Approach
Cerumen impaction can be treated by a variety of techniques, including manual removal, irrigation of the ear canal, or injection of cerumenolytic solutions into the ear canal, as well as a combination of these techniques. The choice of treatment depends on the skill, experience, and comfort level of the clinician, as well as on the patient's history.
Cerumen removal is not needed unless the patient has symptoms attributable to cerumen impaction, or the presence of cerumen is preventing evaluation of the tympanic membrane.[5]
Examination after treatment should be performed to ensure that the impaction has been cleared from the canal.
If treatment is unsuccessful, or in certain circumstances (e.g., perforated tympanic membrane), manual removal, preferably with the aid of a binocular microscope, is the recommended technique.
Manual removal
Manual removal can be performed in children or adults using a variety of instruments. It is helpful to have a co-operative patient who will not move during the procedure. Restraints, in the form of a nurse or parent holding the child, or the placement of the child in a papoose board, might be useful in young children. However, it is imperative not to cause pain during the treatment, whether or not the patient is restrained.
Manual removal can be performed with a variety of instruments, but exposure of the impacted cerumen with adequate light is essential. The clinician can visualise the impaction with a hand-held otoscope, an ear speculum with an external light source, or a binocular microscope. It is not known whether endoscopic vision is as effective as microscopic vision in assisting mechanical removal of impacted cerumen. Ear curettes, right-angle probes, forceps, microsuction devices, or a combination of instruments can be used depending on the location and consistency of the impacted cerumen. The binocular microscope provides excellent light, binocular vision with depth perception, and magnification. By using the binocular microscope, the clinician can usually remove the impacted cerumen painlessly and completely. The main disadvantage of the binocular microscope is its cost; it is not available in most primary care surgeries.[5]
A complication associated with manual removal is skin laceration, with bleeding and pain.
Irrigation of the ear canal
Aural irrigation using a syringe or a mechanical irrigator is a widely used method of cerumen removal. This method appears to be safe if low pressures are used and the stream of water is directed towards the ear canal rather than towards the tympanic membrane. Aural irrigation should be avoided in patients who are known to have a perforated tympanic membrane or a history of ear surgery.[5] Some of the latter patients may have atrophic portions of their tympanic membranes that are prone to perforate in the face of pressure from the irrigation.
Although irrigation of the ear canal for removal of impacted cerumen is relatively safe, the following complications have been reported: tympanic membrane perforation, ear-canal laceration and bleeding, external otitis, pain, vertigo, loss of balance and hearing, and incomplete cerumen removal. Physicians should explain these possible complications prior to irrigation.
In the US and several other regions, soft plastic bulb syringes are widely available over the counter and can be used by patients for self-irrigation. One randomised controlled trial that compared the effectiveness of self-treatment bulb syringes with routine care found a significant reduction in self-reported symptoms in those self-treating with bulb syringes.[9] A 2-year follow-up study found that self-treatment significantly reduced subsequent demand for ear irrigation by health professionals.[10]
Cerumenolytic agents
A variety of chemical agents have been applied to cerumen to soften it and to expedite its removal in conjunction with manual removal or aural irrigation.[11][12][13] Conversely, the use of ear drops (any active treatment) irrigation or manual removal resulted in complete cerumen clearance in only 22 out of 100 patients, in one study.[13]
These agents can be applied either in the clinician's surgery or can be used by the patient in their home. Applying the cerumenolytic agent 15 to 20 minutes prior to syringing the ear increases the success rate of cerumen removal to 97%, and may require a smaller volume of water to clear the cerumen.[12] These agents can be categorised into 3 groups: water-based, oil-based, or non-water-, non-oil-based.
Water-based agents induce hydration and fragmentation of the corneocytes in the cerumen.
Agents include acetic acid, docusate sodium, hydrogen peroxide, and saline solution.
There is insufficient evidence to know whether water-based softeners as a group are better than saline.
There is insufficient evidence to know which water-based softener works best. However, they are better than no treatment.
Oil-based agents lubricate and soften the impacted cerumen.
These include olive oil and mineral oil.
Oil-based agents are as effective as water-based cerumen softeners.
There is insufficient evidence to know which oil-based softener works best.
Non-water-, non-oil-based agents work by an unknown mechanism.
These include urea hydrogen peroxide (carbamide peroxide).
They may be more effective than oil-based agents but less effective than water-based agents.
The physician or nurse can apply a dropperful of any of the agents into the ear canal and can then attempt mechanical removal or irrigation in a few minutes. For wax that is very hard, it is helpful to send the patient home with instructions to instil a dropperful of mineral oil, olive oil, or acetic acid in the ear once a day and have the patient return in a few days for another attempt at removal.
The use of cerumenolytic agents has been associated with the following complications: allergic reactions, external otitis, pain or vertigo in the presence of a non-intact tympanic membrane, and transient hearing loss. These agents should not be used in the presence of a non-intact tympanic membrane.
Management of specific patient groups and refractory impaction
Manual removal, preferably with the aid of a binocular microscope, is considered in special circumstances, including a history of tympanic-membrane perforation; ear-canal stenosis; prior ear surgery, including canal-wall-down mastoidectomy; an un-cooperative child; external otitis; or when previous treatment methods are unsuccessful. Aural irrigation, especially with tap water, should be performed with caution in patients with diabetes, because they have an increased risk of developing malignant external otitis.[14][15] Occasionally, an un-cooperative child or an individual with a congnitive impairment may need a general anaesthetic to facilitate removal of a cerumen impaction.
Patients with persistent cerumen impaction, following unsuccessful treatment attempts, are referred to a clinician with specialised equipment and training for cleaning and evaluating the ear canal and tympanic membrane.[1]
Ear candling
This is a form of complementary medicine. Ear candles are hollow tubes of fabric soaked with beeswax. The narrow end of the tube is placed in the ear canal, and the broad end is lighted as a flame. Supposedly, the 'chimney effect' of the candle will draw out the wax. There is no evidence for the efficacy of this method. However, complications of this treatment, including burns and occlusion of the ear canal from the burning wax, have been reported, and the US Food and Drug Administration (FDA) and the American Academy of Otolaryngology warn against the use of ear candles.[1][16][17]
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