Ear Wax Impaction

Basics
Physical examination
Management
Cerumenolytic agents (Ear wax softeners)
Irrigation
Manual removal
Modifying factors
Assess outcomes
Prevent cerumen impaction
Ear buds

Ear wax (cerumen) consists of sebaceous and ceruminous gland secretions combined with hairs and desquamated skin. It is a naturally occurring substance.

Ear canal epithelium migrates outward from the drum and deeper parts of the ear canal. This is a self-cleaning mechanism.

Impacted ear wax can cause discomfort, itching, decreased hearing and in some cases may contribute to tinnitus and dizziness. It is a common complaint to primary care facilities but may present to the emergency department as a primary or add-on complaint.

Basics

Cerumen impaction is defined as accumulation of cerumen that:

• Causes symptoms
• Prevents a needed assessment of the ear canal or tympanic membrane
• Or both

It is important for patients to understand that cerumen does not always need to be removed. In fact, cerumen has many beneficial properties:

Physical Examination

Careful examination of the external ear canal should reveal the offending wax. Useful equipment include:

• An otoscope
• A handheld speculum
• Binocular microscope (rarely available in the primary or emergency care setting)

Management

Definitive removal of cerumen in the emergency centre is not always indicated. Wax should be removed if it causes symptoms or if it prevents important evaluation of the ear.

Management options include cerumenolytic agents, irrigation and manual removal

Cerumenolytic agents (Ear wax softeners)

Wax-softening agents may be used by clinicians or by the patient at home.

It can be used alone or in combination with irrigation or manual removal. Instilling an agent prior to irrigation or using an agent at home several days prior to irrigation is recommended.

By far the best wax solvent is simple water.

Three types of agents available:

• Water-based
  • Acetic Acid
  • Hydrogen peroxide
• Oil-based
  • Waxol®
  • Olive oil
  • Liquid petrolatum
• Non-water, non-oil based
  • Glycerine

Water-based agents have a true cerumenolytic effect by inducing hydration and fragmentation of corneocytes. Oil-based preparations are not true cerumenolytics. They lubricate and soften cerumen without disintegrating the cerumen.

Ask the patient to instil the chosen agent into the ear once or twice a day for a few days. This will often result in the wax simply running out of the ear. If not, further intervention may be warranted.

Precautions

Instilling cerumenolytic may result in:

• Discomfort
• Transient hearing loss
• Dizziness
• Skin irritation

Avoid in patients with active infections of the ear canal. Apply for limited periods of time (5-7 days). Risk of adverse reactions is lowest with water or saline.

Irrigation

Irrigation is simple, effective and safe for use in normal ears. Ear wax softeners can enhance the efficacy of irrigation (i.e. tap water / saline).

NEVER Irrigate if:

• History of perforated tympanic membrane
• Patient who had ear surgery
• Anatomic abnormalities of ear canal

Clinicians must often rely on history to establish that the eardrum is intact, since the tympanic membrane is usually not visualised in cases of wax impaction.

Aural irrigation in patients with anatomic abnormalities ( congenital malformations, exostosis, scar tissue) can cause water to be trapped in the external auditory canal.

Remember that malignant otitis externa may follow in diabetes patients post irrigation. In these patients it is prudent to:

• Perform the procedure with caution
• Re-acidify the canal afterwards with acetic acid drops
• Instruct the patient to report new otalgia or otorrhoea

How to syringe an ear:

• Confirm no previous history of TM perforation, grommet insertion, middle ear or mastoid surgery

Procedure:

• Warm water to body temperature
• Pull the pinna up and back to straighten the ear canal
• Use a dedicated ear syringe or 20cc syringe with wide-bore plastic intravenous cannula attached
• Aim the jet of water towards the roof of the ear canal
• Use a gentle, constant stream of water
• Receiver to collect water, placed under the ear
• STOP if the patient complains of pain

Pitfalls:

• Water temperature is by far the most important factor. If the water is too hot or cold, syringing will induce vertigo
• Test syringe before use. Fill the ear canal gently and then use a constant flow of water.
• Keep your patient dry with a towel or linen saver.
• A good light source i.e. headlamp, is of utmost importance. You must see where you place the tip of the syringe.

