Impacted ear wax

Cerumen impaction also known as impacted ear wax, is defined as an accumulation of cerumen (ear wax) that causes symptoms, prevents assessment of the ear, or both ¹. Cerumen or earwax is formed in the outer two-thirds (cartilaginous portion) of the ear canal, not the inner third (bony portion) that ends at the eardrum and it is a naturally occurring, normally extruded product of the external ear canal. Cerumen (earwax) is composed of secretions and sloughed epithelial cells and hair from the external ear canal. Cerumen (earwax) cleans, protects, and lubricates the external ear canal skin and is naturally extruded. Cerumen (earwax) acts as a self-cleaning agent to keep your ears healthy. Dirt, dust, and other small pieces of stuff stick to the earwax which keeps it from getting farther into your ear. Chewing, jaw motion, and growing skin in your ear canal help to move old earwax from inside your ears to the ear opening, where it then flakes off or is washed off when we bathe. This normal process of making wax and pushing the old wax out continues nonstop. Cerumen (earwax) is also the primary reason why your ear canal can become blocked. While often harmless, cerumen may accumulate and block the ear canal of one or both of your ears can lead to a host of symptoms: discomfort, hearing loss, tinnitus, dizziness, fullness, itching, ear ache (otalgia), discharge, odor, and chronic cough ². Cerumen also can contribute to ear canal infection (otitis externa) ³. In addition, cerumen impaction can prevent diagnostic assessment by preventing complete examination of the external auditory canal and/or eardrum (tympanic membrane) or by interfering with diagnostic assessment (ie, audiometry, tympanometry) ⁴. Because the external ear canal is innervated by the auricular branch of the vagus nerve, coughing or even cardiac depression can accompany stimulation of the canal from cerumen impaction or removal attempts ⁵.

An anatomic deformity and an increased number of hairs in the external ear canal, as well as physical barriers to natural wax extrusion (e.g., cotton swabs, hearing aids, earplug-type hearing protectors) have been associated with an increased incidence of cerumen impaction ⁶. Earwax blockages commonly occur when people try to clean their ears on their own by placing cotton swabs or other items in their ears. This often just pushes wax deeper into the ear, rather than removing it.

Cerumen impaction is more common in the elderly and in patients with mental retardation. Estimates suggest that between 19% and 65% of patients over 65 years old have cerumen impaction ⁷ and that elderly patients in nursing homes are likely at the upper end of this spectrum ⁸. In the developmentally delayed adult population, 28% to 36% have excessive or impacted cerumen ⁹. Moreover, the presence of cerumen impaction has been associated with hearing loss ¹⁰ and diminished cognitive function ⁷ in these populations.

The prevalence of cerumen impaction varies widely but is still high in healthy adults and children. In a study of 1507 adults screened for hearing loss, 2.1% had occluding cerumen. 20 Another study estimates that cerumen impaction is present in approximately 10 percent of children and 5 percent of healthy adults ⁸. Impacted cerumen was the diagnosis for 3.6% of 8,611,282 emergency room visits for otologic complaints in the United States between 2009 and 2011 ¹¹.

Multiple treatment options exist for cerumen impaction, depending on available equipment, physician skill, and patient circumstances. Impacted ear wax treatment options include watchful waiting, manual removal, the use of ceruminolytic agents, and irrigation with or without ceruminolytic pretreatment and manual removal ¹². Combinations of these treatment options also exist (eg, cerumenolytic followed by irrigation; irrigation followed by manual removal). Manual removal other than irrigation may be performed with a curette, probe, hook, forceps, or suction under direct visualization with headlight, otoscope, or microscope ². The training, skill, and experience of the clinician play a significant role in the treatment option selected ¹³. In addition, patient presentation, patient preference, and urgency of the clinical situation influence choice of treatment.

Though generally safe, treatment of cerumen impaction can result in significant complications. Ear drum (tympanic membrane) perforation, ear canal laceration, infection of the ear, bleeding, or hearing loss occurs at a rate of about 1 in 1000 ear irrigations ¹⁴. Applying this rate to the approximate number of ear irrigations performed in the United States estimates that 8000 complications occur annually and likely require further medical services. Other complications that have been reported include otitis externa (sometimes secondary to external auditory canal trauma), pain, dizziness, and fainting (syncope) ¹⁵.

Cerumen removal is the most common ear, nose, and throat (ENT) procedure performed in primary care; approximately 4 percent of primary care patients will consult their physician for cerumen impaction ¹⁶. Referral to an otolaryngologist (ENT specialist) for further evaluation is indicated if treatment with a ceruminolytic agent followed by irrigation is ineffective, if manual removal is not possible, if the patient develops severe pain or has vertigo during irrigation, or if hearing loss is still present after cerumen has been removed. The use of cotton swabs, ear candles (ear candling) and olive oil drops or sprays should be avoided ¹². Persistent symptoms despite resolution of the impaction should also prompt further evaluation for an alternative diagnosis.

