Cerumen Impaction

Definition

Cerumen impaction is a condition in which earwax has become tightly packed in the external ear canal to the point that the canal is blocked.

Description

Cerumen impaction develops when earwax accumulates in the inner part of the ear canal and blocks the eardrum. It affects between 2%-6% of the general population in the United States. Impaction does not happen under normal circumstances because cerumen is produced by glands in the outer part of the ear canal; it is not produced in the inner part. The cerumen traps sand or dust particles before they reach the ear drum. It also protects the outer part of the ear canal because it repels water. The slow movement of the outer layer of skin of the ear canal carries cerumen toward the outer opening of the ear. As the older cerumen reaches the opening of the ear, it dries out and falls away.

Causes and symptoms

Causes

Cerumen is most likely to become impacted when it is pushed against the eardrum by cotton-tipped applicators, hair pins, or other objects that people put in their ears; and when it is trapped against the eardrum by a hearing aid. Less common causes of cerumen impaction include overproduction of earwax by the glands in the ear canal, or an abnormally shaped ear canal.

Symptoms

The most important symptom of cerumen impaction is partial loss of hearing. Other symptoms are itching, tinnitus (noise or ringing in the ears), a sensation of fullness in the ear, and pain.

Diagnosis

The diagnosis of impacted cerumen is usually made by examining the ear canal and eardrum with an otoscope, an instrument with a light attached that allows the doctor to look into the canal.

Treatment

Irrigation is the most common method of removing impacted cerumen. It involves washing out the ear canal with water from a commercial irrigator or a syringe with a catheter attached. Although some doctors use Water Piks to remove cerumen, most do not recommend them because the stream of water is too forceful and may damage the eardrum. The doctor may add a small amount of alcohol, hydrogen peroxide, or other antiseptic. The water must be close to body temperature; if it is too cold or too warm, the patient may feel dizzy or nauseated. After the ear has been irrigated, the doctor will apply antibiotic ear drops to protect the ear from infection.

Irrigation should not be used to remove cerumen if the patient's eardrum is ruptured or missing; if the patient has a history of chronic otitis media (inflammation of the middle ear) or a myringotomy (cutting the eardrum to allow fluid to escape from the middle ear); or if the patient has hearing in only one ear.

If irrigation cannot be used or fails to remove the cerumen, the patient is referred to an ear, nose, and throat (ENT) specialist. The specialist can remove the wax with a vacuum device or a curette, which is a small scoop-shaped surgical instrument.

Some doctors prescribe special ear drops, such as Cerumenex, to soften the wax. The most common side effect of Cerumenex is an allergic skin reaction. Over-the-counter wax removal products include Debrox or Murine Ear Drops. A 3% solution of hydrogen peroxide may also be used. These products are less likely to irritate the skin of the ear.

Alternative treatment

One alternative method that is sometimes touted as a way to remove impacted cerumen is ear candling. Ear candling involves the insertion of a burning candle or a cone of wax-soaked linen or cotton into the affected ear. The person lies on his or her side with the affected ear uppermost. A collecting plate is placed on the ear to catch melted wax. The cone or candle is threaded through a hole in the plate into the ear canal and lit. A variation on this technique involves blowing herbal smoke into the ear through homemade pottery cones. Practitioners of ear candling claim that the heat from the burning candle or smoke creates a vacuum that draws out the impacted cerumen. Some also claim that ear candling improves hearing, relieves sinus infections, cures earache or swimmer's ear, stops tinnitus, or purifies the mind. None of these claims are true. Ear candling is not recognized as an acceptable alternative practice by naturopaths, homeopaths, practitioners of Native American medicine, or any other authority on complementary and alternative medicine.

Ear candling is not only an ineffective way to remove impacted cerumen, it can actually damage the ear. According to a 1996 survey of 122 otolaryngologists (doctors who specialize in treating ear, nose, and throat disorders) in the Spokane area, the doctors reported 21 severe ear injuries resulting from ear candling, including 13 cases of external burns, 7 cases of ear canal obstruction from melted candle wax, and 1 case of eardrum perforation. Ear candles cannot legally be sold as health devices in the United States because they do not have Food and Drug Administration (FDA) approval. A similar ban is in effect in Canada. Ear candles are, however, available over the Internet and in some health food stores with the labeling "for entertainment only."

