Continuing Education Activity

Cerumen impaction is defined by the American Academy of Otolaryngology as an accumulation of cerumen in the external auditory canal (EAC) that causes symptoms, prevents necessary ear assessment, or both. The EAC functions to collect and amplify sound while protecting the middle and inner ear from infection, trauma, and foreign bodies. Cerumen forms a hydrophobic barrier, and the delicate skin of the EAC facilitates directional desquamation, promoting natural self-cleaning. While excessive cerumen is often asymptomatic, patients may present with hearing loss, ear fullness, pruritus, dizziness, tinnitus, or otalgia. Diagnosis relies on clinical assessment, and management strategies range from observation in asymptomatic cases to procedural removal, with ear irrigation being a common, controlled method for symptomatic individuals or those requiring clearance before topical therapy. Careful consideration of contraindications, including tympanic membrane perforation, acute otitis externa, or recent ear surgery, is essential to prevent complications such as canal laceration, vertigo, infection, or tympanic membrane injury.

This activity enhances clinicians’ competence in evaluating and managing cerumen impaction using ear irrigation. Participants review relevant anatomy, indications, contraindications, procedural technique, and risk mitigation strategies. Emphasis is placed on patient safety, proper equipment use, and the prevention of complications. Clinicians gain practical skills for assessment, irrigation, and follow-up care while learning to collaborate effectively with interprofessional team members, including nursing, audiology, and primary care colleagues, to ensure coordinated, high-quality care and optimize patient outcomes.

Objectives:

• Identify patients at increased risk for recurrent cerumen accumulation, such as those with dermatologic disorders, narrow canals, or hearing aids.
• Apply best practices for patient preparation and procedural techniques for safe and effective ear irrigation for cerumen impaction.
• Determine which cases of cerumen impaction require referral to an otolaryngologist rather than management with ear irrigation alone.
• Implement effective collaboration and communication among interprofessional team members to improve outcomes and treatment efficacy for patients with cerumen impaction.

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Introduction

Cerumen, commonly known as earwax, is a naturally occurring substance produced in the outer portion of the external auditory canal (EAC). The EAC contains pilosebaceous glands, ceruminous glands, hair follicles, and sebaceous glands. Modified sweat secreted by ceruminous glands exhibits bactericidal and fungicidal properties and contributes to lubrication and self-cleaning of the EAC. As dead skin cells are shed and migrate out of the canal, they combine with sebaceous secretions and ceruminous sweat to form cerumen, which consists primarily of dead keratinocytes.[1] Cerumen functions as a protective barrier that traps foreign particles. Pathologies of the EAC include sebaceous cysts, furuncles, and glandular tumors, although cerumen accumulation and impaction remain the most common clinical concern.

The American Academy of Otolaryngology defines cerumen impaction as "an accumulation of cerumen associated with symptoms, preventing the necessary assessment of the ear, or both."[2] Although cerumen is typically expelled from the EAC spontaneously with jaw movement, this mechanism may fail in some patients, leading to impaction. The condition occurs more frequently when normal cerumen extrusion is impeded by hearing aids, persistent use of earplugs or earbuds, or attempts to clean the ears with cotton-tipped applicators. Common symptoms include ear fullness, otalgia, pruritus, dizziness, cough, and decreased hearing.[3][4] Prevalence estimates indicate that approximately 5% of healthy adults, 10% of children, 57% of older adults, and 33% of patients with intellectual disability experience cerumen impaction.[5][6][7]

Irrigation of the EAC is one of several treatment options for cerumen impaction and is readily available in general practice and emergency departments. Nonclinicians may perform irrigation, which carries both advantages and potential disadvantages. Ear irrigation may be performed alone or after pretreatment with a cerumenolytic agent, such as acetic acid, mineral oil, or hydrogen peroxide.[8] A comprehensive history and physical examination, including otoscopy, is essential to confirm an intact tympanic membrane, verify the absence of tympanostomy tubes, and identify anatomical abnormalities, including squamous debris or retraction pockets suggestive of cholesteatoma or prior ear surgery, before attempting irrigation. Referral to an otolaryngologist is recommended if contraindications are present or irrigation fails to remove the cerumen.

Anatomy and Physiology

In most adults, the EAC follows a posterosuperior-to-anteroinferior trajectory, extending from lateral to medial. In children younger than 3 years, the EAC is predominantly directed posterosuperiorly. The lateral third of the EAC consists of fibrocartilage, whereas the medial two-thirds comprises the osseous portion, with skin tightly adhering to the periosteum and lacking subcutaneous tissue. The tympanic membrane is the most medial portion of the EAC, separating it from the middle ear. The bony canal narrows at the isthmus, approximately 6 mm lateral to the tympanic membrane, which may impede the removal of foreign bodies or cerumen located medial to this point.

Two tracts exist within the EAC and extend to surrounding structures. Laterally, the fissures of Santorini are lymphatic channels traversing the incomplete cartilaginous covering of the lateral third, connecting this region to the parotid gland, glenoid fossa, and infratemporal fossa. Medially, an embryologic defect at the inferior tympanic ring, the foramen of Huschke, may connect the medial EAC to the parotid gland and glenoid fossa. Both channels may allow extension of infection or malignancy into adjacent structures and should be considered during cerumen irrigation.

