Cerumen Impaction Removal
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Removal of cerumen (wax) from the ear forms a significant part of the workload of an otolaryngologist and is, therefore, an essential skill to master. [1] However, general practitioners, emergency department staff, nurses, audiologists, audiological physicians, and alternative medicine practitioners may all be confronted with the scenario of excess ear wax that causes difficulty in examination, hearing loss, or discomfort. [2]
Cerumen impaction is defined as an accumulation of cerumen that causes symptoms, prevents assessment of the ear, or both. [14]
In an evaluation of 279 children with acute otitis media with effusion, ear wax needed to be removed to visualize the tympanic membrane in 29% of consultations. [3]
Many options are available to attempt to clear ear wax. These include the following:
Advising the patient to avoid the use of cotton tip applicators for routine cleaning. Normal external ear canal skin will desquamate in such a way that wax tends to be pushed to the outside. Regular “cleaning” with cotton tip applicators may be pushing wax deeper into the canal.
A multitude of over-the-counter and commercially available products are sold. Opinion varies on which is the most effective. These products can usually be divided into wate- based (such as peroxide ear drops), oil-based (such as olive oil), and non-water non-oil based (such as carbamide peroxide and glycerol-combination preparations). [16]
Wax-softening drops are intended to soften the wax over a period of hours to days. It is often prescribed for 2 weeks for maximal effect. The drops may be enough to clear obstruction as the ear canal skin will assist in pushing out the wax over time. However, these may also worsen the patient symptoms in the short term by converting a partial obstruction to a complete blockage. In these cases, mechanical wax removal under vision (micro-suctioning) or irrigation of the ear may need to be considered to improve symptoms.
This procedure involves the use of warm (ideally body temperature) water under pressure directed into the ear canal to mechanically remove the wax. While a seemingly simple procedure it has a significant risk of damaging the tympanic membrane (ear drum) and middle ear structures, which led to it being a common reason for litigation in general practice in the past. Pressure-controlled devices limit the risk but tympanic membranes vary in strength from patient to patient and the risk of damage remains. Ear irrigation should not be undertaken without undergoing specific training, taking a full otological history, otological examination, seeking informed consent from the patient, and with the correct pressure-limited instrumentation.
This is typically done using an operating microscope with the patient awake. The operating microscope affords depth perception and allows accurate targeting of the wax. The wax may be removed with small suction tips (micro-suction), small forceps (called crocodile forceps), blunt instruments (for example, Jobson Horne Probes), or small cotton tip applicators.
The ear is composed of external, middle (tympanic cavity) (malleus, incus, and stapes), and inner (labyrinth) (semicircular canals, vestibule, cochlea) portions. The auricle and external acoustic meatus (or external auditory canal) compose the external ear. The external ear functions to collect and amplify sound, which then gets transmitted to the middle ear. The skin of the external ear canal is unique in that it exhibits directional desquamation or growth. This allows the normal external ear to be self-cleaning. If a dot of ink is placed on the tympanic membrane and the patient followed up over weeks the ink dot will be seen to move outwards and in a circular pattern.
The tympanic cavity (middle ear) extends from the tympanic membrane to the oval window and contains the bony conduction elements of the malleus, incus, and stapes. The primary functionality of the middle ear is that of bony conduction of sound via transference of sound waves in the air collected by the auricle to the fluid of the inner ear. The inner ear, also called the labyrinthine cavity, is essentially formed by the membranous labyrinth encased in the bony osseous labyrinth. The labyrinthine cavity functions to conduct sound to the central nervous system as well as to assist in balance.
For more information about the relevant anatomy, see Ear Anatomy.
Cerumen in the external ear canal is physiological.
Cerumen, commonly known as ear wax, is a hydrophobic protective covering in the ear canal. It acts to shield the skin of the external ear canal from water damage, infection, trauma, and foreign bodies. [13, 14]
Cerumen impaction is asymptomatic but in some circumstances it requires removal when causing symptoms or to facilitate ear examination.
Indications to address the cerumen include the following: [4, 15, 16]
Specific contraindications exist for each specific procedure. Individual assessment should dictate which technique is the most appropriate [16] .
Topical anesthetic drops have no documented benefits in ear wax removal.
Local anesthetic injections into the ear, although effective, are particularly painful and are therefore not used.
General anesthesia may be needed in some cases. For instance, special needs patients that are unable to comply may need to have a general anesthetic to allow cleaning of the ears.
The techniques used in cerumen removal include microsuction, mechanical removal, and irrigation. Instruments are shown in the image below.
Instrumentation needed for mechanical wax removal under vision including micro-suction includes the following:
Equipment needed for irrigation of the ear includes the following:
Patient positioning may vary according to individual clinician preference or may be dictated by anatomical limitations.