Prognosis

In most cases, impacted cerumen is successfully removed by irrigation with no lasting side effects. Irrigation can, however, lead to infection of the outer or the middle ear if the patient has a damaged or absent ear drum. Patients who try to remove earwax themselves with hair pins or similar objects run the risk of perforating the ear drum or damaging the fragile skin covering the ear canal, causing bleeding and the risk of infection.

Prevention

The best method of cleaning the external ear is to wipe the outer opening with a damp washcloth folded over the index finger, without going into the ear canal itself. Two techniques have been recommended to prevent cerumen from reaccumulating in the ear. The patient may place two or three drops of mineral oil into each ear once a week, allow it to remain for two or three minutes, and rinse it out with warm water; or place two drops of Domeboro otic solution in each ear once a week after showering.

Patients who wear hearing aids should have their ears examined periodically for signs of cerumen accumulation.

KEY TERMS

Cerumen— The medical term for earwax.

Curette— A small scoop-shaped surgical instrument that can be used to remove cerumen if irrigation does not work or cannot be used.

Ear candling— An alternative method for removing impacted cerumen with a lighted hollow cone of paraffin or beeswax. It does not work, and is not considered an acceptable treatment for any ear problem or disorder.

Impaction— A condition in which earwax has become tightly packed in the outer ear to the point that the external ear canal is blocked.

Irrigation— The technique of removing cerumen from the ear canal by flushing it with water.

Myringotomy— Surgical cutting of the ear drum to allow fluid to escape from the middle ear.

Otitis media— Inflammation of the middle ear. Patients who have had recurrent otitis media should not have cerumen removed by irrigation.

Tinnitus— A sensation of noise or ringing in the ears. Tinnitus may be a symptom of cerumen impaction.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD, editors. "External Ear: Obstructions." Section 7, Chapter 83 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Jackler, Robert K., MD, and Michael J. Kaplan, MD. "Cerumen Impaction." In "Ear, Nose, & Throat." Current Medical Diagnosis & Treatment 2001, edited by L. M. Tierney, Jr., MD, et al., 40th ed. New York: Lange Medical Books/McGraw-Hill, 2001.

PERIODICALS

Crummer, R. W., and G. A. Hassan. "Diagnostic Approach to Tinnitus." American Family Physician 69 (January 1, 2004): 120-126.

Ernst, E. "Ear Candles—A Triumph of Ignorance Over Science." Journal of Laryngology and Otology 118 (January 2004): 1-2.

Whatley, V. N., C. L. Dodds, and R. I. Paul. "Randomized Clinical Trial of Docusate, Triethanolamine Polypeptide, and Irrigation in Cerumen Removal in Children." Archives of Pediatrics and Adolescent Medicine 157 (December 2003): 1177-1180.

ORGANIZATIONS

American Academy of Family Physicians (AAFP). 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. (800) 274-2237 or (913) 906-6000. 〈http://www.aafp.org〉.

American Academy of Otolaryngology, Head and Neck Surgery, Inc.. One Prince St., Alexandria, VA 22314-3357. (703) 836-4444. 〈http://www.entnet.org〉.

OTHER

Health Canada/Santé Canada. It's Your Health: Ear Candling. Ottawa: Health Canada/Santé Canada, 2002.

Cerumen impaction

Definition

Cerumen impaction refers to the buildup of layers of earwax within the ear canal to the point of blocking the canal and putting pressure on the eardrum. Ironically, cerumen impaction is often caused by misguided attempts to remove earwax.

Description

Cerumen impaction develops when earwax accumulates in the inner part of the ear canal and blocks the eardrum. It does not happen under normal circumstances because the cerumen is produced by glands in the outer part of the ear canal; it is not produced in the inner part. Cerumen traps sand or dust particles before they reach the eardrum. It also protects the outer part of the ear canal because it repels water. The slow movement of the outer layer of skin of the ear canal carries cerumen toward the outer opening of the ear. As the older cerumen reaches the opening of the ear, it dries out and falls away.

Demographics

Cerumen impaction affects between 2 percent to 6 percent of the general population in the United States. It apparently affects males and females equally.

Causes and symptom

Causes

Cerumen is most likely to become impacted when it is pushed against the eardrum by cotton-tipped applicators, hair pins, or other objects that people put in their ears, and when it is trapped against the eardrum by a hearing aid. Less common causes of cerumen impaction include overproduction of earwax by the glands in the ear canal or an abnormally narrow ear canal that tends to trap the wax.

