# 018 Cerumen Impaction Management
Authors: Luke Jakubowski MD, Tom Kidder MD Steve Denson MD, Yana Thaker
Objectives
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List complications of cerumen impaction
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List medical interventions to aid in resolution of cerumen impaction
ACGME Competencies: Patient Care, Medical knowledge
Context: Inpatient and outpatient
Action: Course of treatment for a patient presenting with cerumen impaction.
Incidence/Prevalence: In one study, 35 percent of hospitalized patients older than 65 years had cerumen impactions and 75 percent of those had improved hearing after documented earwax removal.1 Of elderly in nursing homes, one study showed that 57% of patients had cerumen impactions.2 Chronic manipulation with cotton-tip applicators, narrow external ear canals, hair in the lateral canal, hearing aids and earplugs have been associated with an increased incidence of cerumen impaction. Cerumen impactions can effect hearing and cause irritation, pain, tinnitus, dizziness, and vertigo and lead to otitis externa. When physical removal is not possible or well tolerated, medical management may assist in the resolution.
Underlying Science: Cerumen serves a natural protective function for the skin in the external auditory canal. Cerumen is hydrophobic, slightly acidic (pH 6.0 to 6.5) and formed by glandular secretions and sloughed epithelium in the lateral one third of the external auditory canal(3).
Treatment: Treatment of cerumen impactions can be done with manual removal, irrigation or cerumenolytics. Irrigation and cerumenolytics should be avoided in patients with tympanic membrane perforations or tympanostomy tubes (ear tubes). Initial treatment with cerumenolytics is reasonable in most patients. There are three types of cerumen-softening preparations: water-based, oil-based, and non–water-based/non–oil-based. The use of ceruminolytics before irrigation may increase the success of irrigation by 97%(4). Use of a ceruminolytic agent 15 to 30 minutes before irrigation was found to be as effective as several days of treatment (5).
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Agent
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Use
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Dosing
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Water-Based
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10% Trolamine polypeptide oleate-condensate (Cerumenex)
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Soften cerumen before irrigation
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Fill affected ear canal 15-30 min before irrigation
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Docusate sodium (Colace)
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Soften cerumen before irrigation
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Fill affected ear canal with 1 mL 15-30 min before irrigation
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3% Hydrogen peroxide
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Soften cerumen before irrigation
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Fill affected ear canal 15-30 min before irrigation
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2.5% Acetic acid
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Home treatment of impacted cerumen
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Fill affected ear with 2-3 mL twice daily for up to 14 days
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10% Sodium bicarbonate
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Soften cerumen before irrigation or as an alternative to irrigation
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Fill affected ear with 2-3 mL 15-30 min before irrigation, or alternatively for 3-14 days at home with or without irrigation
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Water or saline
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Soften cerumen before irrigation
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If irrigation is attempted without softening and is ineffective with the first irrigation attempt, instill water and wait 15 min before repeating irrigation
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Non–Water-Based/Non–Oil-Based
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Carbamide peroxide (Debrox, Murine removal kit)
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Soften cerumen before irrigation or as an alternative to irrigation
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Put 5-10 drops into affected ear twice daily for up to 7 days
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50% Choline salicylate and glycerol (e.g., Earex Plus, Audax); ethylene oxide polyoxypropylene glycol (Addax); propylene glycol; 0.5% chlorbutol
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Soften cerumen before irrigation or as an alternative to irrigation
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Put 3 drops into affected ear twice daily for 4 days
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Oil-Based
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57.3% Arachis oil, 5% chlorbutol, 2% paradichlorobenzene, 10% oil of turpentine (e.g., Cerumol)
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Soften cerumen before irrigation or as an alternative to irrigation
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Fill affected ear with 5 mL twice daily for 2-3 days
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Arachis oil, almond oil, rectified camphor oil (e.g., Otocerol, Earex)
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Soften cerumen before irrigation or as an alternative to irrigation
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Put 4 drops into affected ear twice daily for up to 4 days
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Olive oil, almond oil, or mineral oil
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Soften cerumen before irrigation
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Put 3 drops into affected ear at bedtime for 3-4 days
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From McCarter D, Courtney A, Pollart S. Cerumen impaction. Am Fam Physician. 2007;75:1523-1528.
References
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McCarter DF, Courtney AU, Pollart SM. Cerumen impaction. Am Fam Physician 2007 May 15;75(10):1523-1528.
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Roeser RJ, Ballachanda BB. Physiology, pathophysiology, and anthropology/epidemiology of human ear canal secretions. J Am Acad Audiol 1997 Dec;8(6):391-400.
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Flint PW, Cummings CW, ScienceDirect, Electronic Book Collection. Cummings otolaryngology head & neck surgery. 2010.
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Hand C, Harvey I. The effectiveness of topical preparations for the treatment of earwax: a systematic review. Br J Gen Pract 2004 Nov;54(508):862-867.
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Pavlidis C, Pickering JA. Water as a fast acting wax softening agent before ear syringing. Aust Fam Physician 2005 Apr;34(4):303-304.
Author Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.
Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm
Copyright/Referencing Information: Users are free to download and distribute Geriatric Fast Facts for educational purposes only. Citation: Luke Jakubowski MD, Tom Kidder MD Steve Denson MD, Yana Thaker, Fast Fact #18: Cerumen Impaction Management, September, 2012.
Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm
Disclaimer: Geriatric Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Geriatric Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.