Cerumen Impaction

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Example Management | References

Definition

Cerumen impaction refers to the accumulation of earwax (cerumen) in the external auditory canal to the extent that it causes symptoms or prevents necessary assessment of the ear canal or tympanic membrane.

Aetiology

The causes of cerumen impaction include:

• Narrow or abnormally shaped ear canals: Can make natural wax removal difficult.
• Overproduction of cerumen: Due to irritation or infection.
• Insertion of objects into the ear canal: Such as cotton swabs, hearing aids, or earplugs pushing wax deeper.
• Age-related changes: In older adults, cerumen tends to be drier and harder, leading to impaction.
• Hairy or overhanging ear canals: Excess hair can trap cerumen.

Pathophysiology

Cerumen is produced by the ceruminous and sebaceous glands in the outer third of the ear canal. It serves to protect the ear by trapping debris and has antimicrobial properties. Normally, cerumen migrates outward naturally. Impaction occurs when this self-cleaning mechanism fails due to obstruction, excessive production, or mechanical factors pushing wax inward.

Risk Factors

• Use of hearing aids or earplugs
• Regular use of cotton swabs or earbuds
• Narrow or hairy ear canals
• Elderly age
• Dermatological conditions (e.g., eczema, psoriasis)
• History of recurrent earwax impaction

Signs and Symptoms

Cerumen impaction may present with:

• Hearing loss (conductive)
• Earache (otalgia)
• Sensation of fullness in the ear
• Tinnitus
• Dizziness or vertigo
• Cough (via stimulation of the auricular branch of the vagus nerve)
• Itching in the ear

Investigations

• Clinical examination: Otoscopic examination to visualize cerumen impaction.
• Hearing assessment: If hearing loss is reported.
• Exclude other pathologies: Rule out otitis externa or foreign bodies.

Management

Primary Care Management

• Cerumenolytic agents: Use of ear drops containing oils (olive oil) or sodium bicarbonate ear drop to soften wax.
• Irrigation: Flushing the ear canal with water or saline after softening the wax (not recommended if perforation is suspected).
• Manual removal: Performed by trained professionals using instruments like curettes under direct visualization.
• Patient education: Advising against the use of cotton swabs or inserting objects into the ear canal.

Specialist Management

• Microsuction: Performed by ENT specialists, especially in cases where irrigation is contraindicated.
• Treatment of underlying conditions: Managing skin conditions like eczema that may contribute to impaction.
• Regular monitoring: For patients with recurrent impaction or those using hearing aids.

Example Management for Cerumen Impaction

A patient presents with decreased hearing and fullness in the right ear. Otoscopic examination reveals cerumen impaction obstructing the ear canal. The initial management includes recommending over-the-counter cerumenolytic ear drops to soften the wax for 3-5 days. If symptoms persist, the patient returns for ear irrigation in the clinic. Post-procedure, the patient is advised on proper ear care and cautioned against using cotton swabs. Follow-up is scheduled to ensure symptom resolution.

References

1. NICE. (2016). Cerumen (Earwax) Removal. Retrieved from NICE
2. NHS. (2021). Earwax Build-up. Retrieved from NHS
3. American Academy of Otolaryngology–Head and Neck Surgery Foundation. (2017). Clinical Practice Guideline: Earwax (Cerumen Impaction). Retrieved from AAO-HNSF
4. British Tinnitus Association. (2020). Ear Wax Removal and Tinnitus. Retrieved from BTA

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