Symptoms

The most important symptom of cerumen impaction is partial loss of hearing. Other symptoms are itching , tinnitus (noise or ringing in the ears), a sensation of fullness in the ear, and otalgia, or pain in the ear. The pain is caused by the pressure of several layers of impacted earwax against the ear drum.

In children younger than one year, cerumen impaction is sometimes discovered during a routine check-up when the doctor finds that the earwax is blocking his or her view of the eardrum. In these cases the cerumen must be removed so that the doctor can finish checking the child's ears and sense of hearing.

When to call the doctor

Impacted cerumen is not a medical emergency. Family care practitioners recommend that parents try to remove the impacted wax at home before calling the doctor. Several over-the-counter products are described below under the heading of Treatment. The way to use these products is to tilt the child's head to one side and fill the ear canal with the eardrops, using an eyedropper. Allow the drops to soak in for a few minutes and then treat the other ear if needed. This home treatment method may be repeated twice a day for three or four days.

Parents should, however, take the child to the doctor in the following circumstances:

• The child complains of dizziness or pain in the ear.
• The impaction does not improve after several days of treatment at home.
• The child has had a myringotomy or ear tube placement.
• The child has a history of discharges from the ear.

Diagnosis

The diagnosis of impacted cerumen is usually made by examining the ear canal and eardrum with an otoscope, an instrument with a light attached that allows the doctor to look into the canal.

Treatment

Irrigation is the most common method of removing impacted cerumen. It involves washing out the ear canal with water from a commercial irrigator or a syringe with a catheter attached. Although some doctors use Water Piks to remove cerumen, most do not recommend them because the stream of water is too forceful and may damage the eardrum. The doctor may add a small amount of alcohol, hydrogen peroxide, or other antiseptic. The water must be close to body temperature; if it is too cold or too warm, the child may feel dizzy or nauseated. After the ear has been irrigated, the doctor applies antibiotic ear drops to protect the ear from infection.

Irrigation should not be used to remove cerumen if the patient's eardrum is ruptured or missing; if the patient has a history of chronic otitis media (inflammation of the middle ear) or a myringotomy (cutting the eardrum to allow fluid to escape from the middle ear); or if the child has hearing in only one ear.

If irrigation cannot be used or fails to remove the cerumen, the doctor can remove the wax with a vacuum device or a curette, which is a small scoop-shaped surgical instrument. Manual removal of the impaction is effective in 97 percent of children. The doctor holds the child's head steady with one hand while using the curette with the other hand to ease the impacted wax away from the sides of the ear canal. The doctor begins the removal in the area where the cerumen has already started to separate from the wall of the canal.

Some doctors prescribe special eardrops, such as Cerumenex, to soften the wax. The most common side effect of Cerumenex and similar products is an allergic skin reaction. Over-the-counter wax removal products include Debrox or Murine Ear Drops. A 3 percent solution of hydrogen peroxide may also be used. These products are less likely to irritate the skin of the ear.

Alternative treatment

One alternative method that is sometimes touted as a way to remove impacted cerumen is ear candling. Ear candling involves the insertion of a burning candle or a cone of wax-soaked linen or cotton into the affected ear. The person lies on his or her side with the affected ear uppermost. A collecting plate is placed on the ear to catch melted wax. The cone or candle is threaded through a hole in the plate into the ear canal and lit. A variation on this technique involves blowing herbal smoke into the ear through homemade pottery cones. Practitioners of ear candling claim that the heat from the burning candle or smoke creates a vacuum that draws out the impacted cerumen. Some also claim that ear candling improves hearing, relieves sinus infections, cures earache or swimmer's ear, stops tinnitus, or purifies the mind. None of these claims is true, however. Ear candling is not recognized as an acceptable alternative practice by naturopaths, homeopaths, practitioners of Native American medicine, or any other authority on complementary and alternative medicine.

Ear candling is not only an ineffective way to remove impacted cerumen, it can actually damage the ear. According to a 1996 survey of 122 otolaryngologists (doctors who specialize in treating ear, nose, and throat disorders) in the Spokane area, the doctors reported 21 severe ear injuries resulting from ear candling, including 13 cases of external burns , seven cases of ear canal obstruction from melted candle wax, and one case of eardrum perforation. Ear candles cannot legally be sold as health devices in the United States because they do not have Food and Drug Administration (FDA) approval. A similar ban is in effect in Canada.

