EM@3AM: Cerumen Impaction

Authors: Elizabeth Adams, MD (EM Resident Physician, UTSW, Dallas, TX) // Reviewed by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.


A 17-year-old male with no past medical history presents to the ED with a complaint of right ear fullness and hearing loss which has been present for the last month. He reports that he tried to clean out his ear 3 days ago with a cotton-tipped swab but has had worsening of the pain and hearing loss after attempting this. He denies any prior hearing problems, dizziness, headache, vomiting, gait disturbances, vision changes, or fevers.

Vital signs on arrival to the ED include HR 68, BP 118/72, SpO2 99% on RA, RR 14, Temp 98.8F. On exam, patient is non-toxic appearing, comfortable, without rash. HEENT exam reveals normal external auditory canal and tympanic membrane on the left, but you are unable to visualize the right tympanic membrane due to cerumen impaction. The patient does not experience pain with manipulation of the pinna. There is no erythema or posterior auricular swelling/tenderness present on exam.

What is the most likely cause of this young man’s ear discomfort and hearing loss? What is the next step in management of this patient?


Answer: Cerumen Impaction

 

Background:

  • Cerumen (also known as ear wax) is produced in the outer portion of the external auditory canal and protects the canal and tympanic membrane from debris, trauma, infection, and water1.
  • Cerumen is made of secretions from sebaceous and ceruminous glands and sloughed epithelial cells2.
  • As cerumen is produced, it migrates outward and is cleared. Failure of this migration outward due to mechanical obstruction, anatomic variation of the external auditory canal, counterproductive at-home cleaning methods (such as cotton-tipped swabs), or over-production of cerumen can lead to the build-up of cerumen1.

 

Pathophysiology:

  • Cerumen impaction is defined as blockage of the ear canal by cerumen prohibiting evaluation of the tympanic membrane or leading to symptoms – most frequently, otalgia, itching, ear fullness, hearing loss, vertigo, or even persistent cough1.

 

History and Exam:

  • Elicit the presence of pain, hearing loss, tinnitus, headache, nausea/vomiting, dizziness/vertigo, fevers, drainage from the ear, and history of frequent ear infections.
  • Assess for factors that contribute to disease of the ear including use of in-ear headphones or hearing aids, prior trauma or surgery to the ear, use of home earwax cleaning products, dermatologic conditions (including eczema, psoriasis and seborrheic keratosis), and immunocompromised states or diabetes.
  • Examine externally for erythema, swelling, or tenderness to the pinna and posterior auricular area. Evaluate for pain with manipulation of the pinna.
  • Inspect inside the ear with an otoscope to evaluate the skin of the external auditory canal (EAC) for rash, vesicles, drainage, presence of cerumen impaction, or foreign body. Inspect the tympanic membrane, if visible.
  • Consider the possibility of referred pain from the posterior oropharynx to the ear. Inspect the oropharynx.
  • If hearing loss is reported, perform a “Hum Test,” to determine conductive vs sensorineural hearing loss3
    • Have the patient hum and localize which side, if any, sounds louder.
    • If the affected ear is louder, it is likely conductive hearing loss.
    • If the unaffected ear is louder, it is concerning for sensorineural hearing loss. Abrupt hearing loss is abrupt is concerning for sudden sensorineural hearing loss (SSNHL) which can be irreversible if not identified and treated early4.

 

Differential Diagnosis:

  • Otitis Externa
  • Malignant Otitis Externa
  • Otitis Media
  • Foreign Body
  • Mastoiditis
  • Varicella Zoster Virus/Shingles
  • Tympanic Membrane Perforation
  • Cholesteatoma
  • Presbycusis
  • Meniere’s Disease
  • Labyrinthitis
  • Sensorineural Hearing Loss
  • Sudden Sensorineural Hearing Loss (SSNHL) – see article below for more information on this time-sensitive otologic emergency4

 

ED Evaluation:

  • Perform a thorough exam to determine the presence of foreign body or infection contributing to symptoms.
  • When a cerumen impaction is identified, the need to intervene is determined by the presence of symptoms.
  • Removal of impacted cerumen is recommended in symptomatic patients, unless there is presence of a non-intact TM.
  • Removal of impacted cerumen is recommended in patients who are unable to express symptoms, such as young children or those with cognitive impairment1.
  • Asymptomatic patients should not routinely have cerumen removed1,2.

 

Management:

  • There are multiple option available for removal of cerumen — including the use of cerumenolytics, irrigation, or manual removal under direct visualization2,5.
    • Cerumenolytics – variety of options including hydrogen peroxide (diluted in water), normal saline, or pre-mixed cerumenolytics (such as Debrox – combination of hydrogen peroxide and urea); instill solution into the ear canal, place cotton ball in the ear, and position patient in lateral recumbent position to retain solution in EAC for 10-15 minutes, repeating as necessary to soften wax and facilitate removal (possibly combined with irrigation methods)2,6.
    • Irrigation – use soft catheter tip (for example an 18-gauge angiocath) to flush EAC with warm/room temperature saline solution (or combine with hydrogen peroxide) and continue as patient tolerates until impaction is resolved. Consider pre-treatment with cerumenolytics prior to irrigation6.
    • Manual Removal – perform manual removal only under direct visualization with plastic or metal curette in a cooperative patient who can tolerate the procedure without moving.
  • Use caution when removing cerumen in patients with diabetes, anticoagulant use, immunocompromised states, ear canal stenosis, perforated tympanic membrane, or prior surgery to the TM (such as tympanostomy tubes).
  • Following cerumen removal, inspect for lacerations or abrasions to the EAC and for the presence of trauma to the tympanic membrane.
  • If the patient reported hearing loss, assess for subjective improvement in hearing following cerumen removal.
  • Referral to an otolaryngologist is recommended for incompletely resolved cerumen impaction, history of recurrent cerumen impaction, TM perforation, or unresolved hearing deficit.

