1. Cerumen Impaction

2. Definition
Cerumen (Ear wax) is a naturally occurring product that provides some protection against common ear pathogens. They are normally extruded naturally from the ear canal.
Excessive built up in the ear canal can lead to potential pathological conditions
Cerumen buildup and blockage commonly occur in people who use Q-tips and cotton swabs to clean their ear canals.
Occur in anyone, but generally asymptomatic

3. Epidemiology Cerumen impaction is present in approximately:
10% of children
5% of normal healthy adults
57% of older patients in nursing homes
36% of patients with intellectual disability
Roughly 4% of primary care visits are related to cerumen removal
Most common Otolaryngology procedure performed in a primary care setting.

4. Common Causes
Anatomic deformity or an increased number of hairs in the external auditory canal.
Physical barriers to wax extrusion. Examples: using cotton swabs to clean ear canal, hearing aids, earplug-type hearing protectors.

5. Signs and Symptoms Fullness in the ear Pain in the ear Hearing loss
Tinnitus
Itchiness in the ear
Discharge from the ear
Odor coming from the ear
Dizziness

6. Otoscopy Appearance: Exam of the right external auditory canal shows complete obstruction of the canal with semi-moist cerumen. Anterior canal skin seen shows healthy epithelial lining. Red arrow indicates superior orientation. R6

7. Otoscopy Appearance: Limited view of the right external auditory canal shows complete obstruction of canal with thick dark cerumen. Note abundant hair lining canal and intertwined within cerumen. Red arrow indicates superior orientation. R7

8. Otoscopic Appearance

9. Diagnosis Direct visualization with an otoscope.
Foreign body and swollen canal from otitis externa can block tympanic membrane view and should be ruled out before attempting to remove cerumen.
Audiology exam if suspected hearing loss after removal of cerumen.

10. Treatment Ceruminolytics alone
3 types of cerumen-softening preparations available:
1) Water-based
2) Oil-based
3) Non-water/Non-oil based
Irrigation of the external auditory canal
Manual removal using a curette, forceps, or suction

11. Pediatric Otolaryngology Referral Guidelines for Cerumen Impaction
Pain develops and persists after cerumen removal. Stop further removal attempts and refer patient to an otolaryngologist.
Vertigo developed during irrigation with water at body temperature
Very swollen ear canal, unusual anatomy, or a history of tympanic membrane perforation, radiation, or surgery.