Incidence

1. Certain individuals are at increased risk of excessive earwax due to overproduction or inability of the ear to clear itself. The populations most likely to be diagnosed with cerumen impaction include the elderly, young children, those with mental disabilities, and institutionalized patients. The incidence in nursing home patients may be as high as 60%.

Pathogenesis

1. Wax builds up in the external canal. With age, the normal self-cleaning mechanisms of the ear fail. Cilia, which have become stiff, cannot remove cerumen and dirt from the ear canal. Placing cotton swabs, paper clips, bobby pins, and so forth into the ear canal may also impact cerumen.

Predisposing Factors

1. Age (decreased function of ear cilia).
2. Use of hearing aids.
3. Recurrent otitis externa.
4. Dermatologic conditions of the external canal.
5. Previous audiologic surgeries.
6. Keratosis obturans.

Common Complaints

1. Dryness and itching of ear canal.
2. Dizziness.
3. Ear pain.
4. Hearing loss.

Other Signs and Symptoms

1. Fullness in the ear.
2. Chronic cough.
3. Tinnitus.

Subjective Data

1. Elicit onset and duration of symptoms.
2. Elicit history of cerumen impaction.
3. Question the patient regarding the method used to clean the ears.
4. Determine personal or family history of anatomic deformity.
5. Assess for any physical barriers to wax extrusion such as cotton swabs, hearing aids, or devices utilized to protect hearing (ear plugs).

Physical Examination

1. Check temperature, pulse, respirations, and blood pressure.
2. Inspect:
   1. Observe ears for thick, light to dark brown wax occluding the auditory canal.
   2. Observe tympanic membrane if possible. Perforated tympanic membrane is associated with otitis media.
   3. Inspect nose and throat.

Diagnostic Tests

1. Cerumen impaction is diagnosed with direct visualization of an otoscope.
2. When hearing loss is the primary subjective complaint, you may consider a hearing assessment. Expected outcomes associated with cerumen impaction include conductive hearing loss of 35 to 40 dB and positive Rinne (tuning fork test reveals bone conduction greater than air conduction in affected ear).

Differential Diagnoses

1. Cerumen impaction.
2. Foreign body in the ear canal.
3. Otitis externa: White, mucus-like ear discharge is associated with otitis externa.

Plan

1. General interventions:
   1. Cerumen removal may be attempted by irrigation with or without cerumenolytics or by manual removal using a curette, forceps, or suction.
   2. Manual removal requires a cooperative patient and involves the use of a metal or plastic loop or spoon. Manual removal does not expose the ear to moisture and therefore may lessen the risk of infection. Manual removal may provide the safest alternative when there is a question of tympanic membrane rupture.
   3. Irrigation may be done with or without pretreatment with a cerumenolytic agent. Irrigation instruments include bulb syringes, 20-mL syringes adapted for irrigation, or oral jet irrigators (ear irrigator tips increase safety). Contraindications include tympanic membrane perforation or myringotomy tube. Also, patients with a history of middle-ear disease, surgery, radiation, vertigo, or potential sharp foreign body should not undergo irrigation.
   4. Cerumenolytics are softening agents that are either water- or oil-based, or not water- or oil-based. These products are considered to be equally effective. None of these products are considered safe unless the tympanic membrane is intact (no perforations or myringotomy tubes). Cerumenolytics can be used as a stand-alone treatment for the patient to use at home or utilized as a pretreatment prior to irrigation in the clinic.
2. Patient teaching: See Section III: Patient Teaching Guide “Cerumen Impaction (Earwax).”
3. Pharmaceutical therapy:
   1. Research has not identified a specific treatment (manual, irrigation, or cerumenolytic agent) or product (Debrox, hydrogen peroxide, etc.) as the first-line treatment for cerumen impaction, as many patient variables influence the most appropriate treatment option.
   2. Prevention has become a therapy mainstay, and recent research has supported the weekly use of an ear rinse of 70% isopropyl alcohol as safe, effective, and cost-efficient.

Follow-Up

1. If cerumen is removed no immediate follow-up is required. Consider having patient return in 4–6 weeks to recheck ears for cerumen.

Consultation/Referral

1. Consult or refer the patient to a specialist (otolaryngologist) when cerumen cannot be cleared.

Individual Considerations

1. Geriatrics:
   1. Cerumen impaction is common in older adult and geriatric patients secondary to the atrophic cilia and dry epithelium of the ear canal.
   2. To prevent uncertainty and fears, elderly with hearing loss need to be reminded that as a liquid treatment/water is held for 15 minutes in the canal, cerumen expands and might temporarily cause further hearing loss. Continue to encourage the patient during any treatment and, if necessary, have the nurse stay with patient during the wait time.