Earwax (Cerumen) Impaction

Definition and epidemiology

Earwax (cerumen) forms when the secretions of the ceruminous and sebaceous glands in the outer, cartilaginous third of the ear canal mix with shed skin. It moisturises the canal skin, traps dust and microorganisms, and is usually carried out of the ear by the outward migration of the canal epithelium. The presence of wax is therefore not a disease in itself. The 2017 guideline of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) defines cerumen impaction as an accumulation of wax that causes symptoms, prevents a needed assessment of the ear, or both; the canal does not have to be completely blocked (Schwartz et al., 2017).

Excessive or impacted wax is found in about one in ten children, one in twenty adults and more than a third of older people and people with developmental disabilities (Schwartz et al., 2017). Rates of up to 57% have been reported among older nursing home residents (McCarter et al., 2007). In the United States an estimated 12 million people seek care for the problem each year (Schwartz et al., 2017).

Symptoms and signs

The commonest complaints are a feeling of fullness or blockage, reduced hearing, itching, tinnitus and sometimes earache (otalgia). Cough, dizziness and an unpleasant smell are less common (Schwartz et al., 2017). Symptoms often begin suddenly after water enters the ear, because the wax swells and closes the last narrow gap in the canal.

Otoscopy shows yellow-brown or dark wax, soft or hard, filling the canal and hiding the eardrum. The hearing loss is usually mild: in 50 ears, impacted wax raised thresholds by a mean of 11.4 dB and by at most 38.1 dB (Cronin and Zhao, 2020). Young children, adults with communication difficulties and older people with cognitive impairment may not be able to report symptoms, and the guideline recommends actively looking for obstructing wax in these groups and promptly deciding whether it needs removing (Schwartz et al., 2017). In hearing aid users the first sign is often that the aid sounds weaker or starts to whistle with feedback.

Causes and risk factors

Wax accumulates more easily with a narrow or tortuous canal, dense canal hair, drier secretions and slower epithelial migration with age, skin conditions, and regular occlusion of the canal by hearing aids, in-ear headphones or earplugs. Lesions that narrow the canal, such as exostoses, also hinder clearance (Schwartz et al., 2017). Rather than removing wax, cotton buds usually push it deeper and irritate the canal skin; they have been implicated in both impaction and otitis externa (McCarter et al., 2007). NICE and the AAO-HNS advise against cleaning the ears with cotton buds or similar small objects (NICE, 2018; Schwartz et al., 2017).

Hearing aid users are a distinct risk group. An earmould or in-the-ear aid disrupts the canal’s self-cleaning mechanism, pushes wax inwards and raises humidity in the canal. In a study of people using a hearing aid in one ear, wax and debris were significantly more common in the aided ear than in the unaided ear (Orji et al., 2014). Wax can also block the receiver opening and the wax guard, reducing the output of the aid.

Audiological and clinical assessment

The diagnosis is made by otoscopy. The AAO-HNS guideline recommends asking about factors that may change how wax is removed, such as anticoagulant use, diabetes, immunosuppression, previous head and neck radiotherapy, canal stenosis, exostoses and a non-intact eardrum (Schwartz et al., 2017). For the audiologist, impaction matters in two ways: it causes a measurable conductive loss, and it undermines the validity of other tests.

• Otoscopy: the first step of every audiological assessment. If the eardrum cannot be seen, wax removal is arranged before testing; NICE also recommends removal when wax prevents examination or ear impressions being taken (NICE, 2018).
• Pure-tone audiometry: complete occlusion produces a mild conductive loss with an air-bone gap and normal bone conduction. The length of the plug was not significantly related to the degree of loss (Subha and Raman, 2006).
• Tympanometry: wax blocking the canal or the probe tip gives a flat (type B) trace with a low ear canal volume. The low volume distinguishes this pattern from the flat trace with normal volume seen in otitis media with effusion.
• OAE and ABR: wax narrowing the canal can reduce or abolish OAE responses and cause misleading ‘refer’ results in screening; it also affects the placement of insert earphones for ABR.
• Real-ear measurement (REM) and impressions: a probe tube buried in wax gives false readings, and impressions should only be taken from a clear canal.

The differential diagnosis includes foreign bodies that may lie within the wax, otitis externa and otomycosis, and keratosis obturans and external auditory canal cholesteatoma. If symptoms persist after the wax has cleared, another diagnosis should be sought (Schwartz et al., 2017).

Treatment and audiological rehabilitation

Routine removal is not recommended for people without symptoms whose ears can be adequately examined (Schwartz et al., 2017). When treatment is needed there are three main approaches: wax-softening (cerumenolytic) drops, irrigation, and manual removal with instruments or by microsuction. The choice of method and its delivery rest with the doctor or a suitably trained clinician.

A Cochrane review found that drops may help to clear wax compared with no treatment, but no clear difference emerged between oil-based, water-based and other drops, and the certainty of the evidence is low. Adverse effects were uncommon and mild (Aaron et al., 2018). NICE NG98 advises against manual syringing in adults and supports electronic irrigation, microsuction or other methods such as manual removal with a probe, provided the clinician is trained, aware of contraindications and properly equipped. If irrigation fails, softening drops are repeated or water is instilled into the canal 15 minutes before a second attempt; if that also fails, the person is referred to a specialist ear care or ENT service (NICE, 2018).

Where irrigation is unsuitable, for example after a perforation or ear surgery, manual removal is preferred; it requires specific equipment and training (Horton et al., 2020). Microsuction is well tolerated, but in one study the noise of the procedure caused a temporary threshold shift in 86% of ears, largest at 6 kHz (Cronin and Zhao, 2020). Audiometry performed straight after microsuction may therefore underestimate hearing. The AAO-HNS guideline recommends against ear candling (Schwartz et al., 2017).

In Türkiye, patients usually reach audiology on referral from an ENT doctor; if impaction is found before testing, it should be stated in the report and passed back to the referring doctor. For hearing aid users the guideline recommends otoscopy at every healthcare encounter (Schwartz et al., 2017), and changing the wax guard and cleaning the receiver opening should be routine at hearing aid checks.

Impact on quality of life and advice

Impaction may seem trivial, but its impact varies. In older people and those with cognitive impairment, unnoticed wax further reduces hearing that may already be poor and makes communication harder; in hearing aid users it can create the impression that the aid is not working and lead to unnecessary repair visits. In children it can mean repeated screening tests and parental anxiety.

Practical advice: do not clean your ears with cotton buds, hairpins, keys or similar objects; wiping the outer ear and the canal entrance with a towel is enough (NICE, 2018). People who get impaction often may use softening drops at regular intervals on medical advice (Schwartz et al., 2017). Avoid ear candling. If you use a hearing aid, wipe it daily with a dry cloth, change the wax guard regularly, and when it sounds weaker, have the filter and your ear checked first. If your ear suddenly blocks, hurts or discharges after water gets in, seek advice rather than trying to fix it yourself.