impacted cerumen

Ear wax:

• a build-up of earwax in the ear canal can cause hearing loss and discomfort, contributes to infections, and can exacerbate stress, social isolation and depression (1)
• also earwax can prevent adequate clinical examination of the ear, delaying investigations and management; GPs cannot check for infection and audiologists cannot test hearing and fit hearing aids if the ear canal is blocked with wax
• excessive earwax is common, especially in older adults and those who use hearing aids and earbud-type earphones
• in the UK, it is estimated that 2.3 million people each year have problems with earwax sufficient to need intervention

• cerumen (ear wax)
  • is a complex mixture of lipids
  • is produced by the sebaceous glands of the external auditory meatus as a means of protecting the epithelial lining of the tract
  • is made up of epithelial cells, hair, and secretions of the external ear (2)
• impacted cerumen
  • seen in about 4% of primary care patients(2)
  • commoner in children (2)
  • in this condition,cerumen, which may be hard, obstructs the auditory canal
  • risk factors for cerumen impaction are (3):
    • old age
      
    • learning disability
      
    • use of cotton swabs in ears
    • hearing aids
      
    • earplugs
• clinical features of cerumen (2)
  • ear discomfort
  • hearing loss
  • tinnitus
  • dizziness
  • chronic cough
• diagnosis
  • by direct visualization using an otoscope (2)
    
    
• management
  • consider ear irrigation using an electronic irrigator, microsuction or another method of earwax removal (such as manual removal using a probe) for adults in primary or community ear care services if:
    • the practitioner (such as a community nurse or audiologist):
      • has training and expertise in using the method to remove earwax
      • is aware of any contraindications to the method
    • the correct equipment is available
    • when carrying out ear irrigation in adults (1):
      • use pre-treatment wax softeners, either immediately before ear irrigation or for up to 5 days beforehand
      • if irrigation is unsuccessful:
        • repeat use of wax softeners or
        • instil water into the ear canal 15 minutes before repeating ear irrigation
      • if irrigation is unsuccessful after the second attempt, refer the person to a specialist ear care service or an ear, nose and throat service for removal of earwax.

     

    • possible complications of wax removal are:
    • pain,otitis externa,perforation of tympanic membrane, tinnitus,dizziness,syncope,cough, cardiac arrest (2)
      
      
• golden advice to patients
  • "Never put cotton swabs or other objects into the ear canal" (3)

Reference:

• (1) NICE (June 2018). Hearing loss in adults: assessment and management
• (2) McCarter DF et al. Cerumen Impaction, American Family Physician. May 15, 2007
• (3) Earwax: What you should know.American Academy of Family Physicians, 2007