Usually, the patient is semi-reclined. Although having the patient sitting upright saves positioning time, the attic region is difficult to access with the patient in this position.
Positioning the patient supine with the head on a pillow simulates the operative view and allows good access to the external ear canal and tympanic membrane, including the attic. The supine position also aids patient stability. This is particularly beneficial if the patient experiences vertigo during the microsuction, as is often the case after mastoidectomy.
Patient positioning and room setup are shown in the images below.
See the list below:
Assemble and prepare all necessary equipment.
Take time to explain the procedure to the patient and obtain consent.
Connect suction tip and turn on the suction machine and microscope light.
Position the patient’s head facing away from the operator, the neck flexed laterally and the shoulder pulled down.
Examine the pinna, outer portions of the external canal, and the adjacent scalp for any evidence of previous surgery incision scars, signs of infection, or discharge.
See the list below:
Assess the cerumen. Gently probe with a blunt instrument such as Jobson Horne curette to determine whether the cerumen is soft, hard, or bony hard.
Assess whether tympanic membrane is visible. Look for any air spaces around the cerumen.
Before beginning the cerumen removal, ensure that the microscope and operator are optimally positioned. The microscope should be positioned to provide the optimal view of the ear canal, and the operator should be sitting comfortably and with a straight back.
See the list below:
If space permits, use an instrument to remove the wax. A ring probe (Jobson Horne curette) may be used to scoop the wax out; experienced practitioners may prefer to use a wax hook. If the cerumen is of a harder consistency, attempt to push the wax away from the ear canal walls toward the middle and then pull it out with a crocodile forceps.
If the wax is occlusive, use the large-bore suction (16 or 18 ga) device to remove the wax piecemeal. As soon as the hair-bearing skin is passed, downsize the suction device to 20 ga or larger. As experience grows, one develops a sense of the depth of the tympanic membrane, which allows for safe use of the large-bore sucker closer to the tympanic membrane. But suctioning on the tympanic membrane with a large-bore risks causing a perforation and significant discomfort to the patient and should be avoided.
Once the cerumen is cleared, reposition the microscope. This may reveal additional cerumen or pathology, especially in the anterior recess or the attic area or if a mastoid cavity is present.
If the patient reports discomfort during the procedure, postpone the cerumen removal for 2 or more weeks and encourage the patient to instill ear drops such as sodium bicarbonate (5%) ear drops twice daily. Such drops soften the cerumen and make it easier to remove.
See the list below:
Try to stick to the anterior wall while clearing the canal. At the anterior wall, the angle with the tympanic membrane is more acute, and the transition to the tympanic membrane is less likely to be missed.
Ask the patient to report pain, as this is a safety net. Pain is likely due to trauma to the ear canal skin. However, touching the malleus can cause pain and is to be avoided. A very stoic patient may try to grin and bear the pain when the malleus is accidentally touched; if he or she does so, this warning sign may be missed.
Do not hesitate to postpone the cerumen removal for 2 weeks, as pain and time can be saved by softening the cerumen with drops first. Drops can be selected at the clinician’s individual preference, as reviews have failed to demonstrate significant differences between various drops. [5, 6, 7, 8] In 2009, a review of completed trials also failed to demonstrate a significant difference between using water or commercially available drops. [5]
Take special care with pediatric patients. Carefully explaining the procedure, allowing the child to touch the suction device, and introducing suction into the ear canal slowly may help children as young as 4 years to tolerate a microsuction session. However, most children only tolerate this procedure at age 8 years or older. Using a Jobson Horne probe or a ring curette may be a viable alternative in pediatric patients who do not tolerate microsuction.
Adjust to the individual patient’s needs. Meticulous cleaning is required in patients with otitis externa, but less so if they are having a mold made for a hearing aid. However, for patients who simply present with excessive wax buildup, the clinician only needs to remove most of the cerumen, and the rest can be cleared with weekly olive oil drops.
If visual inspection reveals a foreign body instead of or in addition to cerumen, removal of the foreign body may require different techniques. See Medscape Reference article Ear Foreign Body Removal Procedures for more information.
A 0-degree rigid endoscope may be quicker and easier to access than a microscope when visualizing the cerumen, ear canal, and tympanic membrane. [9]
Some cases are better dealt with in theatre under general anesthetic and this option should be discussed as part of informed consent
Most patients tolerate the procedure very well with no analgesia. A minority of patients experience a mild amount of discomfort or even pain.
Some patients experience short-term vertigo.
Because of the noise generated by the suction tip, tinnitus may be worsened in some patients. Suction should be limited or avoided in patients with symptomatic tinnitus.
