat glands. Here, the latter are also called ceruminal glands. Similar to any other region of the human body, skin cells within the ear passage are shed after passing through distinct phases of differentiation. Hairs may fall out now and then.

Both sebaceous and ceruminal glands contribute to production of cerumen, a secretion that fulfills a variety of protective functions. On the one hand, it has antibacterial and antimycotic properties and thus reduces the risk of infection. On the other hand, it clears the external auditory canal from fallen hair, dead cells, debris, dust and any foreign body that may have entered the ear. Therefor, a constant outward flow is required. It is induced by chewing movements.

Any pathological condition that interferes with ceruminal flow will result in an accumulation of cerumen and all the aforementioned particles within the external ear. For instance, some patients have a very narrow external auditory canal; others may suffer from dermatological diseases that yield increased quantities of desquamated cells. Also, people wearing a hearing aid may involuntarily provoke an accumulation of cerumen which, in medical terms, is designated impacted cerumen.

One of the most common causes for impacted cerumen is the ineffective attempt to remove earwax with cotton swabs, hair pins, keys or any other not suitable object. The result of such measures generally is a compact mass of cerumen lodged in front of the tympanic membrane. The aforementioned mechanisms are insufficient to clear this mass and patients now have an increased risk for hearing loss, infection, inflammation and ear pain.

Removal of cerumen should only ever be carried out by a trained health care professional.

References

Article

  1. Guest JF, Greener MJ, Robinson AC, Smith AF. Impacted cerumen: composition, production, epidemiology and management. Qjm. 2004; 97(8):477-488.
  2. Baxter P. Association between use of cotton tipped swabs and cerumen plugs. Br Med J (Clin Res Ed). 1983; 287(6401):1260.
  3. Isaacson JE, Vora NM. Differential diagnosis and treatment of hearing loss. Am Fam Physician. 2003; 68(6):1125-1132.
  4. McCarter DF, Courtney AU, Pollart SM. Cerumen impaction. Am Fam Physician. 2007; 75(10):1523-1528.
  5. Gabriel OT. Cerumen impaction: Challenges and management profile in a rural health facility. Niger Med J. 2015; 56(6):390-393.
  6. Okuda I, Bingham B, Stoney P, Hawke M. The organic composition of earwax. J Otolaryngol. 1991; 20(3):212-215.
  7. Ibraimov AI. Cerumen phenotypes in certain populations of Eurasia and Africa. Am J Phys Anthropol. 1991; 84(2):209-211.
  8. Pata YS, Ozturk C, Akbas Y, Gorur K, Unal M, Ozcan C. Has cerumen a protective role in recurrent external otitis? Am J Otolaryngol. 2003; 24(4):209-212.
  9. Gerchman Y, Patichov R, Zeltzer T. Lipolytic, proteolytic, and cholesterol-degrading bacteria from the human cerumen. Curr Microbiol. 2012; 64(6):588-591.
  10. Propst EJ, George T, Janjua A, James A, Campisi P, Forte V. Removal of impacted cerumen in children using an aural irrigation system. Int J Pediatr Otorhinolaryngol. 2012; 76(12):1840-1843.

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Last updated: 2019-06-28 11:59