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Earwax (Cerumen) Impactation and Management - Complete review

Updated: Aug 28, 2023

How do I clean my ears? When to treat? What is the best way to manage it? by Paula Cunha - Audiologist at Beyond Hearing


Problems attributed to the accumulation of earwax (cerumen) are among the most common reasons for people to present to their general practitioners with ear trouble. (8)

About 90% of people believe that ears should be cleaned. It is commonly performed and part of the daily hygiene routine. However, there is a truth to the saying: “Do not put anything smaller than your elbow in your ear!"


The following text provides evidence-based information and recommendations on ear wax management, including causes, symptoms, methods, and contraindications. It also focuses on education, prevention, referral, and coordination of care.



What is Earwax?

Earwax is a natural substance secreted in the ear canal, also known by the medical term

cerumen. It is composed of glandular secretion mixed with exfoliated squamous epithelium (dead skin) as a brown, orange, red, yellowish, or grey waxy substance.







Figure 1. Cerumen is formed in the outer two-thirds (cartilaginous portion) of the ear canal, not the inner third (bony portion) that ends at the eardrum. Impacted cerumen (green-like collection) can completely obstruct the ear canal. Adapted and reproduced with permission. (1)


Why do I have it? Why does ear wax accumulate?

It protects, cleans, and lubricates the delicate skin of the external auditory canal and the tympanic membrane against bacteria, fungi, and water.


Its self-cleaning mechanism occurs through epithelial migration and movement of the jaw (talking and chewing) (7). It is an ongoing process.


“Did you know: These cells migrate at speeds of about 0.05 mm/day, similar to the rate of nail growth? (10)


When the self-cleaning mechanism is disrupted, wax accumulates and can become impacted.


Figure 2. Otoscopic view of impacted cerumen


The diagnosis of cerumen impaction is when the accumulation of ear wax causes symptoms, prevents necessary ear assessment, or both.


What are the common causes of earwax build-up?

Anatomical variations, and infectious or dermatological diseases, can interfere with the normal migratory process.

Table 1: Risk factors for ear wax build-up


Prevalence

Ear Wax build-up is one of the most common reasons why patients seek medical care for ear-related problems - Children 10%, Healthy Adults 5%, Elderly 57% (1)


There is a high incidence and prevalence of cerumen impaction in elderly patients, young children, and the cognitively impaired.


The percentage of hearing aid users with impaction is higher than the general population. (1)


“Did you know that a higher incidence of cerumen has been reported in children whose ears were cleaned with cotton tips?”


What are the symptoms of a blockage of the ear canal?

Symptoms, diagnosis cerumen, and indications for treatment

While often harmless, cerumen impaction can lead to unpleasant symptoms and should be diagnosed by health history, physical examination of the ear (otoscopy), and audiological evaluation.

Table 2: Common symptoms of blockage ears


Treatment is strongly recommended when the accumulation of cerumen causes symptoms, prevents or interferes with assessment of the ear, or both. Otherwise, leave it alone.


Asymptomatic cerumen does not require active management, except in populations at risk: those who are not able to express symptoms like young children, cognitively impaired persons, and those who wear hearing devices.


“Did you know: That hearing loss associated with cerumen impaction may further impair cognitive function?” (1)


Other factors that influence treatment choice and modify management to achieve safer outcomes are the use of anticoagulant therapy, immunocompromised state, diabetes mellitus, radiation therapy to the head and neck, ear canal stenosis, exostoses, nonintact tympanic membrane. Also, increased risk of ear bleeding, and postprocedure Otitis externa (including malignant), lead to osteoradionecrosis, trauma, and vertigo.

Table 3: Modify factors that influence treatment choice.


To minimize harm, avoid potential complications related to treatment, and achieve safe outcomes, the healthcare professional should be trained and have the proper equipment.


Effective treatment options - based on supporting evidence

How to safely remove ear wax

There are 3 most safe and significantly effective treatment options: Cerumenolytic Agents, Irrigation, and/or Manual Removal. Observation is also a reasonable method since cerumen naturally and spontaneously migrates toward the outside of the ear canal. They can be used in isolation or a combination of treatments, on the same day or at intervals.


