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Introduction: Impacted Cerumen

Heidi James, MD and Rob Orman, MD

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There’s more than one way to crack the wax!

  • Impacted cerumen is distressing for patients, but its management can be one of the more satisfying procedures that a primary care provider performs.  There are numerous techniques for relieving patients of their distress, some supported in the literature and others developed by creative physicians.  Examples include the use of a 60 cc syringe with an 18 gauge angiocath, use of a dental pick with pulsating water, use of the LED Elephant (a squirt bottle specifically designed for this use), and manual removal with a lighted curette.  Some involve high pressure irrigation with warm water, with or without added hydrogen peroxide.

  • One of the controversies in cerumen removal is whether adjunctive ear drops should be used to assist in loosening the wax.  Candidate cerumenolytics include docusate sodium (liquid Colace), sodium bicarbonate, sterile water, chlorobutanol, triethanolamine polypeptide oleate (Cerumenex), hydrogen peroxide, and oil (such as canola, olive, or mineral oil).   What is their efficacy?

    • A 2009 Cochrane review of 9 trials, 11 different cerumenolytics, and 697 patients concluded the following:  “Trials have been heterogeneous and generally of low or moderate quality, making it difficult to offer an definitive recommendations on the effectiveness of cerumenolytics for the removal of symptomatic ear wax.  Using drops of any sort appears to be better than no treatment, but it is uncertain if one type of drop is any better than another.”

      • Burton MJ, et al Ear drops for the removal of ear wax. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD004326.

    • More recent updates since the Cochrane review also suggest that the use of adjunctive ear drops is better than no drops at all, but whether one ear drop is better than another is still a matter of debate.

  • A clinical practice guideline published in 2008 regarding the management of cerumen impaction offers that following advice:

    • Routinely check for ear wax in anyone who has a hearing aid, no less frequently than every three months (or whenever you happen to see him/her in the office).

    • Evaluate for cerumen impaction in someone with disabilities, because unrecognized hearing loss can mimic some delays.

    • After completing the procedure for ear wax removal, recheck that the wax is gone and confirm that the patient has an intact tympanic membrane.

    • If the patient’s ear wax is cleared, ensure that the symptoms (tinnitus, hearing loss, or otalgia) are resolved.  If not, think of another diagnosis.

Roland PS, et al. Clinical practice guideline: cerumen impaction. Otolaryngol Head Neck Surg. 2008 Sep;139(3 Suppl 2):S1-S21. PMID: 18707628

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Palliative Cerumen Emergencies Full episode audio for MD edition 194:36 min - 91 MB - M4AHippo Primary Care RAP January 2016 Summary 1 MB - PDF