Position of the patient:

• Adult: Sitting sideways-on in front of you with the ear to be syringed pointing towards the source of light
• Child: Seated on an adult’s lap with both the head and body firmly held.

Helpful Hints

It is sometimes difficult to get hard, impacted wax out of the ear canal. Remember that wax dissolves best in water. Lie the patient down with the wax-filled ear uppermost and fill the ear canal with water. Get the patients to pump the tragus for 10 minutes- Refilling the canal a few times. Try syringing again.

Avoid solutions containing alcohol. Alcohol in the middle ear space is both painful and ototoxic.

Manual removal

Manual removal of wax is often quicker, allows direct visualisation of ear canal and does not expose the ear to moisture.

Instrumentation of the ear canal is risky however and the clinician should be wary of causing damage to delicate ear structures. This is especially true in children.

Preferred method in  patients with:

• Abnormal otologic findings
• Systemic illness that may compromise immunity

You will need a good light source (like an otoscope or headlamp), proper equipment and the ability to directly visualise the canal and wax.

To remove the wax you can use formal instruments off an ENT tray such as a blunt tip wax hook or a Johnson probe if available.

Consider using a hair pin or the round end of a paper clip as a gentle wax hook if you do not have specialised equipment.

Complications:

• Trauma to ear canal
• Perforation of tympanic membrane
• Infection

Modifying factors:

Management of cerumen impaction can be influenced by host factors and anatomic abnormalities of the ear canal and tympanic membrane.

Host Factors:

• Immunocompromised state
• Diabetes mellitus
• Anticoagulant therapy

Anatomic abnormalities:

• Ear canal stenosis
• Exostoses (swimmer’s ear)
• Perforated tympanic membrane

Patients with an immunocompromised state are at risk for malignant otitis externa after tap water ear irrigation.

Patients with diabetes mellitus have a significantly higher pH of cerumen which may facilitate the growth of pathogens.

Precautions to be used in both these patient groups:

• Take care to minimise trauma
• Consider using ear drops to acidify the ear canal post irrigation (acetic acid drops)
• Provide close follow-up (otorrhoea-otalgia)

Patients on anti-coagulation therapy are at higher risk for cutaneous haemorrhage and subcutaneous hematomas.

• Careful instrumentation is extremely important

Anatomic factors may be acquired or congenital. It can limit visualisation and increase the likelihood of trauma.

• Specialised equipment and procedures may be required
• Refer to ENT specialist

Assess outcomes

• If impaction is not resolved, use additional method.
• If full or partial symptoms persist despite resolution of impaction, consider an alternative diagnosis.

Prevent cerumen impaction

• Instil prophylactic topical agents especially in high risk patients
• Irrigate the ear canal before impaction
• Routine cleaning of ear canal by general physician

Ear buds

• Expert opinion recommends against the use of cotton-tip swabs to remove wax from the ear canal.
• Patients should be educated.
• Ear bud use negatively affects the self-cleaning mechanism of the ear canal. It may CAUSE impaction.
• The cotton tip may separate, requiring removal as a foreign body.
• Product label of cotton-tip swabs specifically notes that the product should NOT be placed into the ear canal.

References

Roland PS et al. Otolaryngology – Head and Neck Surgery 2008: 139, S1-S21.Clinical practice guideline: Cerumen impaction.

Corbridge R et al. Oxford Handbook of ENT and Head and Neck Surgery.Oxford University Press; 2006

Marx JA et al. Rosen’s Emergency Medicine: Concepts and clinical practice, 7^th ed. St. Louis, MO: Mosby; 2009