Strength of recommendations (A, B, C, D, I) and quality of evidence (good, fair, poor) are defined at the end of "Major Recommendations" field.
Definitions: Impacted cerumen
- Obstruction of the ear canal by cerumen/ear wax (Clinical Practice Guidelines for Nurses in Primary Care [Health Canada], 2000).
- Excessive accumulation of cerumen in auditory canal is known as cerumen impaction. Cerumen is considered to be impacted if one or more of the following conditions are present:
- Visual: Cerumen impairs the exam of clinically significant portions of the external auditory canal, tympanic, membrane, or middle ear.
- Qualitative: Extremely hard, dry, irritative cerumen causes symptoms such as pain, itching, and/or hearing loss.
- Inflammatory: This is associated with foul odor, infection, or dermatitis.
- Quantitative: Presence of obstructive, copious cerumen that requires a physician's/provider's skill to remove with magnification and multiple instrumentation. ("Cerumen removal," 2006).
Risks vs. benefits of cerumen removal should be evaluated before attempting the procedure:
- Evaluation as to the need to visualize will be prime importance, since most otitis media is viral and, therefore, self-resolving.
- Hearing loss is usually not improved significantly vs. iatrogenic damage risk for primary care providers
- First attempt loop device by the provider who has training in the following if irrigation attempt is unsuccessful.
- Specific recommendation or use of a cerumenolytic is of limited value to patient or provider from present literature review.
Treatment options for removal of impacted cerumen should be individualized treatment decisions based on amount, location, and quality/consistency of the cerumen as well as the individual's health status based on history and physical exam. Treatment options include:
- Eardrops/cerumenolytics (pharmacological and nonpharmacological)
- Ear syringe/irrigation
- Curettage
- Suction
- Combination of above treatment options
(Crummer & Hassan, 2004; Dunphy, 2004; Aung & Mulley, 2002; Deguine & Pulec, 2002; Marcinuk & Roland, 2002; Grossan, 2000; Grossan, 1998)
Subjective Assessment/History and Symptom Analysis
- Chief complaint(s) and/or clinical manifestations, of possible cerumen impaction, may be unilateral or bilateral with complaints of
- Hearing loss
- Itching
- Irritation
- Pain
- Fullness
- Vertigo, loss of balance
- Tinnitus
- Chronic cough
("Ceruman removal," 2006; Subha & Raman, 2006; Baer, 2005; Mandel, Dohar, & Casselbrant, 2004; Memel et al., 2002) Evidence Good, Recommendation B
- Review of systems pertaining to possible cerumen impaction and based on presenting complaints
- Head: Headache (H/A) relieved by over-the-counter (OTC) medications; vision problems
- Eyes: Watery, itching
- Ears: Unilateral or bilateral pain, itching, fullness, tinnitus, loss of hearing
- Nose: Clear-yellow nasal discharge and/or congestion
- Throat: Scratchy, post-nasal drip (PND), cough
- Neck: Lymphadenopathy
- Cardiovascular (CV): Light-headedness, syncope, headache
- Neurological: Sensation of loss of balance, dizziness, or vertigo
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000) Evidence Good, Recommendation B
- History of present illness
- Onset, duration, location, severity, aggravating and alleviating factors related to clinical manifestations stated in chief complaint
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000) Evidence Good, Recommendation B
- Past medical history
- Ear infections
- Perforation of tympanic membrane
- Presence of tubes, ear surgeries, ear trauma
- Severe vertigo
- Cholesteatoma
- Benign growths of bony canal
- Ear pathology, (e.g., psoriasis, external otitis, exotoses)
- Prior cerumen removal, number of times
- Type of cerumen removal procedures and associated problems (e.g., irrigation, ear curette, cerumenolytics (pharmacological and non-pharmacological)
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000) Evidence Good, Recommendation B
- Family history
- Cerumen impaction
- Ear pathologies (infections, structural anomalies, loss of hearing)
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000) Evidence Good, Recommendation B
- Social history
- Noise pollution
- Toxin exposures
- Ear hygiene activities (decrease or increase risk of cerumen impaction, ear infections)
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000) Evidence Good, Recommendation B
- Medication history
- Aspirin (ASA), nonsteroidal anti-inflammatory drugs (NSAIDs), ototoxic antibiotics
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000) Evidence Good, Recommendation B
- Allergies
- Environmental allergies
- Medication allergies, including neomycin, a common ingredient in antibiotic otic solutions
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000) Evidence Good, Recommendation B
Objective Assessment/Physical Examination (pertaining to possible cerumen impaction)
- Head, eyes, ears, nose, and throat (HEENT): Assess for allergy symptoms, infection, structural, and sensorineural pathologies
- Weber and Rinne tests to assess for conductive or sensorineural hearing loss
- Ears: External canals and tympanic membranes (TMs) should be inspected for signs of foreign bodies, structural pathologies; perforation of the TM; cerumen impaction; infection (pus)
- Cerumen should be assessed for amount, color, consistency (hard, soft, wet, dry)
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000) Evidence Good, Recommendation B
- Cardiovascular
- Auscultation over the neck, periauricular area, orbits, and mastoid should be performed for vascular origin of tinnitus.