At the moment, there are no studies that compare or specify one method as a superior option versus another. However, there are risks, specific adverse effects, and contraindications. (1)


Table 4 shows a summary overview of the 3 most effective treatment options, including benefits, potential risks, and contraindications. The patient preference is also highly considered when possible.


Cerumenolytic agents

A topical compound that softens or disintegrates earwax and it is the first choice of action.

There are 3 forms:

1. Water-based

2. Oil-based

3. Non-water or non-oil based


There is no benefit or superiority of one agent over another (8). Using ear drops is better than no treatment. The use of cerumenolytics prior in conjunction with another method shows significant ease of wax removal and fewer adverse side effects like discomfort and vertigo. (5)


Irrigation or Syringing

Flush out the earwax with water at body temperature and low pressure, directed at the ear wall (not toward the tympanic membrane). It should be safe for normal ears.


However, complications from syringing are an increasingly common reason for presentation to ear, nose, and throat (ENT) specialists and medico-legal complaints against General Practitioners (2).


Reacidifying the ear canal should be considered after treatment

(vinegar, acetic acid, and alcohol if the tympanic membrane

is intact). (1)


Manual removal (suction and/or use of instruments)

It is an effective therapy and uses a suction tip, curette, alligator, forceps, and/or hook. Under direct visualization, it is often quicker and does not expose the ear to moisture. It requires a trained, skilled, and experienced clinician.



It is the preferred technique ENT specialists use, including patients with Modifying Factors (ear surgery, nonintact tympanic membrane, exostoses, diabetics, immunocompromised). Prowse and Mulla showed in a study 91% successful clearance with aural microsuction (i.e. sufficient to view the tympanic membrane).


Some patients report that microsuction is a noisy procedure. However, studies found no evidence of any shift in audiometric thresholds following microsuction aural toilet. (6) The prior use of cerumenolytics appears to further reduce their severity.

Table 4 SOURCE: Adapted from Clinical Practice Guideline (Update): Earwax (Cerumen Impaction). Otolaryngology-Head and Neck Surgery, 2017. (1)

* Modify Factors: increased risk of bleeding (use of blood thinner), skin or tympanic membrane trauma, increased risk of post-procedural Otitis media; head and neck radiation; ear surgery, dermatological conditions (eczema, dermatitis, dysplasia), anatomical challenges (stenosis, exostoses), diabetes, immunocompromised.

** Include, but are not limited to


Direct assessment and reevaluation after any procedure are required to confirm the effectiveness of treatment. If multiple attempts to remove the ear wax are ineffective, or If the impaction is resolved, but symptoms persist, a further evaluation for alternative diagnosis should be considered, this may include: hearing loss, infections, temporomandibular joint syndrome, medication side effects, head & neck tumors, eustachian tube dysfunction, or other disorders, and a referral to a specialist may be requested. In rare cases, sedation or general anesthesia may be needed.


Did you know: that some studies showed statistically significant improvement in hearing and cognitive function after earwax removal? (1)


What about Ear Candling and the use of Cotton Tips?

For patient safety, reducing harm, avoiding ineffective treatments, low quality of evidence, and few clear advantages, as the risks involved exceed benefits, the methods above are not recommended.

Many problems with ear wax result from people using cotton tips in an attempt to remove the wax. But what they actually do is push the wax further into the ears, causing it to impact and accumulate. So, to quote the words said by many: "Do not put anything smaller than your elbow in your ear!"(10). Lee et al showed that complications do arise from self-cleaning of the external auditory canal - home use of jet irrigation, and cotton-tipped swabs.

Ear Candling does not show any evidence of removing earwax and actually showed deposits after candling composed of candle wax. Complications of candling include ear blockage, ear canal burns, tympanic membrane perforation, conductive hearing loss, otitis externa, and hair fire (1).


The links below show experiments done by Dr. Cliff with ear candling.


How do I clean my ears?

