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Wednesday, August 13, 2025

Earwax build-up


Introduction

Earwax build-up, medically termed cerumen impaction, refers to the accumulation of cerumen in the external auditory canal to the extent that it causes symptoms, prevents necessary assessment of the ear, or both.

Cerumen is a natural secretion produced by ceruminous and sebaceous glands in the outer third of the external auditory canal. It plays a protective role by trapping dust, microorganisms, and debris, lubricating the ear canal, and providing antibacterial and antifungal properties.
In normal conditions, cerumen gradually migrates outward with jaw movement and epithelial shedding, but in some individuals, this self-cleaning mechanism fails, leading to build-up.

Epidemiology

  • Prevalence:

    • ~2–6% in the general healthy adult population

    • Up to 10% in children

    • 30% or more in elderly individuals, especially those in long-term care facilities

  • High-risk groups:

    • Hearing aid users

    • Patients with intellectual disability

    • People with narrow or hairy ear canals

Etiology and Risk Factors

1. Overproduction or Altered Composition

  • Idiopathic increased cerumen production

  • Genetic variation (wet vs. dry type cerumen)

2. Obstruction of Normal Clearance

  • Anatomical variations: narrow, tortuous ear canal, excessive hair

  • Ear canal skin disorders: eczema, seborrheic dermatitis

3. Mechanical Factors

  • Use of cotton buds, hairpins, hearing aids, or earplugs (push cerumen deeper)

4. Age-related Changes

  • Cerumen becomes drier and harder with age, reducing natural expulsion

  • Decreased jaw movement in elderly

Pathophysiology

Cerumen normally migrates from the medial to lateral canal via epithelial migration and aided by jaw motion. Obstruction or interference with this process allows accumulation and compaction. Hard cerumen can cause pressure, irritation, and blockage of sound conduction.

Clinical Features

Symptoms

  • Hearing loss (conductive, usually mild and reversible)

  • Earache or fullness

  • Tinnitus

  • Itching in the ear canal

  • Cough (via auricular branch of the vagus nerve stimulation)

  • Vertigo (rare)

Signs

  • Otoscopic visualization of impacted cerumen obscuring the tympanic membrane

  • Possible erythema or irritation of ear canal skin

Complications

  • Secondary otitis externa

  • Perforation of tympanic membrane if removal attempts are traumatic

  • Worsening hearing loss in hearing aid users

  • Chronic cough due to vagal nerve stimulation

Diagnosis

Diagnosis is clinical and made via otoscopy.

  • Impacted cerumen appears as yellow, orange, brown, or black material blocking the ear canal.

  • The tympanic membrane may be partially or completely obscured.

Management

Treatment is indicated if cerumen is symptomatic or prevents necessary examination of the tympanic membrane.
Asymptomatic cerumen may be left alone.

1. Cerumenolytic Agents

Aim to soften and break down wax for easier removal.

  • Water-based: saline, water, hydrogen peroxide 3%, carbamide peroxide 6.5%

  • Oil-based: mineral oil, olive oil, almond oil

  • Combination agents: glycerin with sodium bicarbonate
    Dosage example: Carbamide peroxide 6.5% — 5–10 drops into affected ear twice daily for up to 4 days.
    Contraindicated if tympanic membrane perforation is suspected.

2. Irrigation (Ear Syringing)

  • Performed with body-temperature water or saline under gentle pressure.

  • Requires intact tympanic membrane and absence of active infection.

  • Not recommended for patients with history of ear surgery, perforation, or recurrent otitis externa.

3. Manual Removal (Instrumentation)

  • Performed by trained clinicians using curettes, forceps, or suction under direct visualization.

  • Preferred for hard, dry wax or in patients with ear canal abnormalities.

  • Requires patient cooperation; safer in ENT setting for difficult cases.

4. Microsuction

  • Uses a small vacuum device under direct visualization with a microscope.

  • Suitable for patients with narrow canals, ear surgery history, or perforated eardrum.

Prevention and Patient Education

  • Avoid inserting cotton buds or foreign objects into ears.

  • For recurrent cerumen impaction, periodic use of cerumenolytic drops may be advised.

  • Hearing aid users should have regular ear checks.

  • Maintain ear dryness to reduce risk of otitis externa post-removal.

Prognosis

  • Excellent when treated; symptoms usually resolve immediately after removal.

  • Recurrence is common in some individuals and may require maintenance strategies




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