3.01 Cerumen Impaction (Ear Wax Blockage)
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agk's Library of Common Simple Emergencies

Presentation
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The patient may complain of "wax in the ear," a 
"stuffed up" or foreign body sensation, pain, 
itching, decreased hearing, tinnitus, or 
dizziness. On physical examination, the dark 
brown, thick, dry cerumen, perhaps packed down 
against the ear drum, where it does not occur 
normally, obscures further visualization of the 
ear canal.

What to do:
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- Explain what you are going to do to the 
   patient. Cover him with a waterproof drape, 
   have him hold a basin or thick towel below 
   his ear, and tilt the ear slightly over it.
- Fill a 20ml syringe with warm water at 
   approximately 98.6F (37C) and fit it with a 
   soft tubing catheter. Aim along the anterior 
   superior wall of the external ear canal 
   (visualize directly) and squirt with all 
   your might.
- Repeat until all of the cerumen is gone. Dry 
    the canal.
- If multiple attempts at irrigation prove to 
   be unsuccessful, then gentle use of a 
   cerumen spoon (ear curette) may be necessary 
   to pull out the excess wax. Warning the 
   patient about potential discomfort or minor 
   bleeding before using the ear curette will 
   save lengthy explanations and apologies 
   later.
- Reexamine the ear and test the patient's 
   hearing.
- Warn the patient that he has thick ear wax, 
   that he may need this procedure done again 
   someday, and that he should never use swabs 
   in his ear.

What not to do:
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- Do not irrigate an ear with a suspected or 
   known tympanic membrane perforation, or 
   myringotomy tubes.
- Do not waste time attempting to soften wax 
   with ceruminolytic detergents.
- Do not irrigate with a cold (or hot) 
   solution.
- Do not blindly insert a rigid instrument down 
   the canal.
- Do not irrigate with a stiff over-needle 
   catheter. It can cause a painful abrasion 
   and bleeding or even perforate the tympanic 
   membrane.
- Do not leave water pooled in the canal. That 
   can cause an external otitis. A final 
   instillation of 2% acetic acid (Acetasol, 
   Domboro Otic, half-strength vinegar) will 
   also prevent iatrogenic swimmer's ear.

Discussion
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This technique virtually always works within 
5-10 squirts. If the irrigation fluid is at 
body temperature, it will soften the cerumen 
just enough that it floats out as a plug. If 
the fluid is too hot or cold it can produce 
vertigo, nystagmus, nausea, and vomiting.

A conventional blood-drawing syringe, fitted 
with a butterfly catheter, its tubing cut l cm 
from the hub, seems to work better than the big 
chrome-plated syringes manufactured for 
irrigating ears. An alternative technique is to 
use a WaterPik. Cerumen spoons can be dangerous 
and painful, especially with children, for whom 
this irrigation technique has proven more 
effective in cleaning the ear canal to provide 
for assessment of the tympanic membrane.

Cerumen is produced by the sebaceous glands of 
the hair follicles in the ear canal, and 
naturally flows outward along these hairs. One 
of the problems with ear swabs is that they can 
push wax inwards away from these hairs and 
against the ear drum, where it can then stick 
and harden. Patients may ask about "ear 
candles" to remove wax, but these are also not 
very effective compared to the technique above.

References
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- Robinson AC, Hawke M: The efficacy of 
   ceruminolytics: everything old is new again. 
   *J Otolaryngol* 1989;18:263-267.

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