impacted cerumen

Last edited 01/2023 and last reviewed 05/2023

Ear wax:

    • a build-up of earwax in the ear canal can cause hearing loss and discomfort, contributes to infections, and can exacerbate stress, social isolation and depression (1)
    • also earwax can prevent adequate clinical examination of the ear, delaying investigations and management; GPs cannot check for infection and audiologists cannot test hearing and fit hearing aids if the ear canal is blocked with wax
    • excessive earwax is common, especially in older adults and those who use hearing aids and earbud-type earphones
    • in the UK, it is estimated that 2.3 million people each year have problems with earwax sufficient to need intervention
  • cerumen (ear wax)
    • is a complex mixture of lipids
    • is produced by the sebaceous glands of the external auditory meatus as a means of protecting the epithelial lining of the tract
    • is made up of epithelial cells, hair, and secretions of the external ear (2)
  • impacted cerumen
    • seen in about 4% of primary care patients(2)
    • commoner in children (2)
    • in this condition,cerumen, which may be hard, obstructs the auditory canal
    • risk factors for cerumen impaction are (3):
      • old age
      • learning disability
      • use of cotton swabs in ears
      • hearing aids
      • earplugs
  • clinical features of cerumen (2)
    • ear discomfort
    • hearing loss
    • tinnitus
    • dizziness
    • chronic cough
  • diagnosis
    • by direct visualization using an otoscope (2)

  • management
    • consider ear irrigation using an electronic irrigator, microsuction or another method of earwax removal (such as manual removal using a probe) for adults in primary or community ear care services if:
      • the practitioner (such as a community nurse or audiologist):
        • has training and expertise in using the method to remove earwax
        • is aware of any contraindications to the method
      • the correct equipment is available
      • when carrying out ear irrigation in adults (1):
        • use pre-treatment wax softeners, either immediately before ear irrigation or for up to 5 days beforehand
        • if irrigation is unsuccessful:
          • repeat use of wax softeners or
          • instil water into the ear canal 15 minutes before repeating ear irrigation
        • if irrigation is unsuccessful after the second attempt, refer the person to a specialist ear care service or an ear, nose and throat service for removal of earwax.
      • possible complications of wax removal are:
        • pain,otitis externa,perforation of tympanic membrane, tinnitus,dizziness,syncope,cough, cardiac arrest (2)

  • golden advice to patients
    • "Never put cotton swabs or other objects into the ear canal" (3)

Notes (4):

  • manual water-filled syringes are no longer recommended in the UK because of potential damage to hearing and risk of litigation (4)
  • contraindications to use of an electronic irrigator include
    • pre-existing otological conditions (for example, perforated eardrum, grommet, mastoid cavity, infection)
    • presence of foreign body
    • previous problems with wax removal
    • irrigation is contraindicated in patients with only one functioning ear
  • specialist referrals resulting from complications of irrigation (for example, perforated eardrum) are estimated at 1/1000
  • are anecdotal reports that drying the external ear after irrigation reduces the risk of ear infection

Reference:

Related pages:

syringing (to remove ear wax )

hearing loss (conductive)

tinnitus

otalgia