Cerumen

INTRODUCTION — Cerumen, commonly known as ear wax, is a hydrophobic protective covering in the ear canal. It acts to shield the skin of the external canal from water damage, infection, trauma, and foreign bodies [1,2]. Accumulation of cerumen is usually asymptomatic but can occasionally cause bothersome symptoms, such as hearing loss and/or ear discomfort.

This topic will focus on the indications and techniques for cerumen removal.

EPIDEMIOLOGY — Cerumen accumulation can affect up to 6 percent of the general population and a much higher percentage of persons with cognitive impairment [3,4]. Excessive or impacted cerumen is present in approximately 1 in 10 children, 1 in 20 adults, and 1 in 3 older adults [2,5]. In the United States, cerumen accumulation leads to 12 million patient visits and 8 million cerumen removal procedures annually [6].

ANATOMY — Cerumen is found in the external auditory canal (EAC), which begins at the meatus of the auricle and ends at the tympanic membrane (figure 1) [7]. The lateral one-third of the EAC (cartilaginous EAC) consists of hair and glandular-bearing skin on top of fibrocartilaginous tissue. The sebaceous and ceruminous glands within the skin appendages found in the cartilaginous EAC are responsible for the components of cerumen. The medial two-thirds of the EAC (bony EAC) consist of thin skin adherent to the periosteum of the temporal bone. The canal narrows in most individuals at the isthmus, which is located at the junction of the bony and fibrocartilaginous portions of the canal [8]. Cerumen trapped medial to the isthmus tends to become impacted and cause hearing loss.

At the most medial end of the external canal is the tympanic membrane. The lateral layer of the tympanic membrane consists of keratinizing squamous epithelium that is in continuity with the epithelium of the external canal [9,10]. Lateral epithelial migration allows for removal of sloughing squamous epithelial cells. Further description of the ear canal and discussion of its relationship to external ear canal disease are presented elsewhere. (See "External otitis: Pathogenesis, clinical features, and diagnosis", section on 'Anatomy' and "External otitis: Pathogenesis, clinical features, and diagnosis", section on 'Pathogenesis and risk factors'.)

CERUMEN ACCUMULATION AND IMPACTION — Cerumen is composed of secretions of both sebaceous and ceruminous glands located in the lateral one-third of the ear canal. These secretions mix with desquamated skin, the bacteria of normal skin flora, and occasional depilated hair to form cerumen [5,11,12]. Any water trapped in the ear canal also mixes with cerumen.

Accumulation of cerumen that causes bothersome symptoms and/or prevents a needed assessment of the ear canal is termed cerumen impaction [2].

The migratory pattern of the epithelium lining the ear canal is from medial to lateral. This skin migration along with movement of the soft tissues around the temporal-mandibular joint serve to eliminate excess cerumen from the ear canal [7,10]. Cerumen accumulates when this system is thwarted, breaks down, or is inadequate.

The main reasons that cerumen accumulates in the ear canal include [3]:

●Prevention of the natural ear canal skin migration due to ear canal disease – Ear canal disease can occur within the bone, soft tissues, or skin of the ear canal. Bony obstructions can be congenital or acquired and may be related to head and neck malformations. Bony obstructions due to Paget disease or fibrous dysplasia are examples of acquired disease. Bony growths within an otherwise normal canal (a single osteoma or multiple exostoses) are not uncommon (picture 1 and picture 2). Infectious and dermatologic diseases (eg, otitis externa, eczema) can be found in the ear canal, as well as cutaneous manifestations of systemic disease (eg, systemic lupus erythematosus, Crohn disease, Sjögren’s syndrome). These disorders also tend to cause excess exfoliation of the canal skin and atrophy or hypertrophy of the ceruminous and sebaceous glands.

●Narrowing of the ear canal – Anatomic variations of the ear canal are common. A particularly tortuous canal or an ear canal with excess narrowing at the isthmus may tend to accumulate cerumen. Soft tissue stenoses of the ear canal can occur in patients with multiple or severe infections of the ear canal, or after surgery on the ear. Tumors of the tissues in or around the ear canal also cause generalized narrowing. Excessive ear canal hair can trap cerumen at the meatus. Another source of obstruction is collapse of the cartilage that makes up the lateral one-third of the ear canal (eg, trauma).

