3.01 Cerumen Impaction (Ear Wax Blockage)

agk’s Library of Common Simple Emergencies

Presentation

The patient may complain of “wax in the ear,” a “stuffed up” or foreign body sensation, pain, itching, decreased hearing, tinnitus, or dizziness. On physical examination, the dark brown, thick, dry cerumen, perhaps packed down against the ear drum, where it does not occur normally, obscures further visualization of the ear canal.

What to do:

• Explain what you are going to do to the patient. Cover him with a waterproof drape, have him hold a basin or thick towel below his ear, and tilt the ear slightly over it.
• Fill a 20ml syringe with warm water at approximately 98.6F (37C) and fit it with a soft tubing catheter. Aim along the anterior superior wall of the external ear canal (visualize directly) and squirt with all your might.
• Repeat until all of the cerumen is gone. Dry the canal.
• If multiple attempts at irrigation prove to be unsuccessful, then gentle use of a cerumen spoon (ear curette) may be necessary to pull out the excess wax. Warning the patient about potential discomfort or minor bleeding before using the ear curette will save lengthy explanations and apologies later.
• Reexamine the ear and test the patient’s hearing.
• Warn the patient that he has thick ear wax, that he may need this procedure done again someday, and that he should never use swabs in his ear.

What not to do:

• Do not irrigate an ear with a suspected or known tympanic membrane perforation, or myringotomy tubes.
• Do not waste time attempting to soften wax with ceruminolytic detergents.
• Do not irrigate with a cold (or hot) solution.
• Do not blindly insert a rigid instrument down the canal.
• Do not irrigate with a stiff over-needle catheter. It can cause a painful abrasion and bleeding or even perforate the tympanic membrane.
• Do not leave water pooled in the canal. That can cause an external otitis. A final instillation of 2% acetic acid (Acetasol, Domboro Otic, half-strength vinegar) will also prevent iatrogenic swimmer’s ear.

Discussion

This technique virtually always works within 5-10 squirts. If the irrigation fluid is at body temperature, it will soften the cerumen just enough that it floats out as a plug. If the fluid is too hot or cold it can produce vertigo, nystagmus, nausea, and vomiting.

A conventional blood-drawing syringe, fitted with a butterfly catheter, its tubing cut l cm from the hub, seems to work better than the big chrome-plated syringes manufactured for irrigating ears. An alternative technique is to use a WaterPik. Cerumen spoons can be dangerous and painful, especially with children, for whom this irrigation technique has proven more effective in cleaning the ear canal to provide for assessment of the tympanic membrane.

Cerumen is produced by the sebaceous glands of the hair follicles in the ear canal, and naturally flows outward along these hairs. One of the problems with ear swabs is that they can push wax inwards away from these hairs and against the ear drum, where it can then stick and harden. Patients may ask about “ear candles” to remove wax, but these are also not very effective compared to the technique above.

References

• Robinson AC, Hawke M: The efficacy of ceruminolytics: everything old is new again. J Otolaryngol 1989;18:263-267.

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