 

Complications:

  • Iatrogenic trauma/bleeding to external auditory canal or tympanic membrane
  • Otitis externa from external auditory canal trauma
  • Infection or water accumulation behind an untreated cerumen impaction
  • Use of cold or hot water during irrigation or removal can lead to nausea, vomiting and vertigo
  • Untreated cerumen impaction can contribute to delirium in elderly patients and can affect speech and language development in children if an associated hearing deficit is not addressed

 

Take-home Points:

  • Impacted cerumen can lead to pain, discomfort or hearing deficits and can contribute to delirium in elderly or speech and language delays in children and should be managed appropriately in symptomatic patients.
  • Options for management of cerumen impaction include cerumenolytics, irrigation and manual removal. The method of choice depends on availability of equipment and preference of provider.
  • Consider the diagnosis of sudden sensorineural hearing loss – an otologic emergency – in patients with sudden onset hearing loss that is not conductive, or not resolved after treatment of cerumen impaction.

A 20-year-old woman presents to the ED with acute onset hearing loss in her right ear. Otoscopy reveals cerumen impaction on the right. The left ear exam is normal. Weber and Rinne tests are performed. What are the expected results of the tests given this information?

A) Air conduction greater than mastoid conduction on right

B) Lateralizes to the right with forehead conduction

C) No lateralization with forehead conduction

D) Weber test will lateralize to the left

 

 

 

 

Answer: B

Hearing is a special sensory function of the vestibulocochlear nerve (cranial nerve VIII). There are many causes of hearing impairment or loss, including aging, stroke, blunt or penetrating trauma, cerumen impaction, medications, infection, barotrauma (e.g., loud noises, diving), congenital disorders, electrolyte abnormalities, cholesteatoma, or otoliths within the semicircular canals in the inner ear. Hearing loss is either sensorineural or conductive. Mixed cases are described as well. The Weber and Rinne tests with a vibratory tuning fork can be employed at the bedside to determine the type of hearing loss. The Weber test is performed by placing a vibrating tuning fork on the midline of the forehead. If there is conductive hearing loss, the sound will lateralize to (i.e., be heard louder in) the affected side. If there is sensorineural hearing loss, the sound will lateralize to the unaffected side. The Rinne test is performed by placing the tuning fork on the mastoid process and then, when the sound is no longer heard, placing it in front of the patient’s ear. If the patient is then unable to hear with the tuning fork in this position or the sound is not heard louder in this position, this is considered an abnormal test and conductive hearing loss is present. This suggests that bone conduction (when the tuning fork is in contact with bone) is greater than air conduction (when the tuning fork is in front of the patient’s ear). Cerumen impaction causes conductive hearing loss. Therefore, if the right ear is affected (as in this case), sound lateralizes to the right with forehead conduction (Weber test), and the Rinne test will be abnormal, meaning that sound will be diminished or inaudible when the tuning fork is moved from the right mastoid in front of the right ear.

Air conduction greater than mastoid conduction on the right (A) suggests a normal Rinne test. Cerumen impaction on the right would cause mastoid conduction to be greater than air conduction. No lateralization with forehead conduction (C) indicates a normal Weber test. With right-sided cerumen impaction, the sound will lateralize to the affected (right) side. Therefore, Weber test will lateralize to the left (D) is also incorrect.

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Further Reading:

  1. Schwartz SR, Magit AE, Rosenfeld RM, et al. “Clinical Practice Guideline (Update): Earwax (Cerumen Impaction) Executive Summary.” Otolaryngology–Head and Neck Surgery. 2017;156(1):14-29. doi:10.1177/0194599816678832
  2. Dinces E. “Cerumen.” UpToDate, 17 June 2021.
  3. Ahmed OH, Gallant SC, Ruiz R, Wang B, Shapiro WH, Voigt EP. “Validity of the Hum Test, a Simple and Reliable Alternative to the Weber Test.” The Annals of Otology, Rhinology, and Laryngology, U.S. National Library of Medicine, June 2018. 127(6):402-405. doi: 10.1177/0003489418772860
  4. Weber P. “Sudden Sensorineural Hearing Loss in Adults Evaluation and Management.” UpToDate, 10 May 2022,
  5. Simpson B, and Claire. “Cerumen Removal.” 29 June 2021.
  6. Mitka M. “Cerumen Removal Guidelines Wax Practical.” 2008;300(13):1506. doi:10.1001/jama.300.13.1506

 

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