Tympanic membrane anatomy should be appreciable if irrigation successfully removes the impacted cerumen. The normal tympanic membrane is pearly gray and translucent. A cone of light appears in the anterior, inferior quadrant and points toward the nose. The malleus's umbo and handle should be apparent. The tympanic membrane is somewhat conical, with a concavity at the umbo, and exhibits no perforation. Bulging of the tympanic membrane, distortion of the cone of light, and limited visibility of the umbo and malleus handle may indicate infection or fluid in the middle ear space, consistent with serous or purulent otitis media. Eustachian tube dysfunction may result in tympanic membrane retraction or serous otitis media.

Irrigation fluid must approximate the patient’s core body temperature. Liquids that are too cold or hot may provoke dizziness due to the proximity of the lateral semicircular canal to the EAC. The vestibulocochlear nerve (cranial nerve VIII) consists of the vestibular and cochlear components. The vestibular nerve, responsible for spatial orientation, balance, and coordination, innervates the semicircular canals. The cochlear nerve mediates hearing.[9] Warm water induces reflexive nystagmus toward the ipsilateral side, whereas cold water induces reflexive nystagmus toward the contralateral side. The mnemonic COWS—cold, opposite, warm, same—helps clinicians recall the pattern of nystagmus responses.

Indications

Ear pain (otalgia) is a common reason for visits to family physician offices and emergency departments. Otalgia is primary when the pathology originates in the ear and secondary when it is associated with disease processes and an ear examination with normal findings. [10] Cerumen impaction is most commonly addressed at the patient's or family's request because of otalgia, aural fullness, and impaired hearing. 

Aural fullness, whether accompanied by otologic symptoms or not, represents a frequent reason for consultation with otolaryngology specialists. The majority of cases are caused by cerumen impaction, which can be reliably and effectively addressed by microscopic or micro-endoscopic removal in an outpatient setting. Nonetheless, a subset of patients presents with less common conditions, such as keratosis obturans (KO) and external auditory canal cholesteatoma (EACC), for which routine outpatient care may prove inadequate. [11]

Cerumen impaction can also be treated with cerumenolytics or ear irrigation. Cerumen should be treated whenever symptoms are present or when it prevents a needed otoscopic examination. [12] During the COVID-19 lockdown, ear candling practices were studied, and complications were observed, indicating that ear candling can be hazardous and should be avoided. These complications include ear pain, burning of the pinna or external auditory canal, burning of the hair or scalp, ear blockage, ear discharge, and tympanic membrane perforation. [13] Commonly used OTC cerumen removal devices do not result in a meaningful reduction of cerumen burden when used by the public, and do not show superiority to cotton swabs. [14]

Additional consequences of cerumen impaction include irritation, ear fullness, otalgia, pruritus, a sensation of imbalance, and cough. Ear irrigation is a common method for cerumen removal and may also serve as a means of caloric stimulation, which is discussed separately.[15] Other indications for cerumen removal by ear irrigation include the presence of a foreign body, preparation for hearing aid or earmold fitting, suspicion of external ear canal abnormalities such as eczema, exostosis, or tumor, and possible middle ear pathology.[16]

Contraindications

Patient-centered care requires individualized assessment of patients with cerumen impaction. Ear irrigation must be considered in the context of patient and family preferences and the patient’s history, including prior ear surgery, trauma, or documented hearing loss. The procedure should be conducted to minimize discomfort and, most importantly, prevent worsening of hearing or introduction of infection.

Relative contraindications for ear irrigation, compared with alternative cerumen removal techniques, include poor visualization of the ear canal, inability of the patient to sit upright, lack of patient cooperation, or patient refusal of the procedure, particularly if prior irrigation caused discomfort. Additional contraindications comprise a known history of tympanic membrane perforation, ventilation tube placement, or previous ear surgery, especially tympanomastoidectomy; the presence of discharge suggestive of otitis externa, otitis media, or tympanic membrane perforation; cerumen compaction; and prior radiation therapy to the area.

Equipment

Local anesthetics provide no benefit during ear irrigation for cerumen impaction, whether by topical administration as otic drops or local injection. General anesthesia may be necessary in select cases, such as in the treatment of patients with special needs.

To safely perform ear irrigation, the following equipment and materials should be prepared: 

• Upright chair with headrest, ideally capable of vertical adjustment to optimize patient positioning
• Face shield for eye protection
• Otoscope for canal and tympanic membrane assessment
• Pressure-controlled ear irrigation device with regulated water-pressure restriction
• Water, preferably maintained at 37 °C
• Alternatively, a 30- to 60-mL syringe attached to an intravenous catheter, with the needle removed
• Ear irrigation or emesis basin to collect water and cerumen
• Absorbent sheeting to protect surfaces and clothing

The following supplies are optional but may be utilized to enhance procedural safety and efficacy:

• Cerumenolytic agent, such as a small volume of hydrogen peroxide
• Suction device capable of generating 300 mm Hg pressure, equipped with a reservoir, built-in filter, and 16- and 18-gauge suction tips
• Aural specula for canal visualization
• Headlight for illumination
• Crocodile forceps for cerumen extraction
• Wax hooks or loops for mechanical removal

The clinician should verify that all items are clean, accessible, and ready for use before beginning the procedure. Proper selection and preparation of equipment and materials help optimize efficiency and outcomes.