Figure 1. Impacted ear wax treatment options (shared decision grid for patients and caregivers regarding therapeutic options for earwax management)

Ear wax DOs and DON’T

• DO know that cerumen or earwax is normal. Earwax that does not cause symptoms or block the ear canal should be left alone.
• DO understand the symptoms of impacted ear wax or cerumen impaction such as: decreased hearing, fullness sensation, ringing in the ear (tinnitus), and distortion or changes to hearing aid function.
• DO see your health care provider if you have symptoms of hearing loss, ear fullness or ear pain if you are certain they are not from ear wax. Fluid behind the ear drum (otitis media), ear canal infection (otitis externa) and sudden inner ear hearing loss can seem like an ear wax impaction.
• DO ask your health care provider about ways you can treat your earwax impaction at home. You may have certain ear or medical conditions which may make some treatment options unsafe.
• DO seek immediate medical attention if you have ear pain, drainage or bleeding. These are NOT symptoms of earwax impaction and need to be checked out by your health care provider.
• DON’T over clean you ears. Too much cleaning may bother your ear canal, cause infection and may even increase the chances of earwax impaction.
• DON’T put cotton swabs, hair pins, car keys, toothpicks or other things in your ear. These can all injure your ear and may cause a cut in your ear canal, poke a hole in your ear drum or hurt the hearing bones, leading to hearing loss, dizziness, ringing and other symptoms of ear injury.
• DON’T use ear candles. Ear candles do not remove ear wax and can cause serious damage to your ear canal and ear drum.
• DON’T ignore your symptoms if home remedies are not helping. Seek medical attention if your symptoms do not go away.
• DON’T irrigate or try earwax removing or softening drops if you’ve had previous ear surgery or a hole in your ear drum unless clear to do so by your ear, nose and throat surgeon (otolaryngologist)
• DON’T forget to clean your hearing aids as the manufacturer and your hearing health professional recommend.

Can I use cotton swabs to clean inside my ears?

You should avoid putting things in your ears. You may see some earwax come out on a cotton swab, bobby pin, paperclip, or other item you put in your ear canal, but you are really only pushing earwax back into your ear, which may cause problems. Putting things in your ears irritates them. You can also injure your ear by putting a hole in an eardrum, cutting or scratching the ear canal skin, or even causing an ear infection.

What about ear candling?

Ear candling or ear coning is NOT a safe option for earwax removal. Research shows that ear candling does NOT create a vacuum to suck earwax from the ear. Any wax left on the ear candle is from the candle itself, not earwax. Some risks of the ear candling process are the following:

• Burns to the ear canal
• Ear blockage from candling wax
• Hole in eardrum
• Ear infection

Ways to help reduce earwax buildup

Helpful prevention choices:

• Rubbing alcohol or hydrogen peroxide drops or irrigation
• Earwax softening drops or agents
• Irrigation with bulb syringe or irrigation kits
• Checking of the ear canal for earwax by clinician for hearing aid users
• Physically removing earwax by health care provider

NOT advised:

• Daily olive oil drops or sprays
• Ear candling
• Putting any objects in your ear (e.g., cotton-tipped swabs, pens/pen tops, paper clips).

Should I do anything to prevent earwax buildup?

Not everyone needs prevention, but it is best for some groups. If you are elderly, use hearing aids, or have a history of making too much earwax, you may need regular treatment. It is important to remember that earwax is natural and helpful to the body. It does not always need to be removed. You do not have to do anything unless you have earwax buildup that causes symptoms or prevents your health care provider from examining your ears.

Impacted ear wax causes

The wax in your ears is secreted by glands in the skin that lines the outer half of your ear canals. The wax and tiny hairs in these passages trap dust and other foreign particles that could damage deeper structures, such as your eardrum.

Ear wax protects the ear by:

• Trapping and preventing dust, bacteria, and other germs and small objects from entering and damaging the ear
• Protecting the delicate skin of the ear canal from getting irritated when water is in the canal

In most people, a small amount of earwax regularly makes its way to the opening of the ear, where it’s washed away or falls out as new wax is secreted to replace it. If you secrete an excessive amount of wax or if earwax isn’t cleared effectively, it may build up and block your ear canal.

In some people, the glands produce more wax than can be easily removed from the ear. This extra wax may harden in the ear canal and block the ear. When you try to clean the ear, you may instead push wax deeper and block the ear canal. For this reason, health care providers recommend against trying to reach into your own ear to clean it.

Impacted ear wax, symptoms

Earwax impaction symptoms:

• Ear pain
• Itching
• Fullness in the ear or a sensation that the ear is plugged
• Ringing in the ear (tinnitus)
• Dizziness
• Hearing loss
• Discharge coming from the ear
• Odor coming from the ear
• Cough
• Change in hearing aid function

You should see your health care provider if you have symptoms and you are not sure if they are caused by earwax. You might have a different ear problem that needs medical care.

Patients seek treatment for cerumen impaction for a host of symptoms. Reported symptoms include pain, itching, sensation of fullness, tinnitus, odor, drainage, and cough. Complete cerumen occlusion can also result in significant hearing loss ². Hearing loss can range from 5 to 40 dB depending on the degree of occlusion of the canal with cerumen ⁸. While cerumen impaction may be asymptomatic in some cases, management may be necessary for diagnostic purposes so that the ear canal and/or ear drum (tympanic membrane) can be visualized or diagnostic assessment can be performed ¹⁹.

