Cerumen Impaction

Aka: Cerumen Impaction, Impacted Ear Wax, Ear Canal Bleeding after Cerumen Removal

1. Mechanism
   1. Apocrine/Sebaceous Gland secretions produce cerumen
      1. Located in skin lining outer half of canal
      2. Cerumen acidifies canal with Lysozymes
         1. Prevents Bacterial and fungal growth
      3. Cerumen is lipid rich and therefore hydrophobic
         1. Prevents skin penetration and maceration
   2. Cerumen is spontaneously cleared from the canal by jaw motion and other mechanisms
   3. Impaction occurs from attempts to remove cerumen
   4. Exacerbated by swimming and showering
      1. Water moistens and expands cerumen
2. Symptoms
   1. Otalgia
      1. Cerumen Impaction is painless, unless:
         1. Cerumen touches Tympanic Membrane
         2. Cerumen injures external canal
   2. Hearing Loss
      1. Requires completely obscured canal
      2. Even a tiny hole of patency will maintain Hearing
   3. Vertigo or disequilibrium
      1. Associated with cerumen touching Tympanic Membrane
   4. Other symptoms
      1. Ear fullness Sensation
      2. Ear Pruritus
      3. Tinnitus
3. Indications: Removal of cerumen
   1. Hearing Loss
   2. Otalgia
   3. Cerumen obscures exam
      1. Diagnosis requires 75% of Tympanic Membrane viewed
      2. Ear evaluation requires cerumen removal in 33% cases
      3. Children under age 1 year more often require removal
      4. Cerumen removal required for auditory or vestibular testing
      5. Cerumen does not affect Tympanic Temperature reading
4. Management: Cerumen Removal
   1. Cerumen Softening Agents
      1. See Cerumen Softening Agents
      2. Debrox drops
      3. Acetic acid 1.5% with water
      4. Hydrogen Peroxide or Benzalkonium chloride
   2. Office cerumen removal
      1. Manual Cerumen Removal
      2. Warm Water Ear Lavage
      3. Cerumen removal by Ear Canal Suction
      4. Cerumen softening before irrigation not effective
         1. Agents that have shown no benefit compared with saline
            1. Triethanolamine polypeptide (Cerumenex) drops
            2. DocusateSodium 1 ml
            3. Carbamide Peroxide
         2. References
            1. Whatley (2003) Arch Pediatr Adolesc Med 157:1177 [PubMed]
            2. Roland (2004) Arch Otolaryngol Head Neck Surg 130 [PubMed]
5. Management: Ear Canal Bleeding after Cerumen Removal
   1. Visualize ear canal for Trauma (exclude Tympanic Membrane or middle ear Trauma)
   2. Local pressure may be applied with a cotton-tipped applicator
   3. Persistent minor bleeding (consult ENT for significant bleeding from ear canal Trauma)
      1. Place ear wick in canal followed by 1-2 drops of nasal Decongestant (or Tranexamic Acid)
      2. Patient should place 1-2 drops of Oxymetazoline (adult) every 12 hours or neosynephrine (child) every 6 hours
      3. Remove wick in 24 hours and return for recurrent bleeding
      4. May place gauze inside a concave eye patch (with elastic band) over the ear
6. Prevention
   1. See Cerumen Softening Agents for home preventive protocol for recurrent impaction
   2. Do not use cotton swabs in the ear canal
      1. Cotton swabs only further impact cerumen that is present
   3. Avoid ear candling (ineffective and risk of adverse effects)
7. References
   1. Malaty (2018) Am Fam Physician 98(8): 525-9 [PubMed]
   2. Singer (2000) Ann Emerg Med 36:228-32 [PubMed]