Glandular secretions from the outer one third of the external auditory canal and desquamated epithelium combine to form cerumen. Cerumen is necessary to provide a hydrophobic and acidic environment to protect the underlying external ear canal epithelium and prevent infection. The external auditory canal is self-cleaning, with cerumen slowly pushed laterally to the external meatus.

Cerumen impaction is the symptomatic accumulation of cerumen in the external canal or an accumulation that prevents a needed assessment of the ear. Complete occlusion is not necessary. Symptoms may include hearing loss, tinnitus, pruritus, fullness, otalgia, cough, odor, and dizziness. Impac-tion often results from instrumentation with cotton-tipped applicators, which should be discouraged. Elderly patients with changes to external canal epithelium, patients with external canal abnormalities (e.g., osteomas, exostoses, stenosis), and users of hearing aids and earplugs are also at risk for impaction. Excessive cerumen production as a primary problem is relatively rare.

In most people, cleaning the external meatus with a finger in a washcloth while bathing is sufficient to maintain the ear canals. Treatment of cerumen impaction by the clinician may involve ceruminolytic agents, irrigation, or manual removal. Ceruminolytic agents include water-based, oil-based, and non-water-, non-oil-based solutions. A Cochrane review found that any type of ear drop (including water and saline) is more effective than no treatment, but study quality was lacking. Office irrigations may be performed using a large syringe with a large angiocath-eter tip. The type of irrigant solution used is probably not critical, although a tepid or warm temperature is important to prevent the patient from becoming vertiginous from a labyrinthine caloric response. Instilling a ceruminolytic 15 minutes before irrigation may improve the success rate. Irrigations should not be performed in those with tympanic membrane perforations or previous ear surgery. Of note, irrigation with tap water has been implicated as a causative factor in malignant otitis externa. Therefore, instilling an acidifying ear drop after irrigation in diabetic patients is recommended. Manual removal requires knowledge of ear anatomy and special care to avoid trauma. A handheld otoscope with a curette and other instruments may be used. Otolaryngologists will often use binocular microscopy to aid with visualization. Those patients inquiring about ear candling should be informed that it has not been shown to be effective and presents a risk of thermal injury to the ear (Burton and Doree, 2008).

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