- Tinnitus of venous origin can be suppressed by compression of ipsilateral jugular vein.
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000) Evidence Good, Recommendation B
- Neurological
- Cranial nerves should be examined for evidence of brain-stem damage or hearing loss
- Stimulation of small branch of vagus nerve that supplies part of the auditory canal may cause cough
- Assess for gross motor and focal neurological deficits
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000) Evidence Good, Recommendation B
Diagnostic Procedures
- Physical exam is main diagnostic tool. (Crummer & Hassan, 2004; Grossan, 2000). Evidence Good, Recommendation B
- Individuals with tinnitus should have an audiometric assessment to identify abnormalities that are structural or neurologic (peripheral or central) in origin (Crummer & Hassan, 2004; Grossan, 2000). Evidence Good, Recommendation B
Criteria for Diagnosis of Impacted Cerumen/Differential Diagnoses
- Conductive hearing loss may indicate
- Cerumen impaction
- Otosclerosis
- Middle ear effusion: usually unilateral hearing loss, TM is dull, hypomobile, and may have bubbles in middle ear
- Perforated TM
- Benign growths of the bony ear canal (exotoses and osteomas)
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000) Evidence Good, Recommendation B
- Subjective tinnitus may indicate
- Cerumen impaction
- Otosclerosis
- Presbycusis
- Ototoxicity (noise, medication)
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000). Evidence Good, Recommendation B
- Vertigo or loss of balance may indicate
- Cerumen impaction
- Meniere's disease
- Acoustic neuroma
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000). Evidence Good, Recommendation B
- Ear pain, irritation, or fullness may indicate
- Cerumen impaction
- External or middle ear infection
- Middle ear effusion; perforated TM
(Baer, 2005; Crummer & Hassan, 2004; Dunphy, 2004; Marcinuk & Roland, 2002; Grossan, 2000) Evidence Good, Recommendation B
Management
Overall treatment factors include ruling out contraindications to removing cerumen and differential diagnoses other than or in addition to impacted cerumen.
Various treatment options exist for cerumen removal and must be chosen on an individual basis.
Management techniques are individualized to patient symptoms and goals.
Individualized treatment decisions are also based on the amount, consistency, and location of the cerumen (Deguine & Pulec, 2002; Grossan, 2000). Evidence Good, Recommendation B
Step 1 – Patient and Family Education
- Explain purpose of cerumen and causes of cerumen impaction.
- Cerumen is a protective secretion produced by the apocrine glands in the outer portion of the ear canal.
- It protects the ear canal and TM by trapping foreign bodies (e.g., dust, moisture, bacteria, and fungi).
- Impacted ear wax is common and not a sign of poor hygiene.
- Human earwax is a Mendelian trait consisting of wet and dry types:
- Wet earwax is brownish and sticky.
- Dry earwax, lacking some of the moist secretions from the apocrine glands, is hard and becomes impacted easier.
- Age-related atrophy of modified apocrine glands leads to decrease in production of watery components making cerumen dryer, harder, coarser and more easily impacted.
- In most persons the ear canal is self-cleansing.
- Ear wax migrates laterally out of the ear and can be safely cleared in the course of normal washing without putting anything into the outer ear smaller than one's index finger. Removal of protective ear wax exposes delicate skin of the ear canal to infection
- May result in otitis externa and non-specific irritation that can lead to a vicious cycle of cleaning and further irritation
- Some individuals produce larger amounts of cerumen or it is the harder and dryer consistency.
- Necessary to extract cerumen when there are signs and symptoms of impaction
- Excessive wax usually presents as increased hearing difficulty that may become worse with the addition of water causing it to expand blocking the canal.
- There can be pain if there is infection or if the wax causes pressure on the TM.
- Impacted cerumen can cause tinnitus.
- Impacted cerumen can cause a cough due to inappropriate stimulation of a small branch of the vagus nerve supplying part of the ear canal.
(Current Medical Diagnosis & Treatment, 2007; Baer, 2005; Aung & Mulley, 2002; Deguine & Pulec, 2002; Grossan, 2000). Evidence Fair, Recommendation C
- Explain rationale for removing impacted cerumen.
- Visualize the external auditory canal, TM, and middle ear structures during an exam
- Decrease risk of infection
- Decrease risk of damaging ear canal and/or TM from pressure
- Decrease risk of discomforts that may result from cerumen impaction including:
- Tinnitus
- Vertigo
- Loss of hearing
- Pain/irritation
(Current Medical Diagnosis & Treatment, 2007; Baer, 2005; Deguine & Pulec, 2002; Grossan, 2000) Evidence Fair, Recommendation C
- Explain risks of self-cleaning.
