Cerumen, often known as earwax, keeps the outer ear clean and protected. When this fails, the wax may become impacted and plug the ear canal. This article presents a discussion on the symptoms and severity of ear wax accumulation, as well as therapeutic alternatives and patient preferences.

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Primary care consultation is often requested to treat the impacted earwax. Untreated wax impaction may cause hearing impairment, which can cause social isolation and sadness. However, for a disorder that is so widespread, there is a dearth of good data to guide practice.

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Cerumen (ear wax) 

Earwax is a complex mixture of lipids that is produced by the sebaceous glands of the external auditory meatus to protect the epithelial lining of the tract. It is composed of epithelial cells, hair, and secretions of the external ear. A buildup of earwax in the ear canal can result in hearing loss and discomfort, contribute to infections, and worsen stress, and social isolation.

Additionally, earwax might delay investigations and treatment by preventing a thorough clinical examination of the ear; for example, if the wax is blocking the ear canal, doctors cannot examine it for infections or fit hearing aids.

Impacted cerumen 

Cerumen impaction is a condition that affects 4% of patients in primary care and is more frequent in children. Risk factors for cerumen impaction include: Elderly, Learning impairment, Putting cotton swabs in your ears, Listening devices, Earplugs

Symptoms of cerumen buildup 

• Persistent cough
• Hearing loss
• Tinnitus
• Dizziness
• Pain in the ears

Diagnosis is done by direct visualisation with an otoscope.

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Why is it important?

Anyone may get earwax buildup, although elderly individuals and those who use hearing aids or earbud earphones experience it more often. Up to 44% of dementia patients living in nursing homes have impacted earwax, and 2.3 million individuals each year have problematic earwax that has to be removed. It is difficult to predict how impacted wax will affect a person since it varies on the amount, consistency, and position of the wax within the ear canal.

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How do I soften my earwax before treatment?

Pre-treatment drops or sprays make it simpler to remove the affected wax by softening it. With the false assumption that self-management with pre-treatment softeners is adequate, it is now a worry that earwax is often left untreated. Both NICE and Cochrane's systematic reviews were unable to determine whether a particular ear drop was more effective or if water or saline was superior to commercially available earwax softeners.

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Strategies for therapy

1. Cerumenolytics are the first-line therapy for symptomatic individuals. Comparatively, to no therapy, the use of cerumenolytic medicines, such as eardrops like docusate sodium, enhances the chance of cerumen removal. However, the efficacy of drops made from oil or water does not change much.
2. Patients should be advised against cleaning the canal with cotton buds. Cotton buds should only be used on the outer ear, and their usage is strictly restricted.
3. A qualified physician or an ENT expert may need to manually remove an obstruction from a patient with a hard impaction or ear canal disease under a microscope. A cerumenolytic will increase the effectiveness of future irrigation.

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Which earwax removal procedures are advised?

The National Institute for Health and Care Excellence (NICE) suggests using electronic water irrigation and micro suction to remove earwax. There isn't a direct comparison of the prices, efficacy, or safety of these two operations.

In the UK, manual water-filled syringes are no longer advised due to possible hearing impairment and lawsuit risk. Today, earwax is removed from the ear canal using low-pressured water that is controlled by electronic instruments.

1. Pre-existing otological disorders (such as a perforated eardrum, grommet, mastoid cavity, or infection), the presence of a foreign substance, or past difficulties with wax removal are all contraindications.
2. Specialist referrals as a consequence of irrigation-related problems (such as a perforated eardrum) are estimated to be 1 in 1000.6 According to anecdotal reports, drying the external ear after irrigation lowers the chance of developing an ear infection. Patients with just one functional ear should not be irrigated.

The preferred technique in secondary care is mechanical suction used to remove wax while being directly seen. In primary care, freestanding working microscopes are too expensive for micro-suction. A possible answer for widespread usage is the use of less expensive, portable, hand-held video-assisted devices that magnify and light the ear canal. Although some pain and little bleeding have been reported, there is little data on the overall safety of micro-suction.

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When should you refer?

Rarely does cerumen treatment need a referral to an ENT specialist. In the following circumstances, referrals should be made;

1. Chronic cerumen impaction; pain or bleeding when syringing.
2. Persistent symptoms despite successful cerumen removal.
3. Failure to remove cerumen after numerous attempts of syringing, preceded by wax-softening drops.
4. Contraindications, particularly perforated tympanic membrane, prior ear surgery, or cerumen impaction in the only or better hearing ear; abnormal tissue in the ear canal,
5. Other concerns.

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Focusing on the essentials

1. Patients should be informed about the ear's self-cleaning process and advised against using any tools to remove earwax.
2. It is advised to use pre-treatment softeners before removal utilising micro-suction or electronic water irrigation.
3. If there are any contraindications to syringing, syringing fails to remove wax or relieve symptoms, or if there are any additional concerns, patients should be sent for a professional ENT examination.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.