Editor’s note: In this article, which appeared in the Winter 2000-2001 issue of Update, former council member, Dr. Paul Brownson, provides a very practical overview of the options for working with employees in hearing conservation programs who experience difficulties associated with cerumen accumulation in the outer ear.
Cerumen Management
Paul J. Brownson, MD, FACOEM, FAAFP
Approximately 2-6% of the general population is afflicted by cerumen (earwax) impaction. Some of the known causes of cerumen impaction include abnormal external earcanal anatomy, occlusion by a hearing aid mold, associated dermatosis, and misguided attempts to remove wax via instrumentation.1 Each week in the United States, it has been estimated that approximately 150,000 cerumen removals take place.2 Otologic complications include failure to succeed in cerumen removal (which is the most common complication), pain, perforated eardrum, dizziness, bleeding and infection.
This article provides some guidance on cerumen management for the OHC and the OHC’s professional supervisor, focused on simple measures the OHC may recommend to the individual prior to referral to an audiologist or physician. It is suggested that the OHC and the professional supervisor review cerumen management issues, and establish a plan or protocol for dealing with cerumen problems.
What is cerumen?
The outer ear is the funnel-like part of the ear you can see on the side of the head, plus the earcanal (the hole which leads down to the eardrum). The earcanal is shaped somewhat like an hourglass—narrowing part way down its length.
Figure 1. Frontal section of the earcanal with magnification of the skin of the cartilaginous and osseous (bony) portions. (image courtesy of Burroughs Wellcome Co.)
The skin of the outer part of the canal has special glands, the ceruminous and sebaceous that produce cerumen (earwax). Earwax functions to trap dust and sand particles to keep them from reaching the eardrum. Usually the wax accumulates a bit, then dries up and tumbles out of the ear, carrying the accumulated sand and dust with it. Or the wax may slowly migrate to the outside where it is wiped off. Wax is not formed in the deep part of the earcanal near the eardrum, it is formed in the outer part of the canal. Earwax is healthy in normal amounts and serves to coat the skin of the earcanal where it acts as a temporary water repellent. In addition to its water repellant effect, earwax may enhance resistance to infection of the earcanal, possibly related to the normally acid pH of earwax. In diabetics, earwax has been found to be less acid, and less protective.1 The absence of earwax may result in dry, itchy ears. Most of the time the earcanals are self-cleaning; that is, there is a slow and orderly migration of earcanal skin from the eardrum to the ear opening. Old earwax is constantly being transported from the earcanal to the ear opening where it usually dries, flakes, and falls out.3 When an individual has wax blocked up against the eardrum, it is often because s/he has been probing their ear with such things as cotton-tipped applicators, bobby pins, or twisted napkin corners. Such objects only serve as ramrods to push the wax in deeper. Also, the skin of the earcanal and eardrum is very thin and fragile and is easily injured. Continual rubbing of the earcanal with a cotton-tipped applicator can abrade the skin and promote an infection. Individuals who wear hearing aids may also develop an accumulation of earwax because the hearing aid or ear mold prevents the normal migration of the wax to the outside. Individuals who wear such devices should always have their health care provider inspect their earcanals for accumulation of cerumen. When wax has accumulated so much that it blocks the earcanal (and reduces hearing), the individual’s audiologist or physician may have to wash it out, vacuum it with suction devices, or remove it with special instruments. The professional issues and techniques of earwax removal have been reviewed elsewhere.4
The physician may prescribe ear drops that are designed to soften the wax. Available products include prescription only (such as Cerumenex) and over-the-counter products (OTC) such as Debrox, or Murine Ear Drops, Audiologist’s Choice (distributed through audiologists and same as Debrox or Murine), or straight hydrogen peroxide (3%).5 While the OTC drops are not as strong as the prescription earwax softeners, they are effective for many individuals, and are less likely to cause irritation or allergic reaction.
The OHC’s role
With appropriate training the OHC will recognize potential cerumen impaction from the otoscopic exam. Under the professional supervisor’s guidance and with careful review of contraindications, the OHC may recommend use of ear drops to facilitate cerumen removal. A history of perforation of the tympanic membrane, the presence of myringotomy (PE) tubes, or cerumen impaction in the only hearing ear are universal contraindications for cerumen management by ear canal irrigation; such cases should be referred to the individual’s physician or otolaryngologist.6 Relative contraindications which also suggest need for referral to an employee’s physician or otolaryngologist include: recent earache, history of ear surgery, chronic otitis media, drainage, dizziness, diabetes mellitus, AIDS, or any other condition that would put the individual at risk.4 The OHC may wish to provide the individual with suggested instructions for use of over-the-counter ear drops, for example:
Suggested Use of OTC Eardrops as Earwax Removal Aid
- For use in the EAR ONLY: Do not use if the individual has a history of perforation of the eardrum (including myringotomy or tympanostomy tubes) or prior ear surgery unless directed by a doctor, ear drainage or discharge, ear pain, irritation or rash in the ear, dizziness, diabetes mellitus, AIDS, chronic otitis media, or any other condition that would put the individual at risk.
- Adults and children over 12 years of age: tilt head sideways and place 5-10 drops into the ear (tip of applicator bottle should not enter ear-canal).
- Keep ear drops in ear for several minutes by keeping head tilted or by placing cotton in the outer part of the earcanal.
- Use 2 times daily for 3-4 days if needed, or as directed by your doctor or audiologist.
- Any wax remaining after treatment may be removed by gently flushing the ear with warm water, using a soft rubber bulb syringe.
- If excessive earwax remains after use of the drops, consult a doctor or audiologist.
- Children under age 12 should consult a doctor.
- Do not use for more than 4 days unless directed by a doctor.
- Avoid contact with the eyes.
References
1. Jabor, M. A., Amedee, R.G. (1997). Cerumen impaction. Journal Louisiana State Medical Society, 149(10), 358-362.
2. Grossan, M. (1998). Cerumen removal—Current challenges. Ear, Nose & Throat Journal, 77(7), 541-46, 544-46, 548.
3. American Academy of Otolaryngology-Head and Neck Surgery. (1995). Earwax . . . and what to do about it. Alexandria, VA.
4. Wilson, P. L., Roeser, R. J. (1997). Cerumen management: Professional issues and techniques. Journal of American Academy of Audiology, 8, 421-430.
5. Freeman, R.B. (1995). Impacted cerumen: How to safety remove earwax in an office visit. Geriatrics, 50(6), 52-53.
6. Davidson, T. M. (2000). Ambulatory healthcare pathways for ear, nose, and throat disorders: Cerumen extraction (ear wax). San Diego, CA. University of California San Diego.