Prognosis

In most cases, impacted cerumen is successfully removed from the child's ear by irrigation or manual extraction with no lasting side effects. Irrigation can, however, lead to infection of the outer or the middle ear if the patient has a damaged or absent eardrum. Older children or adolescents who try to remove earwax themselves with hair pins or similar objects run the risk of perforating the ear drum or damaging the fragile skin covering the ear canal, causing bleeding and the risk of infection.

Prevention

The best method of cleaning the external ear is to wipe the outer opening with a damp washcloth folded over the index finger, without going into the ear canal itself. Two techniques have been recommended to prevent cerumen from reaccumulating in the ear. The patient may place two or three drops of mineral oil into each ear once a week, allow it to remain for two or three minutes, and rinse it out with warm water; or place two drops of Domeboro otic solution in each ear once a week after showering.

Children who wear hearing aids should have their ears examined periodically for signs of cerumen accumulation.

Parents should teach children not to use cotton swabs or other objects to remove wax from the ear, and should advise older children and adolescents against experimenting with ear candling.

Parental concerns

Removal of impacted cerumen from children's ears is a routine procedure and should not ordinarily cause parents a great deal of concern. If the child has repeated episodes of cerumen impaction, parents can discuss various preventive measures with the doctor.

KEY TERMS

Cerumen —The medical term for earwax.

Curette —Also spelled curet; a small loop or scoop-shaped surgical instrument with sharpened edges that can be used to remove tissue, growths, or debris.

Ear candling —An alternative method for removing impacted cerumen with a lighted hollow cone of paraffin or beeswax. It does not work and is not considered an acceptable treatment for any ear problem or disorder.

Impaction —A condition in which earwax has become tightly packed in the outer ear to the point that the external ear canal is blocked.

Irrigation —Cleansing a wound with large amounts of water and/or an antiseptic solution. Also refers to the technique of removing wax (cerumen) from the ear canal by flushing it with water.

Myringotomy —A surgical procedure in which an incision is made in the ear drum to allow fluid or pus to escape from the middle ear.

Otalgia —The medical term for pain in the ear. Impacted cerumen can sometimes cause otalgia.

Otitis media —Inflammation or infection of the middle ear space behind the eardrum. It commonly occurs in early childhood and is characterized by ear pain, fever, and hearing problems.

Tinnitus —A noise, ranging from faint ringing or thumping to roaring, that originates in the ear not in the environment.

See also Ear exam with an otoscope; Myringotomy and ear tubes; Otitis media.

Resources

BOOKS

"External Ear: Obstructions." Section 7, Chapter 83 in The Merck Manual of Diagnosis and Therapy. Edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Jackler, Robert K., and Michael J. Kaplan. "Cerumen Impaction." In "Ear, Nose, & Throat," Current Medical Diagnosis & Treatment 2001, 40th ed. Edited by L. M. Tierney, Jr., et al. New York: Lange Medical Books/McGraw-Hill, 2001.

PERIODICALS

Ernst, E. "Ear Candles—A Triumph of Ignorance Over Science." Journal of Laryngology and Otology 118 (January 2004): 1–2.

Whatley, V. N., C. L. Dodds, and R. I. Paul. "Randomized Clinical Trial of Docusate, Triethanolamine Polypeptide, and Irrigation in Cerumen Removal in Children." Archives of Pediatrics and Adolescent Medicine 157 (December 2003): 1177–80.

ORGANIZATIONS

American Academy of Family Physicians (AAFP). 11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site: <www.aafp.org>.

American Academy of Otolaryngology, Head and Neck Surgery Inc.

WEB SITES

"Cerumen Impaction." FamilyPracticenotebook.com, June 6, 2004. Available online at <www.fpnotebook.com/ENT27.htm> (accessed November 29, 2004).

D'Alessandro, Donna, and Lindsay Huth. "Earwax (Cerumen)." Virtual Children's Hospital, April 2002. Available online at <www.vh.org/pediatric/patient/pediatrics/cqqa/earwax.html> (accessed November 29, 2004).

OTHER

Health Canada/Santé Canada. It's Your Health: Ear Candling. Ottawa: Health Canada/Santé Canada, 2002.

Rebecca Frey, PhD