Key Points
- Cerumen forms when glandular secretions from the outer two-thirds of the ear canal mix with exfoliated squamous epithelium.
- Normally, cerumen is eliminated or expelled by a self-cleaning mechanism, which causes it to migrate out of the ear canal assisted by jaw movement.
- Blockage of the ear canal from cerumen can lead to a host of symptoms including: hearing loss, tinnitus, fullness, itching, otalgia, discharge, odor, or cough.
- In addition, cerumen impaction can prevent diagnostic assessment by preventing complete examination of the external auditory canal and/or ear drum (tympanic membrane) or by interfering with diagnostic assessment (i.e. audiometry, tympanometry).
- Asymptomatic cerumen does not require active management.
- This guideline does not apply to patients with cerumen impaction associated with the following conditions: dermatologic diseases of the ear canal, recurrent otitis externa, keratosis obturans, prior radiation therapy affecting the ear, previous tympanoplasty/myringoplasty or canal wall down mastoidectomy or other surgery affecting the ear canal.
Figure 1. Cerumen
Figure 2. Otoscopic view of impacted cerumen that completely fills the ear canal
Figure 3. Otoscopic view of impacted cerumen, mixed with hair, completely obstructing the ear canal
Table 1. Summary of Guideline Key Action Statements (KAS)
| Statement | Action | Strength |
|---|---|---|
| 1. Primary prevention | Clinicians should explain proper ear hygiene to prevent cerumen impaction when patients have an accumulation of cerumen. | R-C |
| 2A. Diagnosis of cerumen impaction | Clinicians should diagnose cerumen impaction when an accumulation of cerumen as seen on otoscopy 1) is associated with symptoms, or 2) prevents needed assessment of the ear, or 3) both. | R-B |
| 2B. Modifying factors | Clinicians should assess the patient with cerumen impaction by history and/or physical examination for factors that modify management such as one or more of the following: anticoagulant therapy[D] immunocompromised state[D], diabetes mellitus[C], prior radiation therapy to the head and neck[C], ear canal stenosis, exostoses, non-intact tympanic membrane[D]. | R-C/D |
| 3A. Need for intervention if impacted | Clinicians should treat, or refer to another clinician who can treat, cerumen impaction when identified. | S-B |
| 3B. Non-intervention if asymptomatic | Clinicians should not routinely treat cerumen in patients who are asymptomatic and whose ears can be adequately examined. | R-C |
| 3C. Need for intervention in special populations | Clinicians should identify patients with obstructing cerumen in the ear canal who may not be able to express symptoms (young children and cognitively impaired children and adults) and promptly evaluate the need for intervention. | R-C |
| 4. Intervention in hearing aid users | Clinicians should perform otoscopy to detect the presence of cerumen in patients with hearing aids during a health care encounter. | R-C |
| 5A. Recommended interventions | Clinicians should treat, or refer to a clinician who can treat, the patient with cerumen impaction with an appropriate intervention, which may include one or more of the following: cerumenolytic agents, irrigation, or manual removal requiring instrumentation. | R-B |
| 5B. Contraindicated intervention (ear candling/coning) | Clinicians should recommend against ear candling/coning for treating or preventing cerumen impaction. | R-C (against) |
| 6. Cerumenolytic agents | Clinicians may use cerumenolytic agents (including water or saline solution) in the management of cerumen impaction. | O-C |
| 7. Irrigation | Clinicians may use irrigation in the management of cerumen impaction. | O-B |
| 8. Manual removal | Clinicians may use manual removal requiring instrumentation in the management of cerumen impaction. | O-C |
| 9. Outcomes assessment | Clinicians should assess patients at the conclusion of in-office treatment of cerumen impaction and document the resolution of impaction. If the impaction is not resolved, the clinician should use additional treatment. If full or partial symptoms persist despite resolution of impaction, the clinician should evaluate the patient for alternative diagnoses. | R-C |
| 10. Referral and coordination of care | Clinicians should refer patients with persistent cerumen impaction after unsuccessful management by the initial clinician to a clinician with specialized equipment and training for cleaning and evaluating the ear canal and tympanic membrane. | R-C |
| 11. Secondary prevention | Clinicians may educate/counsel patients with cerumen impaction/excessive cerumen regarding control measures. | O-C |
