Guideline sources The following summarized guidelines for the evaluation and management of cerumen impaction are prepared by our editorial team based on guidelines from the American Academy of Otolaryngology- Head and Neck Surgery Foundation (AAO-HNSF 2017). 1 2 2 2 3 3 Definition Cerumen impaction refers to symptomatic accumulation of cerumen in the external ear. 2 Epidemiology The accumulation of a mixture of ceruminous and sebaceous gland secretions mixed with desquamated epithelium results in cerumen impaction. Overproduction of ear wax and narrowing of the ear canal by massess or bony growths may predisopse to impaction. 2 3 Disease course Cerumen impaction is usually asymptomatic but can cause ear discomfort, hearing loss, tinnitus, dizziness, chronic cough, and otitis externa. 2 Prognosis and risk of recurrence https://web.pathway.md/diseases/recNE8RlBBrCssfZx 1/4 6/29/23, 3:49 AM Cerumen impaction Pathway Prognosis and risk of recurrence Cerumen impaction is not associated with increased mortality. 3 Guidelines 1. Screening and diagnosis Diagnostic criteria: diagnose cerumen impaction when an accumulation of cerumen, as seen on otoscopy, is associated with symptoms, prevents assessment of the ear, or both. B 2. Diagnostic investigations Clinical history: Assess patients with cerumen impaction by history and/or physical examination for factors that modify management, such as 1 of the following: anticoagulant therapy immunocompromised state diabetes mellitus prior radiation therapy to the head and neck ear canal stenosis or exostoses nonintact tympanic membrane. B 3. Medical management Indications for treatment: Avoid offering routine treatment of cerumen in asymptomatic patients with adequately examinable ears. D Offer cerumenolytic agents, irrigation, and/or manual removal requiring instrumentation in patients with cerumen impaction. B Cerumenolytic agents: consider administering cerumenolytic agents, including water or saline solution, as part of the management of cerumen impaction. C Assessment of treatment response: assess patients at the conclusion of in-office treatment of cerumen impaction and document the resolution of impaction. B Show 2 more 4. Therapeutic procedures Ear candling/coning: advise against ear candling/coning for the treatment or prevention of cerumen impaction. B Irrigation: consider irrigation in the management of cerumen impaction. C https://web.pathway.md/diseases/recNE8RlBBrCssfZx 2/4 6/29/23, 3:49 AM Cerumen impaction Pathway Manual removal: consider manual removal with instrumentation in the management of cerumen impaction. C 5. Specific circumstances Patients with hearing aids: perform otoscopy to detect the presence of cerumen in patients with hearing aids. B Patients who may not express symptoms: identify patients with obstructing cerumen in the ear canal who may not be able to express symptoms (such as young children and cognitively impaired children and adults), and promptly evaluate the need for intervention. B 6. Preventative measures Primary prevention: explain proper ear hygiene to prevent cerumen impaction in patients who display an accumulation of cerumen. B Secondary prevention: consider educating patients with cerumen impaction or excessive cerumen regarding control measures. C 7. Follow-up and surveillance Indications for specialist referral: Treat cerumen impaction when it is identified. B Refer patients with persistent cerumen impaction to clinicians who have specialized equipment and training to clean and evaluate ear canals and tympanic membranes. B Clinical findings Symptoms Past medical history Cough Autoimmune disorders Dizziness Ear pain Feeling of fullness in the ear Hearing loss Infection Itching Making too much earwax due to injury Perception of noise or ringing in the ears https://web.pathway.md/diseases/recNE8RlBBrCssfZx 3/4 6/29/23, 3:49 AM Cerumen impaction Pathway References 1. Schwartz SR, Magit AE, Rosenfeld RM et al. Clinical Practice Guideline Update): Earwax Cerumen Impaction). Otolaryngol Head Neck Surg. 2017 Jan;156 1_suppl):S1 S29. Open 2. Olajide Toye Gabriel. Cerumen impaction: Challenges and management profile in a rural health facility. Niger Med J. Nov-Dec 2015;56 6 390 3.Nov-Dec 2015;56 6 390 3. Open 3. Garret A Horton, Matthew T W Simpson, Michael M Beyea et al. Cerumen Management: An Updated Clinical Review and Evidence-Based Approach for Primary Care Physicians. J Prim Care Community Health. Jan-Dec 2020;11 2150132720904181.Jan-Dec 2020;11 2150132720904181. Open 4. Garret A. Horton, Matthew T. W. Simpson, Michael M. Beyea et al. Cerumen Management: An Updated Clinical Review and Evidence-Based Approach for Primary Care Physicians. J Prim Care Community Health. 2020 Jan-Dec. Open 5. Olajide Toye Gabriel. Cerumen impaction: Challenges and management profile in a rural health facility. Niger Med J. 2015 Nov-Dec; 56 6 390 393. Open https://web.pathway.md/diseases/recNE8RlBBrCssfZx 4/4