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Practice Guidelines

Cerumen Impaction: An Updated Guideline

from the AAO–HNSF
and irrigation. Patients should be advised
Key Points for Practice
against using cotton swabs or small objects
• Cerumen impaction should be diagnosed when an accumulation to clean the ear.
precludes an ear evaluation or when the accumulation is confirmed by
otoscopy in a person who has symptoms. DIAGNOSIS
• Each time a person with hearing aids presents to the office, otoscopy Cerumen impaction should be diagnosed
should be performed to evaluate for cerumen.
when an accumulation precludes an ear
• Patients presenting with cerumen impaction should be appropriately
evaluation or when the accumulation is con-
treated with a cerumenolytic agent, irrigation, or manual removal.
firmed by otoscopy in a person who has
From the AFP Editors symptoms. Persons who are at risk of impac-
tion but are unable to indicate the presence
of symptoms (e.g., older persons with possi-
Coverage of guidelines Although there are benefits to cerumen, ble dementia; persons who do not speak, but
from other organizations including cleaning and protecting the ear who have had a change in behavior; young
does not imply endorse-
ment by AFP or the AAFP. canal, it can also cause blockages that can children with fever) should be evaluated and
lead to loss of hearing, tinnitus, otalgia, the cerumen removed, if present. Impaction
This series is coordinated
by Sumi Sexton, MD,
itching, and other symptoms. In the United can also be diagnosed in any person with
Associate Deputy Editor. States, approximately 12 million persons cerumen accumulation that could interfere
present for problems related to cerumen, with audiometric or vestibular assessment.
A collection of Practice
Guidelines published in with about 8 million removal procedures An evaluation for cerumen impaction can
AFP is available at http:// performed. This update from the American be done using a history and physical exami- Academy of Otolaryngology–Head and Neck nation to identify issues that may affect
Surgery Foundation (AAO–HNSF) provides management (i.e., anticoagulant use, immu-
CME This clinical content guidance for persons older than six months nocompromise, diabetes mellitus, previous
conforms to AAFP criteria diagnosed with cerumen impaction. radiation to the head or neck, ear canal
for continuing medical
education (CME). See stenosis, exostoses, and perforated tympanic
CME Quiz on page 222. Recommendations membrane). If not recognized, these issues
Author disclosure: No rel- PREVENTION can result in substandard care, harm to the
evant financial affiliations.
For persons presenting with accumulated patient, or incorrect treatment.
cerumen, physicians should discuss appro- Young children and persons with cogni-
priate ear hygiene to prevent impaction. tive impairment are at higher risk of impac-
Many persons commonly perform ear tion, although they may not be able to report
hygiene measures; therefore, the discussion symptoms. Such persons should be assessed
should be focused on safe and effective to determine whether treatment might be
regimens that also avoid such harms as required. It should be noted that removing
scrapes or unintended impaction caused cerumen in this population may be diffi-
by manipulation. Preventive methods may cult and may require assistance; rarely, the
be needed for persons who have a history patient may need to be sedated.
of impaction or greater likelihood of an Cerumen’s typical cleaning process can be
occlusion, including children, older persons, disrupted by such foreign items as hearing
persons with cognitive impairment, and per- aids, putting users at greater risk of impac-
sons who wear hearing aids. Options to limit tion. Impaction can affect how well the
accumulation include cerumenolytic drops hearing aids work. For these reasons, each

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Practice Guidelines

time a person with hearing aids presents to tympanic membrane perforation, infection)
the office, otoscopy should be performed to should be considered. Because ear candling
evaluate for cerumen. has not been proven effective and has asso-
ciated risks, physicians should discourage
TREATMENT its use.
When impaction is diagnosed, the patient If treatment is provided in the office, the
should receive or be referred for treatment. patient should be evaluated after comple-
Treatment should not be provided routinely, tion to document that impaction has been
however, in persons without symptoms resolved, and if not resolved, additional mea-
or whose ears can be effectively evaluated sures should be undertaken. If the impac-
despite cerumen. Patients should be educated tion cannot be safely resolved by the initial
that cerumen is natural and often asymp- treating physician, referral to a subspecialist
tomatic; therefore, it is not necessary for it with specific training and the appropriate
to be removed every time. Impaction may equipment is warranted. In addition, if the
resolve on its own, making watchful waiting patient continues to experience symptoms
an appropriate option. Education on how to after impaction has been alleviated, other
manage cerumen (e.g., topical preparations, causes of symptoms should be explored,
irrigation, cleaning hearing aids and the ear such as sensorineural hearing loss, conduc-
canal) can be provided to patients presenting tive hearing loss, otitis media, drug adverse
with too much cerumen or impaction. effects, and head and neck tumors.
Patients with cerumen impaction should Guideline source: American Academy of Otolaryngol-
be appropriately treated with a cerumeno- ogy–Head and Neck Surgery Foundation
lytic agent (e.g., water, saline), irrigation (via Evidence rating system used? Yes
a syringe or electronic irrigator), or manual
removal to improve symptoms, if present. Literature search described? Yes
In patients without symptoms, the goal is Guideline developed by participants without
to allow for examination of the ear canal or relevant financial ties to industry? No
tympanic membrane, or perform audiomet- Published source: Otolaryngol Head Neck Surg.
ric or vestibular testing. No particular treat- January 2017;156(1 suppl):S1-S29
ment method has been shown to be superior Available at:
to another. Adverse effects of cerumenolytic full/10.1177/0194599816671491
agents (e.g., transient hearing loss, discom- Endorsed by the AAFP, August 2016: http://www.
fort, dizziness, skin irritation), irrigation
(e.g., pain, skin injury, acute otitis externa), earwax.html
and manual removal (e.g., ear canal trauma, LISA HAUK, AFP Senior Associate Editor ■

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For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.