Hard cerumen, probes, specula, and suction devices may all cause lacerations to the ear canal skin. Minor bleeding and discomfort may result.
Using a large-bore suction device close to the tympanic membrane may cause trauma to the tympanic membrane, including a perforation. Such trauma usually heals spontaneously over the following weeks.
Inadvertent force to the ossicular chain may lead to conductive or sensorineural hearing loss.
Overview
What is cerumen impaction removal?
What is the conservative approach to cerumen impaction removal?
What is the role of wax-softening drops in cerumen impaction removal?
What is the role of ear irrigation in cerumen impaction removal?
What is the role of mechanical wax removal under vision in cerumen impaction removal?
What is the anatomy relevant to cerumen impaction removal?
When is cerumen impaction removal indicated?
What are the contraindications for cerumen impaction removal?
What is the role of anesthesia in cerumen impaction removal?
Which instrumentation is needed for mechanical cerumen impaction removal?
Which equipment is needed for irrigation of the ear in cerumen impaction removal?
How is the patient positioned for cerumen impaction removal?
What are the preparation steps in cerumen impaction removal?
How is mechanical cerumen impaction removal performed?
How is irrigation of the ear performed for cerumen impaction removal?
What are pearls in cerumen impaction removal?
What are the possible complications of cerumen impaction removal?
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Lum CL, Jeyanthi S, Prepageran N, et al. Antibacterial and antifungal properties of human cerumen. Journal Laryngol Otol 2009. 2009. 123:375.
Schwartz SR, Magit AE, Rosenfeld RM, et al. Clinical Practice Guideline(update). Otolaryngol Head Neck Surgery. 2017. 156:14.
Mitika M. Cerumen removal guidelines wax practical. JAMA. 2008. 300:1506.
Kate Stephenson, Claude Laurent. Ear Wax removal technique. Open Access guide to Audiology and Hearing Aids for Otolaryngologists. [Full Text].
F Carl van Wyk, MB, ChB, MRCS, FRCS(Edin) ENT and International Board Certified Facial Plastic Surgeon
F Carl van Wyk, MB, ChB, MRCS, FRCS(Edin) is a member of the following medical societies: British Association of Otorhinolaryngologists, Head and Neck Surgeons, British Rhinological Society, European Academy of Facial Plastic Surgery, Royal College of Surgeons of Edinburgh, South African Society of Otorhinolaryngology Head and Neck Surgery
Disclosure: Paid Consultant/Speaker on Sinus Surgery Course Sponsored by Medtronic for: Medtronic.
Raphael Dikamba Muanza, MBChB Registrar Physician, Department of ENT-Head and Neck Surgery, Dr George Mukhari Academic Hospital, Sefako Makgatho Health Sciences University, South Africa
Raphael Dikamba Muanza, MBChB is a member of the following medical societies: South African Medical Association, South African Society of Otorhinolaryngology Head and Neck Surgery
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
Prajoy P Kadkade, MD Assistant Professor of Otolaryngology, Albert Einstein College of Medicine; Attending Physician, Department of Otolaryngology and Communicative Disorders, Director of Otolaryngology, North Shore University Hospital, North Shore-Long Island Jewish Hospital System
Prajoy P Kadkade, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Medical Society of the State of New York
Disclosure: Nothing to disclose.
Prince Cheriyan Modayil, MRCS, MS, MBBS, DO-HNS Clinical Fellow in Otolaryngology, St George’s Healthcare NHS Trust, London
Prince Cheriyan Modayil, MRCS, MS, MBBS, DO-HNS is a member of the following medical societies: Royal College of Surgeons of England, Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.
David K Selvadurai, MD, MBBS, FRCS(CSiG), FRCS(Oto), FRCS(ORL-HNS) Consultant Ear, Nose and Throat Surgeon, Director of Cochlear Implant Program, Surgical Director of Bone Anchored Hearing Aid Program, St George’s Hospital NHS Trust; Consultant ENT Surgeon, St Helier Hospital and The Queen Mary Hospital for Children, UK
David K Selvadurai, MD, MBBS, FRCS(CSiG), FRCS(Oto), FRCS(ORL-HNS) is a member of the following medical societies: British Association of Otorhinolaryngologists, Head and Neck Surgeons, British Association of Paediatric Otorhinolaryngologists, British Medical Association, Otorhinolaryngological Research Society, Royal Society of Medicine
Disclosure: Nothing to disclose.
The authors and editors of Medscape Reference gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.
Medscape Reference thanks Hamid R Djalilian, MD, Associate Professor of Otolaryngology, Director of Neurotology and Skull Base Surgery, University of California Irvine Medical Center, for assistance with the video contribution to this article.
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