Impacted ear wax diagnosis

Earwax impaction is diagnosed through a physical examination and review of your medical history. Your health care provider will look in your ear canal with a tool called an otoscope or other device to see if you have impacted earwax. If you do, you may be treated for the impaction at that time or you may be sent to another provider for treatment.

Impacted cerumen treatment

Impacted earwax can be treated in several ways. Some of the treatments can be done at home, but you may have certain medical or ear conditions that could make home options unsafe. You and your health care provider should discuss possible treatments and decide on the best treatment for you. Figure 1 may help with your discussion ¹⁷.

Available treatments are ²⁰:

1. Watchful waiting, or observation for a period of time. Earwax removal by the body is a natural process, and many impactions clear on their own. Your health care provider might offer the option to wait and see if the problem goes away or gets worse over time.
2. Irrigation, or ear syringing. This involves clearing the wax out of the ear canal by a stream of warm water. Self-irrigation can be done at home. Irrigation is not recommended for patients who get a lot of ear infections, have ear tubes, or have a hole in the eardrum. Home use of oral jet irrigators is not effective and is not recommended as they can lead to damage in the ear.
3. Wax softening agents (cerumenolytics). These are ear drops that soften or break up the wax to help in removal. These solutions can be used alone or together with irrigation or physical removal by a provider.
4. Physical removal of wax with special instruments or a suction device. Physical removal of earwax should only be performed by a health care provider. Your doctor can remove excess wax using a small, curved instrument called a curet or by using suction while inspecting the ear. Your doctor can also flush out the wax using a water pick or a rubber-bulb syringe filled with warm water.

If earwax buildup is a recurring problem, your doctor may recommend that you use a wax-removal medication, such as carbamide peroxide (Debrox Earwax Removal Kit, Murine Ear Wax Removal System). Because these drops can irritate the delicate skin of the eardrum and ear canal, use them only as directed.

Impacted ear wax removal at home

Most cases of ear wax blockage can be treated at home. If your eardrum doesn’t contain a tube or have a hole in it, these self-care measures may help you remove excess earwax that’s blocking your ear canal:

The following remedies can be used to soften wax in the ear:

• Baby oil
• Commercial drops
• Glycerin
• Mineral oil
• Water

Use an eyedropper to apply a few drops of baby oil, mineral oil, glycerin or hydrogen peroxide in your ear canal.

After a day or two, when the wax is softened, use a rubber-bulb syringe to gently squirt warm water into your ear canal. Tilt your head and pull your outer ear up and back to straighten your ear canal. When finished irrigating, tip your head to the side to let the water drain out. When finished, gently dry your outer ear with a towel or hand-held dryer.

Another method is to wash out the wax.

• Use body-temperature water (cooler or warmer water may cause brief but severe dizziness or vertigo).
• Hold your head upright and straighten the ear canal by holding the outside ear and gently pulling upward.
• Use a syringe (you can buy one at the store) to gently direct a small stream of water against the ear canal wall next to the wax plug.
• Tip your head to allow the water to drain. You may need to repeat irrigation several times.

Dry your ear canal. When finished, gently dry your outer ear with a towel or hand-held dryer.

To avoid damaging your ear or causing an infection:

• Never irrigate or use drops to soften the wax in the ear if the eardrum may have a hole in it or you have had recent ear surgery.
• Do not irrigate the ear with a jet irrigator designed for cleaning teeth (such as a WaterPik).

After the wax is removed, dry the ear thoroughly. You may use a few drops of alcohol in the ear or a hair dryer set on low to help dry the ear.

You may clean the outer ear canal by using a cloth or paper tissue wrapped around your finger. Mineral oil can be used to moisturize the ear and prevent the wax from drying.

Do not clean your ears too often or too hard. Ear wax also helps protect your ears. Never try to clean the ear by putting any object, such as a cotton swab, into the ear canal.

• You may need to repeat this wax-softening and irrigation procedure a few times before the excess earwax falls out. However, the softening agents may only loosen the outer layer of the wax and cause it to lodge deeper in the ear canal or against the eardrum. If your symptoms don’t improve after a few treatments, see your doctor.
• Earwax removal kits available in stores also can be effective at removing wax buildup. Ask your doctor for advice on how to properly select and use alternative earwax removal methods.

If you cannot remove the wax plug or you have discomfort, consult a health care provider, who may remove the wax by:

• Repeating the irrigation attempts
• Suctioning the ear canal
• Using a small device called a curette
• Using a microscope to help

DON’T try to dig it out

• Never attempt to dig out excessive or hardened earwax with available items, such as a paper clip, a cotton swab or a hairpin. You may push the wax farther into your ear and cause serious damage to the lining of your ear canal or eardrum.

Cerumen impaction prognosis

The ear may become blocked with wax again in the future. Hearing loss is often temporary. In most cases, hearing returns completely after the blockage is removed. Hearing aid users should have their ear canal checked for excess wax every 3 to 6 months.

Rarely, trying to remove ear wax may cause an infection in the ear canal. This can also damage the eardrum.

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