Experts update best practices for diagnosis and treatment of earwax (cerumen impaction)

"This update is significant because it not only provides best practices for clinicians in managing cerumen impaction, it is a strong reminder to patients that ear health starts with them, and there are many things they should do as well as many things that they should stop doing immediately to prevent damage to their ears," said Seth R. Schwartz, MD, MPH, chair of the guideline update group. "There is an inclination for people to want to clean their ears because they believe earwax is an indication of uncleanliness. This misinformation leads to unsafe ear health habits."

Earwax or cerumen is a normal substance that the body produces to clean, protect, and 'oil' ears. It acts as a self-cleaning agent to keep ears healthy. Dirt, dust, and other small matter stick to the earwax which keeps them from getting farther into the ear. Chewing, jaw motion, and growing skin in the ear canal help to move old earwax from inside the ears to the ear opening where it then flakes off or is washed off during bathing. This normal process of making wax and pushing the old wax out is continual.

At times, the ear's self-cleaning process might not work very well and may lead to a buildup of earwax. When this happens, earwax can collect and block, or partly block, the ear canal. Excessive or impacted cerumen is present in 1 in 10 children, 1 in 20 adults, and more than one-third of the geriatric and developmentally delayed populations.

"Patients often think that they are preventing earwax from building up by cleaning out their ears with cotton swabs, paper clips, ear candles, or any number of unimaginable things that people put in their ears. The problem is that this effort to eliminate earwax is only creating further issues because the earwax is just getting pushed down and impacted further into the ear canal," Dr. Schwartz said. "Anything that fits in the ear could cause serious harm to the ear drum and canal with the potential for temporary or even permanent damage."

Impacted earwax can cause symptoms like ear pain, itching, feeling of fullness in the ear, ringing in the ear (tinnitus), hearing loss, discharge coming from the ear, odor coming from the ear, cough, and/or change in hearing aid function.

The update provides a table of dos and don'ts for clinicians to further educate patients about cerumen impaction. Following are a few of those listed in the update:

• DON'T overclean your ears. Excessive cleaning may irritate the ear canal, cause infection, and even increase the changes of cerumen impaction.
• DON'T put anything smaller than your elbow in your ear. Your mother was right! Cotton swabs, hair pins, care keys, toothpicks...these can all injure your ear and may cause a laceration (cut) in the ear canal, a perforation (hole) in the eardrum, and/or dislocation of the hearing bones, leading to hearing loss, dizziness, ringing, and other symptoms of ear injury.
• DON'T use ear candles. There is no evidence that they remove impacted cerumen, and candling can cause serious damage to the ear canal and eardrum.
• DO seek medical evaluation if you have symptoms of hearing loss, ear fullness, and ear pain if you are not certain that they are from cerumen.
• DO ask your provider about ways that you can treat your cerumen impaction at home. You may have certain medical or ear conditions that may make some options unsafe.
• DO seek medical attention with ear pain, drainage, or bleeding. These are not symptoms of cerumen impaction and need further evaluation.

The primary purpose of the updated guideline is to help clinicians identify patients with cerumen impaction who may benefit from intervention. New evidence, systematic reviews, randomized control trials, observational studies, and an evolved methodology, which included a consumer representative, were at the foundation of the update.

"The update to the 2008 guidelines encompasses a variety of tools for clinicians in treating and communicating with their patients," said Dr. Schwartz. "This includes an algorithm showing the interrelationship of key action statements in a cohesive and understandable way as well as enhanced information on patient education. Having the consumer perspective on the guideline update group provided us a value-added opportunity to incorporate more extensive patient counseling within our treatment protocols."