Earwax (Cerumen) Impaction
Earwax, also known as cerumen, is a normal physiological substance produced in the external auditory canal. Earwax impaction occurs when accumulated wax causes symptoms, such as hearing loss and/or prevents adequate assessment of the ear, such as obstructing visualisation of the tympanic membrane.
This updated UKMLA guide to earwax impaction is based on NICE CKS and NICE NG98, which covers causes, symptoms, diagnosis and management.
Causes and Risk Factors
Risk factors for earwax impaction include:
- >50 y/o (as the cerum glands become atrophied with age, causing the earwax to become drier)
- <5 y/o
- Males
- Narrow or deformed ear canals
- Down syndrome
- Dermatological conditions (e.g. atopic eczema, psoriasis)
- Use of cotton buds (can push earwax deeper, instead of removing it)
Clinical Features and Diagnosis
Earwax impaction is a clinical diagnosis.
Typical clinical features:
- Hearing loss – most common
- Sensation of ear fullness
- Ear discomfort / pain
- Tinnitus
- Itching
- Dizziness / imbalance sensation
Otoscopic findings:
- Direct visualisation of earwax obstructing the external auditory canal
- Earwax may prevent adequate visualisation of the tympanic membrane
Management
Indications to remove earwax:
- Earwax causing hearing loss or other symptoms
- Tympanic membrane obscured by wax but needs to be viewed for a different reason (e.g. tympanic membrane perforation, otitis media)
Methods of removal:
| Step (step up if ineffective) | Description |
|---|---|
| 1 | Wax softeners drops, options include:
|
| 2 | Electronic ear irrigation
|
| 3 | Microsuction / manual removal with a probe |
Do NOT use cotton buds to remove earwax, as they can push wax deeper and worsen impaction.
Contraindications to Ear Irrigation
- Increased risk of infection / trauma / haemorrhage
- Perforated tympanic membrane
- Active infection / dermatitis of the ear canal
- Abnormalities of the ear canal (e.g. exostoses and ear canal stenosis)
- Acute otitis externa with oedematous ear canal and painful pinna
- Grommets in situ
- History of
- Any ear surgery (except extruded grommets within the last 18 months and discharged by ENT)
- Middle ear infection in the previous 6 weeks
- Any previous problems with ear irrigation
- Cleft palate (even if repaired)
- Foreign body in the ear
- Mucus discharge from the ear within the past 12 months (may indicate undiagnosed perforation)
- Hearing in only one ear if it is the ear to be treated
- Confusion or agitation
- Inability to cooperate (e.g. young children and some people with learning difficulties)
Possible Complications of Earwax Removal
- Otitis externa and media
- Tympanic membrane perforation
- Pain
- Vertigo
- Exacerbation of pre-existing tinnitus