●Change in cerumen texture and failure of epithelial migration – As part of the normal aging process, the glands of the ear canal skin tend to atrophy, producing a harder, less fluid cerumen that migrates much more slowly out of the ear canal [13]. In addition, chronic changes of the skin of the ear canal can lead to a loss of the normal migratory pattern of the epithelium [3]. Impaired epithelial migration and elimination of cerumen in the ear canal can also occur as a result of foreign objects placed in the ear canal (eg, cotton).

●Inappropriate attempts at removal are a common reason for cerumen accumulation in an otherwise healthy young adult or child. Cotton-tipped applicators (eg, Q-tips, cotton buds) tend to push cerumen deeper into the ear canal and over time can cause complete obstruction in some individuals. Hearing aids, in-ear headphones (“ear buds”), ear plugs, and swim molds also obstruct the ear canal and, with prolonged use, contribute to cerumen accumulation.

●Overproduction — Some individuals produce a volume of cerumen that overcomes the ear canal's ability to eliminate it in the absence of ear canal disease. This can occur as a response to local trauma or as a result of retained water in the ear canal, or it can be idiopathic.

CLINICAL PRESENTATION — Cerumen accumulation is usually asymptomatic. However, in some patients, cerumen may become impacted, leading to one or more of the following symptoms [6]:

●Hearing loss

●Earache

●Ear fullness

●Itchiness

●Reflex cough

●Dizziness

●Tinnitus

Cerumen is identified in the ear canal on otoscopic examination. Cerumen varies widely in appearance and texture from almost liquid to rock hard. Appearance may depend on the percentage of its different components, duration of time within the ear canal (harder cerumen is usually present for longer periods of time), and the amount of desquamated skin. Color ranges from a deep, dark red to black to off-white. A given individual may have different color cerumen in each ear. The color of the cerumen reflects its composition but does not necessarily depict normalcy or the health of the external canal.

CERUMEN REMOVAL — We generally agree with the 2017 guidelines from the American Academy of Otolaryngology-Head and Neck Surgery for managing cerumen impaction [2].

Indications for removal — Indications for cerumen removal are based on whether or not the patient has symptoms:

●Symptomatic patients – Cerumen removal is indicated for patients with symptoms due to cerumen (eg, hearing loss, earache, ear fullness, or itchiness) [2]. Systematic reviews, including observational studies and randomized trials, have found that symptomatic patients with cerumen accumulation who underwent cerumen removal experienced improved hearing compared with those who were observed without treatment [2]. In one randomized trial, 116 patients seeking cerumen removal for a variety of reasons (78 percent with “blocked ears” and 72 percent with hearing problems) were randomly assigned to irrigation or no treatment. A greater proportion of patients in the treatment group had a 10 decibel (dB) improvement in hearing threshold (34 versus 1.6 percent) [14].

●Patients unable to express symptoms – Cerumen removal is advisable in patients who are unable to express symptoms, such as young children and patients with cognitive impairment [15]. One prospective study of older adult nursing home patients found that patients with cerumen impaction had improved hearing and cognitive function following cerumen removal compared with controls [4].

Asymptomatic patients (who have the ability to identify and accurately communicate symptoms) should not routinely have cerumen removed [2,16]. Many asymptomatic patients will clear cerumen without any intervention [17]. Furthermore, cerumen can serve as a protective layer for the skin of the ear canal, preventing against infection and trauma. Lastly, cerumen removal can result in rare adverse outcomes. (See 'Complications' below.)

Removal methods — Cerumen removal should be performed with the proper methods and tools; improper removal can lead to complications such as tympanic membrane perforation or trauma, laceration of the canal skin, worsened cerumen impaction, and patient discomfort. There are three recommended therapeutic options: cerumenolytic agents, irrigation, and manual removal [2]. There are no head-to-head trials comparing the individual methods for cerumen removal. Systematic reviews have not found superiority of one method over another [2,18]. Selection of cerumen removal method should be based on provider experience [6]. Availability of time, equipment (eg, irrigation system, curettes), and ancillary staff also may influence choice of removal method.

