A 17-year-old male went to an urgent care center with a 12 hour history of right ear pain that was not improving. The pain woke him up from sleep and he was able to return to sleep after some acetaminophen. The pain still woke him a few more times during the night, and was described as a constant, dull pain that was not improving over the rest of the day. He denied any discharge from the ear, popping sounds or acute hearing loss. He denied any trauma or placing anything into the ear. He did say that maybe he felt some water in the right ear. He was on his second day of vacation in Florida and had been swimming in the ocean and a pool the day before, and had not been scuba diving. The past medical history showed some acute ear infections as a young child. The review of systems was negative.
The pertinent physical exam showed a healthy male in no acute distress with normal vital signs. His left ear had moderate cerumen in the external canal and a normal tympanic membrane. The right ear was totally occluded with wax. The right ear was irrigated with warm water which returned a large amount of pelleted amber colored cerumen. Most of the pain immediately improved after irrigation. The external canal had some erythema near the tympanic membrane, but the tympanic membrane itself was not reddened and there was no middle ear effusion present. The diagnosis of cerumen impaction causing pressure along with mild otitis externa was made. The patient was prescribed ofloxacin otic drops and given instructions to use the drops until there was no pain but for at least 48 hours. He was also give instructions about how to prevent cerumen accumulation. He did endorse that he had used cotton-tipped swabs to try to self-clean his ears over the past several months during this discussion and was told not to do this.
Cerumen or ear wax is produced in the outer third of the external auditory canal. It contains exfoliated squamous epithelium along with waxy substances. It is controlled by autosomal alleles and has two main phenotypes – “wet” cerumen which is dominant and common in Caucasian and African populations, and “dry” cerumen which is recessive and found more often in Asian populations. Cerumen protects the external canal and has some antibacterial and antifungal properties including against strains of Staphylococcus aureus, Pseudomonas aeroginosis, and Candida albicans. Staphylococcus aureus and Pseudomonas aeroginosis are the most common causes of otitis externa.
The external auditory canal is a self cleaning mechanism which is assisted by jaw movement. It helps to trap dirt and keep out water. When this self cleaning system fails, cerumen accumulation and potential impaction can occur. Cerumen impaction is defined as “…accumulation that causes symptoms and prevents the needed assessment of the ear canal/tympanic membrane or audiovestibular system or both.” Cerumen impaction is common in children,the elderly and also in developmentally disabled populations.
Treatment is by use of cerumenolytics, aural irrigation or manual removal.
- “Cerumenolytics work by hydrating the desquamated sheets of keratinocytes and by inducing keratinolysis causing disintegration of the cerumen.”
A Cochrane Collaboration review found that cerumenolytics were better than no treatment for cerumen impaction but no particular product was recommended over another. A meta-analysis of two high quality trials found a statistical difference in favor of using triethanolamine polypeptide drops over saline though.
Cerumenolytics usually need several treatments to be successful and should never be used if there is any suspicion that the tympanic membrane is perforated.
- Aural irrigation with warm water or saline is often used. Sometimes it is used after a cerumenolytic. Problems can occur because of pain or irritation with the irrigations.
Irrigation should not be attempted if there is any concern for tympanic membrane perforation.
- Manual removal by curette, suction or other instrumentation is also used frequently. This requires a cooperative patient so as not to cause trauma.
Studies have found that manual removal does not increase the risk of otitis externa.
Cerumen impaction can be prevented by not placing anything into the canal and also by various ceruminolytics.
Cerumen build up and even impaction usually do not cause problems but they can occur. The cerumen in this patient probably absorbed water while swimming and therefore he developed pain because of the expanded mass. A mild otitis externa also appeared to be developing and was treated.
Complications of cerumen can include conductive hearing loss, irritation, infection (otitis externa), itching, pain, ear fullness, tinnitus, dizziness, and vertigo, and has been associated with chronic cough.
Questions for Further Discussion
1. What organisms cause otitis media?
2. What causes acute hearing loss? A differential diagnosis can be found here.
- Symptom/Presentation: Ear Pain
- Age: Teenager
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Soy FK, Ozbay C, Kulduk E, Dundar R, Yazıcı H, Sakarya EU. A new approach for cerumenolytic treatment in children: In vivo and in vitro study. Int J Pediatr Otorhinolaryngol. 2015 Jul;79(7):1096-100.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital