Description
• Occlusion of auditory canal(s) by accumulated earwax (cerumen inspissatum)

ICD-9 code
• 380.4 Impacted cerumen

Incidence/prevalence
• 10% of children
• Up to 35% of adults (overall)
• Perhaps one third of individuals with mental retardation and two thirds of elderly nursing home patients

Likely risk factors
• Specific physical features: deformed ear canals, dense hair growth, etc.
• Use of cotton-tipped swabs
• Wearing of hearing aids or earplugs 
• History of recurrent otitis externa

Complications
• Hearing loss (conductive)
• Dizziness
• Tinnitus
• Otitis media/otitis externa
• Attempts by patients to remove impaction associated with tympanic membrane perforation

History
• Conductive hearing loss (usual presentation)
• Itching
• Discomfort
• Tinnitus
• If cerumen removed, look for signs of otitis externa or tympanic membrane perforation 

Diagnosis
• Direct visualization (via otoscope)
• Rule out
    — Foreign body 
    — Otitis externa
    — Keratosis obturans (plug of densely compressed keratin)
• Auditory testing (Rinne and Weber test) may be useful to confirm hearing loss as conductive.

Prognosis
• Spontaneous resolution (at least partial) is common, as is recurrence of impaction.
• Conductive hearing loss resolves with removal of impaction.
• Removal of impaction associated with improved cognitive functioning in hospitalized/institutionalized elderly persons

Treatment
• Irrigation of external auditory canal with warm saline (contraindications include tympanic membrane perforation or presence of myringotomy tubes)
• Cerumen-softening agents (ceruminolytics) 
    — Definitive evidence of ability to dissolve impaction lacking
    — May be no more effective than irrigation with warm saline
    — Various agents appear similarly effective for dissolving cerumen.
    — Avoid use in patients with a history of tympanic membrane perforation or myringotomy tubes.
• Manual removal by health-care provider using curette, forceps, or suction 
    — Referral to otorhinolaryngologist might be indicated if:
         History of chronic tympanic membrane perforation
         Past history of ear surgery
         Unsuccessful irrigation, etc.
• Patients should not attempt to remove impaction by “ear candling” (application of hot candle wax).
• Formal auditory testing may be indicated if hearing loss fails to resolve with removal of impaction.
• Oral jet irrigators have been associated with some trauma, including tympanic membrane perforation.

Prevention
• Avoid use of cotton ear buds for ear cleaning.
• Weekly application of lipolotion (Ceridal) may reduce recurrence.

For complete references, see www.dynamicmedical.com.