For providers with expertise and equipment (usually otolaryngologists), we suggest manual removal because this involves direct visualization during the removal process, minimizing damage to the ear canal skin and/or tympanic membrane. However, in the primary care setting where equipment and experience with manual removal may not be available, we suggest cerumenolytics rather than irrigation as no equipment is necessary and there is less risk of tympanic membrane perforation. If cerumenolytics fail, we suggest follow-up cerumen removal with irrigation.

Cerumenolytics — Cerumenolytics are safe to use in patients without a history of ear infections (including otitis externa and otitis media), known or suspected perforations, or otologic surgery. For example, if a patient has a history of drainage from the ear, ear pain, or frequent ear infections earlier in life, then the tympanic membrane may be impaired and cerumenolytics should not be employed. Cerumenolytics should be avoided if there is known or suspected tympanic membrane damage or perforation.

Clinicians can apply cerumenolytics or instruct patients to use at home, but patients should be followed up with direct otoscopy. Retention of cerumenolytic drops behind the cerumen may occur, which can result in irritation or damage to the skin of the external auditory canal. Instructions on cerumenolytics typically recommend no more than three to five days of use for this reason.

In one high-quality randomized controlled trial comparing cerumenolytics with no therapy, 97 people (155 ears) with impacted cerumen were treated using a cerumenolytic for five days or received no therapy [17]. Use of a cerumenolytic increased the likelihood of an ear being cleared of cerumen compared with no treatment (53 versus 32 percent, respectively). Of note, one-third of untreated ears cleared during the five days. A systematic review including 10 randomized trials of 11 cerumenolytics found that ear drops were better than no treatment, but there was no significant difference in efficacy between the types of drops [19]. Water and saline solution were also used and found to be similarly efficacious to other cerumenolytics.

The most commonly used cerumenolytics are preparations of mineral oil or hydrogen peroxide, both available over the counter. However, in our practice, we use carbamide peroxide in our patients as it is safe and generally effective. Note that although carbamide peroxide produces hydrogen peroxide, it is less concentrated, and so is less irritating to ear canal skin and less likely to cause inner ear inflammation if there is an underlying perforation. We ask patients to apply 5 to 10 eardrops twice daily up to four days, keeping drops in the ear for several minutes by keeping the head tilted and placing cotton in the ear. To prevent complications, treatment duration should not exceed more than four days. (See 'Complications' below.)

Patients with dryness or excessive exfoliation of the ear canal skin should avoid preparations containing hydrogen peroxide, as this may exacerbate cerumen accumulation. Plain mineral oil and liquid docusate sodium are effective for these individuals.

In addition to cerumenolytics, patients with hard impaction or ear canal disease may require irrigation or manual removal under direct visualization with an otoscope or microscope in the office. Systematic reviews have found that use of a cerumenolytic may improve success of subsequent irrigation; however, it remains unclear which cerumenolytic agent is superior for this purpose [18,20].

Irrigation — Irrigation is one of the most widely practiced forms of cerumen removal. Expert consensus supports irrigation as an effective and safe method for removing cerumen [2]. In one randomized trial of 116 patients seeking care for a variety of reasons (78 percent with “blocked ears” and 72 percent with hearing problems), patients randomly assigned to irrigation were more likely to have an improvement in several symptoms including difficulty hearing on the phone, ear pain, and feeling of blocked ears [14].

We typically perform gentle irrigation of the ear canal with a large catheter-tipped syringe (200 mL) and warm water treated with a bacteriostatic agent (such as dilute hydrogen peroxide 1:10). However, saline or tap water may be just as effective [21]. Irrigation can be performed by the clinician or other trained clinical staff. Direct visualization of the ear canal is not necessary for safe and effective irrigation. The ear canal should be straightened as much as possible by pulling up and posteriorly on the auricle. The tip of the syringe should not be placed past the lateral one-third of the ear canal (usually no more than 8 mm into the canal). By directing the stream of irrigant upwards in the ear canal, the widened area of the ear canal next to the tympanic membrane can be cleared as well [13]. Irrigation tends not to be effective for hard impaction, however. One systematic review found that application of a cerumenolytic agent may assist with irrigation [20], but this is not usually necessary in most cases. Direct otoscopy is performed after irrigation to evaluate the success of the procedure (figure 2). (See 'Cerumenolytics' above.)

