Cerumen impaction
Cerumen impaction is accumulated earwax that occludes the external auditory canal, causing conductive hearing loss, fullness, or itching; management ranges from observation to cerumenolytics, irrigation, or manual/instrument removal, chosen by canal findings and tympanic membrane integrity.
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What this article covers
- Overview
Definition: cerumen impaction is an accumulation of earwax in the external auditory canal sufficient to cause symptoms or to fully obstruct the canal on examination.
- Epidemiology
Common incidental finding: cerumen impaction is a frequent cause of conductive hearing loss identified on routine ear examination across age groups, including as an incidental finding during hearing-loss evaluation in older adults.
- Risk factors
Cotton-swab or foreign-object use in the canal: repeated instrumentation pushes wax deeper rather than removing it, the single most common preventable driver of impaction.
- Pathophysiology
Impaired self-clearance: cerumen is normally expelled from the canal, a process assisted by jaw movement; impaction occurs when this normal expulsion is overwhelmed by excess production, drying, or mechanical obstruction.
- Clinical features
Conductive hearing loss: the most common presentation, often unilateral, due to sound-wave conduction blocked by canal occlusion; may be found incidentally on otoscopy in a patient with no reported hearing complaint.
- Differential diagnosis
Otitis externa: canal skin cellulitis with tragal tenderness, pinna-traction pain, and canal erythema/edema rather than isolated wax occlusion; may coexist with impaction.
- Diagnosis
Clinical diagnosis by direct otoscopic visualization: cerumen impaction is confirmed on otoscopy by seeing wax occluding the external auditory canal; no laboratory or imaging test is required.
- Management
First, decide whether removal is needed at all: asymptomatic cerumen that does not obscure a needed examination does not require removal; treat only impaction that is symptomatic (hearing loss…
- Complications
Canal laceration or trauma: from self-instrumentation with cotton swabs or other objects, or from aggressive mechanical removal.
- Prognosis
Excellent with appropriate removal: symptoms, including conductive hearing loss, typically resolve promptly once the canal is cleared by cerumenolytics, irrigation, or manual removal.
- Prevention
Counsel against inserting any foreign object into the ear canal: patients should be advised not to use cotton swabs or other objects to clean the canal, since this practice pushes wax deeper and is…
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- Otitis externa
Otitis externa is diffuse inflammation of the external auditory canal, usually bacterial (Pseudomonas or Staphylococcus aureus) and diagnosed clinically by tragal tenderness and canal erythema with otorrhea. Uncomplicated disease is treated with topical antibiotic-steroid otic drops for 7 days, while malignant (necrotizing) otitis externa in a diabetic or immunocompromised patient is skull-base osteomyelitis requiring systemic antipseudomonal therapy and urgent otolaryngology referral.
- Hearing loss
Hearing loss is evaluated with the Weber and Rinne tuning fork tests to sort conductive from sensorineural loss at the bedside, then confirmed with audiometry; treatment ranges from cerumen removal or hearing aids to urgent oral prednisone and otolaryngology referral for sudden sensorineural loss.
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A full-thickness defect in the eardrum from trauma or infection, causing sudden ear pain, conductive hearing loss, and otorrhea. Diagnosis is by otoscopy. Most heal spontaneously with dry-ear precautions; a draining ear is treated with ofloxacin otic drops, and a perforation that fails to close by 3 months is referred for myringoplasty or tympanoplasty.
- Cholesteatoma
Cholesteatoma is an abnormal growth of keratinizing squamous epithelium in the middle ear that erodes the ossicles, mastoid, and adjacent skull base; it is confirmed on otoscopy, staged by CT, and requires mastoidectomy with tympanoplasty because no medical therapy is curative.
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Chronic suppurative otitis media is continuous otorrhea through a perforated tympanic membrane for more than six weeks without systemic symptoms. Management starts with topical fluoroquinolone ear drops and aural toilet, escalating to systemic antibiotics or tympanoplasty for refractory disease or cholesteatoma.
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Otosclerosis is a bony overgrowth of the stapes footplate that fixes the ossicular chain and produces slowly progressive, often bilateral conductive hearing loss in young adults, confirmed by a conductive Weber/Rinne pattern and treated with hearing aids or stapes surgery.
- Necrotizing (malignant) otitis externa
Necrotizing (malignant) otitis externa is skull-base osteomyelitis, almost always from Pseudomonas aeruginosa, that spreads from otitis externa into the temporal bone of older diabetics and other immunocompromised patients. Otalgia out of proportion to exam plus granulation tissue at the bony-cartilaginous junction of the canal is the hallmark, and treatment is weeks of antipseudomonal therapy, not a course of ear drops.