- Using cotton tipped swabs and other articles like hair pins, matches, and pencils to remove cerumen at home may:
- Perforate TM or irritate skin in auditory canal leading to external otitis
- Push cerumen further back into auditory canal over-cleansing can destroy natural protective environment of auditory canal
(Baer, 2005; Nussinovitch et al., 2004; Deguine & Pulec, 2002; Grossan, 2000) Evidence Good, Recommendation A
Step 2 – Non-pharmacological Treatment
- Use of an instrument such as an ear wax removal loop or a specific tool like the Jobson Horne probe
- Instrumentation is a preferred method of removing ear wax that is obstructing visualization of the tympanic membrane and its landmarks.
- There is less chance of adverse complication such as a reported 1/1000 adverse event statistic if this method is employed by the provider himself or herself and not delegated (Sharp, et al., 1990; Chang & Pedler, 2005). Evidence Fair, Recommendation B
- Ear irrigation
- Syringing is generally not recommended because of pressure per square inch (psi) that can reach 110 psi.
- Use of specifically made ear electric irrigation devices have built in precautions such as dial-up pressure that is maintained at non harmful levels.
- Instructions can be incorporated into policy for training those if the provider chooses to delegate this procedure.
- Ear irrigation alone can have success rates of 70% in nearly all cases.
- Policy is important when irrigation is used because of the chance of iatrogenic adverse events or worsening of existing problems (Hand & Harvey, 2004; Price, 1997). Evidence Fair, Recommendation B
Step 3 – Pharmacological Treatment
Using ear drops to remove impacted ear wax is better than no treatment, but no particular sort of cerumenolytics can be recommended over any other and no adverse effects were found (Burton & Doree, 2003). Water-based preparations have a cerumenolytic activity, whereas oil-based preparations have only softening effects (Hand & Harvey, 2004). Water-based and oil-based preparations are equally effective in clearing earwax, and they are probably more effective than no treatment. Comparison between different water-based or oil-based preparations does not demonstrate any major advantages of one preparation over another (Hand & Harvey, 2004). A patient with earwax can stay in the waiting room following the initial series of five attempts at syringing, with water instilled in the ear canal. After 15 minutes, the earwax is removed as easily as in the usual strategy using oil instilled for three days (Eekhof et al, 2001).
- Water-based ear drops: Water based preparations include acetic acid, Cerumenex, Colace (Docusate sodium), hydrogen peroxide, Molcer, sodium bicarbonate, Waxsol, Cerumenex (triethanolamine polypeptide) (Hand & Harvey, 2004). One study suggests a single application of Colace followed by irrigation was more effective than Cerumenex with irrigation for dissolving cerumen and allowing complete visualization of the tympanic membrane in patients (Robinson, 2001). Colace appears more effective than most other water-based preparations, but saline is equally, of not more, effective. Evidence Good, Recommendation C
- Oil-based eardrops: Oil-based preparations include almond oil, Cerumol, Diotyl-medo, Earex, and olive oil (Hand & Harvey, 2004). Evidence Fair, Recommendation C
- Non-water, non-oil based eardrops: Non-water, non-oil based preparations include Audax and Exterol. Evidence Fair, Recommendation C
Step 4 – Surgery/Referral
Refer to ear, nose and throat (ENT) specialist for difficult cerumen removal:
- Suspect previous perforation
- Patient gets dizzy when irrigation water is correct temperature (37 degrees Celsius)
- Ear canal partially swollen
- Any attempt at cerumen removal elicits severe pain which suggests adhesion of cerumen to ear canal
- Abnormal ear anatomy
- Individual is unable to cooperate
(Current Medical Diagnosis & Treatment, 2007; Deguine & Pulec, 2002; Grossan, 2000; Rudy, 2000) Evidence Good, Recommendation B
Refer to an ear, nose and throat or other specialist:
- Atypical presentations of hearing loss without cerumen impaction
- Presence of foreign body in ear
- Transparent membrane that has developed parallel to TM
- Sensorineural hearing loss
- Hearing loss without obvious etiology
(Current Medical Diagnosis & Treatment, 2007; Deguine & Pulec, 2002; Grossan, 2000; Rudy, 2000). Evidence Good, Recommendation B
Surgery referral is indicated when:
- Cerumen must be removed under guidance of an operating microscope
(Current Medical Diagnosis & Treatment, 2007; Deguine & Pulec, 2002; Grossan, 2000; Rudy, 2000). Evidence Good, Recommendation B
Definitions:
Quality of Evidence (Based on the U.S. Preventive Services Task Force Ratings)
- Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.
- Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
- Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.
Strength of Recommendations (Based on U.S. Preventive Services Task Force Ratings)
A. There is good evidence that the recommendation improves important health outcomes. Benefits substantially outweigh harms.
B. There is at least fair evidence that the recommendation improves important health outcomes. Benefits outweigh harms.
C. There is at least fair evidence that the recommendation can improve health outcomes but the balance of benefits and harms is too close to justify a general recommendation.
D. There is at least fair evidence that the recommendation is ineffective or that harms outweigh benefits.
I. Evidence that the recommendation is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