There are several mechanical jet irrigators available, some with a special irrigator tip that allows for better control of water pressure and direction of spray. However, their efficacy and safety have not been tested in randomized trials with conventional manual irrigation [22,23].

In immunocompromised patients, including patients with diabetes, acidification of the ear canal should follow irrigation (eg, 2 percent acetic acid otic drops or boric acid powder) [2]. Moisture retained in the ear canal tends to encourage bacterial growth in the wet desquamated skin, made more likely in a higher pH environment. Use of sterile water or saline rather than tap water can also help reduce the risk of infection from trapped water behind retained cerumen.

Manual removal — Manual removal is often quicker than cerumenolytics and irrigation and does not expose the ear to moisture. Manual removal should be performed by clinicians with adequate experience and appropriate equipment. Manual removal requires adequate visualization, usually with an otoscope or binocular microscope. Instruments used for removal of cerumen include curettes (probes with loops), spoons, forceps, right-angled hooks, straight applicator with applied wisps of cotton, and suction (usually with angulated suction tips). Manual removal may be preferred for patients with abnormal otologic findings (eg, perforated tympanic membrane) or patients with immunodeficiency that may be predisposed to infection if moisture is introduced into the ear canal via cerumenolytics or irrigation.

There are no randomized trials evaluating the efficacy of manual removal techniques in comparison to no treatment. There are small case series that have found manual removal to be effective in removing cerumen [24,25]. There are no data investigating the efficacy of curettes or spoons in comparison to other manual methods for cerumen removal.

In our experience, manual devices are most effective for removing cerumen in the lateral one-third of the ear canal. They should be used under direct visualization only and require the patient to be able to remain still during removal. Lighted curettes are plastic, disposable curettes that attach to a light source and can be helpful in visualizing the ear during cerumen removal [26]. Curette technique for cerumen removal is not effective in patients who cannot cooperate with the procedure, when cerumen is impacted against the tympanic membrane, or when the cerumen is very hard.

Suction with direct visualization is an effective adjuvant to the removal techniques mentioned above. Suction is usually performed on soft cerumen. When suctioning is required deep in the external auditory canal (past the isthmus), binocular magnification is essential to prevent inadvertent injury to the tympanic membrane or canal.

Other methods

●Endoscopy has been used to successfully remove cerumen, but this method is most appropriate for specialty use and is not employed in the primary care setting [27].

●There are several home cerumen removal methods that have not been well studied. These home methods include irrigation, manual removal (eg, cotton swabs, bobby pins), and ear vacuum kits [25]. They have not shown efficacy and should not be performed due to risk of injury.

●Ear candling, also called ear coning or thermal auricular therapy, involves lighting one end of a hollow candle and placing the other end in the ear canal. Ear candling has not been shown to be an effective method of cerumen removal and has the potential to injure the ear, as well as cause facial burns. The US Food and Drug Administration (FDA) and various practice guidelines recommend that patients avoid the use of ear candles for cerumen removal [2,28].

Complications — Complications vary between different removal procedures [2]. Cerumenolytics can lead to allergic reactions, otitis externa, earache, transient hearing loss, and dizziness. A common adverse effect of irrigation is retention of water behind incompletely removed cerumen, resulting in maceration of the skin and potential infection. Tympanic membrane perforation, hearing loss, tinnitus, pain, and vertigo can also occur, particularly after aggressive irrigation for cerumen accumulation [29,30]. The most common adverse effects with manual removal of cerumen include ear pain, bleeding, laceration, and perforation of the tympanic membrane.

Certain patient populations are prone to complications with cerumen removal. Narrowing of the ear canal (eg, in patients with congenital narrowing) may limit visualization, making both irrigation and manual instrumentation difficult to perform. Patients with diabetes, HIV infection, or other immunocompromised states may be at increased risk of malignant otitis externa due to cerumen removal [31,32]. In addition, patients receiving anticoagulant therapy are at higher risk of hemorrhage or subcutaneous hematomas. Care should be taken to minimize trauma in all of these populations, and close follow-up should be provided. (See "Malignant (necrotizing) external otitis".)

