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Cerumen impaction

Definition
Cerumen impaction refers to symptomatic accumulation of cerumen in the external ear.
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Pathophysiology
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.
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Disease course
Cerumen impaction is usually asymptomatic but can cause ear discomfort, hearing loss, tinnitus, dizziness, chronic cough, and otitis externa.
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Prognosis and risk of recurrence
Cerumen impaction is not associated with increased mortality.
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Key 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).
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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
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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

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  • Cerumenolytic agents

  • Assessment of treatment response

4.Therapeutic procedures

Ear candling/coning: advise against ear candling/coning for the treatment or prevention of cerumen impaction.
B

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  • Irrigation

  • Manual removal

5.Specific circumstances

Patients with hearing aids: perform otoscopy to detect the presence of cerumen in patients with hearing aids.
B

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  • Patients who may not express symptoms

6.Preventative measures

Primary prevention: explain proper ear hygiene to prevent cerumen impaction in patients who display an accumulation of cerumen.
B

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  • Secondary prevention

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