Ear hygiene and prevention of cerumen impaction

The Clinical Practice Guideline presents some measures that may be beneficial in reducing the accumulation or preventing the recurrence of cerumen impaction:

  1. Use of wax softening drops once a week

  2. Self-irrigation with bulb syringe once weekly (not oral jet)***

  3. Proper care and routine cleaning of hearing devices

  4. Routine cleaning of the ear canal by a healthcare professional

*** Currently, there is no standard protocol for self-irrigation of ears based on the efficacy and safety of irrigation solutions, delivery devices, or frequency of regimens. Studies evaluating the benefits as well as the harms associated with specific interventions designed to prevent or reduce cerumen impaction are very limited. Patients interested in these approaches should be appropriately trained to do them safely (1) and follow the instructions from manufacturers.


At my practice, I advise my clients the same way I do myself: to use a facecloth or a towel after a shower or bath, over your fingertip, and dry the outside of the ear and entrance of the ear canal. It should be enough and safe to remove the excess, plus gives you the feeling of “cleaned and dry ears”.


ALWAYS seek medical advice if any symptom persists.


Key Points to Take Home

  • Ear wax or Cerumen is a natural substance that protects our ear canal and tympanic membrane and it spontaneously migrates toward the outside of the ear canal.

  • It should be treated by a trained and skilled healthcare professional if symptoms present, prevent needed hearing examination, or both. Otherwise, leave it alone.

  • There are 3 effective treatment options: Cerumenolytic Agents, Irrigation, and/or Manual Removal. However, each method has risks, specific adverse effects, and contraindications.

  • Ear Candling and the use of cotton tips should be avoided. "Do not put anything smaller than your elbow in your ear!"

  • Measures that may be beneficial in reducing cerumen impaction include 1. the use of cerumenolytic agents, 2. Self-irrigation with bulb syringe kits****, 3. cleaning hearing devices, or 4. routine cleaning of the ear canal by a clinician.

  • ALWAYS seek medical advice if any symptom persists.

**** Make sure you follow the instructions correctly and safely.


REFERENCES

1. Schwartz SR, Magit AE, Rosenfeld RM, et al. Clinical Practice Guideline (Update): Earwax (Cerumen Impaction). Otolaryngology–Head and Neck Surgery. 2017;156(1_suppl):S1-S29. doi:10.1177/0194599816671491



2. Poulton S, Yau S, Anderson D, Bennett D. Ear wax management. The Royal Australian College of General Practitioners 2015; AFP VOL.44, NO.10.


3. A) Bird S. The potential pitfalls of ear syringing. Minimizing the risks. Aust Fam Physician. 2003 Mar;32(3):150-1. PMID: 12666354.

B) Bird S. Ear Syringing: minimizing the risks. Australian Family Physician Vol. 37, No. 5, May 2008


4. Krouse HJ, Magit AE, O’Connor S, Schwarz SR, Walsh SA. Plain Language Summary: Earwax (Cerumen Impaction). Otolaryngology–Head and Neck Surgery. 2017;156(1):30-37. doi:10.1177/0194599816680327


5. Prowse SJ, Milla O. Aural microsuction for wax impaction: Survey of efficacy and patient perception. J Laryngol Otol 2014;128:621–25.


6. Snelling JD, Smithard A, Waddell A. Noise levels generated within the external auditory canal during microsuction aural toilet and the effect on hearing: A prospective controlled series. Clin Otolaryngol 2009;34:21–25.


7. Meador JA. Cerumen impaction in the elderly. J Gerontol Nurs 1995;21:43–45.


8. Burton MJ, Doree C. WITHDRAWN: Ear drops for the removal of ear wax. Cochrane Database Syst Rev. 2018 Jul 24;7(7): CD004326. doi: 10.1002/14651858.CD004326.pub3. PMID: 30040120; PMCID: PMC6513655.


9. Chang P, Pedler K. Ear examination - a practical guide. ENT • CLINICAL PRACTICE. Australian Family Physician Vol. 34, No. 10, October 2005. p. 857-862.


10. Dean L. Don't put anything smaller than your elbow in your ear: the genetics of ear wax. 2006 Oct 11. In: Dean L, McEntyre J, editors. Coffee Break: Tutorials for NCBI Tools [Internet]. Bethesda (MD): National Center for Biotechnology Information (US); 1999-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2333/


11. YouTube - Dr. Cliff channel








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