Reassessment — After treatment of cerumen impaction, the patient’s symptoms should be reassessed. If hearing loss or ear pain persist despite resolution of impaction, alternative diagnoses should be sought. (See "Etiology of hearing loss in adults" and "Hearing loss in children: Etiology" and "Evaluation of earache in children".)

PREVENTION OF CERUMEN ACCUMULATION — Most patients with conditions predisposing to cerumen accumulation (eg, eczema, otitis externa) cannot prevent recurrent episodes of cerumen accumulation and the need for cerumen removal.

Among individuals without predisposing conditions, routine use of topical emollients appears to prevent accumulation of cerumen. In a randomized trial of 39 children and adults with recurrent cerumen impaction, patients randomly assigned to a topical emollient were less likely to have a recurrence of cerumen impaction compared with those assigned to no treatment (23 versus 61 percent) [33]. Treatment with topical emollient involved weekly instillation for one year with 2 mL of a preparation mixture of paraffinum liquidum, cyclomethicone, and buxus chinensis. The topical emollient used in this study is not readily available in pharmacies.

In our practice, we suggest that patients with a history of recurring symptomatic cerumen impaction (>once per year despite cerumen removal) and otherwise normal ears use a cotton ball dipped in mineral oil and place in the external canal for 10 to 20 minutes once per week (combined with eight hours of not using a hearing aid overnight, if applicable). This helps to liquefy the cerumen and aid the normal elimination mechanisms, thereby potentially reducing the number of visits per year for cerumen removal.

Routine cleaning of the ears by a health professional every 6 to 12 months is also suggested [2].

Patients should be instructed that chronic use of cotton swabs or cerumenolytics should not be employed.

REFERRAL — Referral to an otolaryngologist for cerumen in the ear canal is seldom necessary. Referrals should be made in the following circumstances:

●History of chronic cerumen impaction, perforated tympanic membrane, or ear surgery

●Purulence or necrotic tissue in the ear canal

●Persistence of otologic complaints after removal of cerumen

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topics (see "Patient education: Age-related hearing loss (presbycusis) (The Basics)" and "Patient education: Ear wax impaction (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Causes – The main causes for cerumen accumulation include obstruction due to ear canal disease, narrowing of the ear canal, failure of epithelial migration, and cerumen overproduction. (See 'Cerumen accumulation and impaction' above.)

●Symptoms – Cerumen accumulation is usually asymptomatic. However, in some patients, cerumen may become impacted, leading to hearing loss, ear pain, ear fullness, itching, cough, dizziness, vertigo, and/or tinnitus. Cerumen is identified by visual inspection of the ear canal with otoscopic examination. (See 'Clinical presentation' above.)

●Asymptomatic patients – In asymptomatic patients with cerumen accumulation, we recommend not removing cerumen (Grade 1B). However, removal of cerumen obstructing the ear canal is advisable in patients who cannot express symptoms (eg, those with cognitive impairment). (See 'Indications for removal' above.)

●Symptomatic patients – In patients with symptoms due to cerumen accumulation, options for cerumen removal include cerumenolytic agents, irrigation, and mechanical removal methods. For providers with expertise and equipment (usually otolaryngologists), we suggest manual removal over cerumenolytics and irrigation (Grade 2C). However, in the primary care setting where equipment and experience with manual removal may not be available, we suggest cerumenolytics rather than irrigation (Grade 2C). (See 'Indications for removal' above and 'Removal methods' above.)

●Recurrent symptoms – In patients with recurrent cerumen impaction and no significant ear disease, we suggest using a cotton ball dipped in mineral oil and placing in the external canal once per week to help liquefy cerumen and aid the normal elimination mechanisms (Grade 2C). (See 'Prevention of cerumen accumulation' above.)

●Referral indications – Patients with cerumen impaction should be referred to an otolaryngologist in the following situations: history of chronic cerumen impaction, perforated tympanic membrane, or ear surgery; purulence or necrotic tissue in the ear canal; and persistence of otologic complaints after removal of cerumen. (See 'Referral' above.)