Personnel

An assistant may facilitate cerumen removal by applying gentle traction to the pinna. This maneuver straightens the EAC, promoting more efficient and thorough cerumen extraction.

Preparation

The most critical preparation step is the assessment of whether ear irrigation is appropriate for the patient within the clinical context. Earwax may be softened prior to irrigation using agents such as mineral oil, hydrogen peroxide, 1% sodium docusate solution, or carbamide peroxide solution. Irrigation solutions and water should be warmed to approximately body temperature (37 °C), as cold or hot liquids can cause discomfort, dizziness, or nausea. If an intravenous catheter and syringe are employed, the needle must be removed prior to use. Intravenous catheters are single-use devices and should not be reused.

Technique or Treatment

Ear irrigation involves sequential steps to ensure safe, thorough removal of cerumen while protecting the tympanic membrane and EAC. The process involves the following steps:

• With the patient sitting upright, warm water is drawn into a syringe, and an intravenous catheter is attached to its end. The catheter is inserted into the EAC no further than the cartilage–bone junction, with the cartilaginous portion typically comprising the lateral third of the canal.
• Alternatively, a pressure-controlled ear irrigation device with water-pressure restriction may be employed with the patient in the upright position.
• If time permits, a cerumenolytic agent may be instilled into the EAC and left in place for 15 to 30 minutes prior to irrigation.
• An emesis or ear irrigation basin is held firmly against the skin below the ear to collect irrigation water, and absorbent sheeting is used to prevent contamination of surrounding surfaces.
• The intravenous catheter is directed superiorly and posteriorly within the EAC to allow the water stream to separate cerumen from the tympanic membrane. The stream should be directed toward the tympanic membrane to avoid perforation. Water should be injected at low pressure to avoid trauma, bleeding, or pain.
• Following irrigation, loose cerumen fragments may be removed using a cerumen scoop or alligator forceps, taking care to avoid injury to the EAC or tympanic membrane.
• Otic drops containing antibiotics and steroids may be instilled into the EAC after irrigation.
• Clinicians may prescribe antibiotic drops, such as fluoroquinolones, for patients at high risk of severe infection, including those with diabetes. Drops are typically administered for several days postirrigation to prevent otitis externa.[17]

Referral to an otolaryngologist is indicated when multiple attempts at removing impacted cerumen, including various treatments, are unsuccessful. Referral is also warranted when infection or other medical complications are present.

Complications

Mild, transient symptoms, such as vertigo, hearing loss, and tinnitus, may occur following ear irrigation. These manifestations are often related to the temperature of the water or solution rather than mechanical trauma. Severe discomfort, nausea, or vomiting is uncommon. Although complications from ear irrigation for cerumen removal are rare, they can include ear canal lacerations causing bleeding, discomfort, and increased risk of otitis externa; tympanic membrane perforation, which generally heals spontaneously; and middle ear traumatic injuries, such as disruption of the ossicular chain, potentially resulting in hearing loss. Referral to an otolaryngologist should be considered for patients with suspected complications.

Clinical Significance

Evaluation of the ears is an essential component of the head and neck physical examination. Cerumen may partially or completely obstruct the EAC, often necessitating removal. Cerumen impaction can produce ear fullness, otalgia, pruritus, dizziness, cough, and decreased hearing. Removal of impacted cerumen via ear irrigation frequently provides immediate relief of some or all symptoms, provided no underlying infection, malignancy, or other pathology is present.

Enhancing Healthcare Team Outcomes

Interprofessional collaboration is essential for patient-centered management of cerumen impaction. This collaborative approach enhances clinical outcomes, ensures patient safety, maximizes patient and family satisfaction, and optimizes team performance. Each team member, including physicians, nurses, advanced practice providers, audiologists, and pharmacists, contributes specialized expertise. Roles include cerumen removal when indicated, identification and management of ear infections, hearing aid fitting, trauma assessment, and addressing other otologic concerns.

Healthcare professionals must possess the clinical skills and expertise necessary to accurately diagnose, evaluate, and treat cerumen impaction. Ear irrigation improves patient outcomes, reduces discomfort, and prevents complications, though it must be administered judiciously to suitable patients, with informed consent obtained from both patients and their families. Ethical considerations require careful assessment when selecting treatment for individuals presenting with hearing loss or related symptoms. Clearly defining each team member’s responsibilities ensures effective utilization of specialized skills to enhance patient care and outcomes. Coordinated care delivery reduces errors, minimizes complications and delays, and promotes patient safety, well-being, and satisfaction.

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Disclosure: Andrew Sutton declares no relevant financial relationships with ineligible companies.

Disclosure: Michael Toscano declares no relevant financial relationships with ineligible companies.

Disclosure: Marjorie Launico declares no relevant financial relationships with ineligible companies.