Cerumen impaction

Last updated: September 11, 2023

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Summarytoggle arrow icon

Cerumen impaction is a buildup of cerumen in the external auditory canal (EAC) that is symptomatic and/or prevents clinical evaluation of the auditory canal, tympanic membrane (TM), or the audiovestibular system. While anyone can develop cerumen impaction, risk factors include anatomical ear abnormalities, regular insertion of objects into the ear canal (including hearing aids), dermatological conditions (e.g., eczema, seborrheic dermatosis), and susceptible populations (i.e., young children, individuals with cognitive impairment, and older adults). Symptoms include localized ear discomfort, audiovestibular symptoms, and, in some individuals, nonspecific symptoms such as speech delay and behavioral changes. Cerumen removal is indicated for all individuals with cerumen impaction. Treatment options include manual cerumen removal, EAC irrigation, and cerumenolytics; all options are equally effective and may be used alone or in combination. Individuals should be assessed for risk factors for cerumen removal complications, with management tailored accordingly. Prevention involves patient education on ear hygiene; in individuals with recurrent cerumen impaction, cerumen removal regimens may be considered.

Pathophysiologytoggle arrow icon

The migration of cerumen from the tympanic membrane toward and out of the entrance of the external auditory canal (EAC) is impaired. [2][3]

Risk factors for cerumen impactiontoggle arrow icon

  • Anatomical abnormalities of the external auditory canal (e.g., ear canal stenosis)
  • Regular use of foreign objects in the ear canal, e.g. :
    • Hearing aids
    • Earbud headphones [5]
    • Cotton-tipped swabs or bobby pins for cleaning or scratching
  • Certain dermatological conditions (e.g., eczema, seborrheic dermatosis)
  • Individuals who are unable to recognize or effectively communicate symptoms of cerumen impaction, such as:
    • Older adults, especially those living in long-term care facilities [2][4]
    • Young children [2][4]
    • Individuals with cognitive impairment [2][4]

Clinical featurestoggle arrow icon

Cerumen impaction should be considered in individuals presenting with hearing loss and/or cognitive decline. [2]

Diagnosticstoggle arrow icon

Differential diagnosestoggle arrow icon

Other conditions that could occlude the external auditory canal and/or cause hearing loss or otalgia include: [2]

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

General principles [2][3][4]

Cerumen removal is not indicated for asymptomatic cerumen accumulation that does not prevent assessment of the EAC, TM, or audiovestibular apparatus. Prophylactic removal of nonimpacted cerumen may be considered in individuals who have difficulty expressing or describing symptoms. [2][3]

Cerumenolytic agents and EAC irrigation are contraindicated in individuals who may have a nonintact TM.

Risk factors for cerumen removal complications [2][4]

In individuals with these conditions, select the most appropriate method of cerumen removal and/or refer the patient to otolaryngology.

Risk-factor based selection of cerumen removal methods [2][4]
Risk factor Preferred methods Important considerations
Nonintact TM or prior ear surgery
Increased risk of bleeding
Anatomical abnormality of the EAC
Increased risk of infection
Active otitis externa or dermatitis of the ear canal
History of head or neck radiation
Previously diagnosed unilateral deafness [3]

Cerumenolytic agents [2][4]

Can be used alone or in combination with EAC irrigation or manual removal of cerumen.


  • Instill 1–3 mL (i.e., 20–60 drops) into the affected ear canal to soften and/or dissolve cerumen.
  • In-office: Place in the EAC ∼ 15 minutes prior to otic lavage and/or manual removal.
  • At home: Instill several drops once or twice a day for at least 3–15 days and then return for reexamination. [2]

Contraindications [2]


All cerumenolytic agents (including water) are equally effective. [2][4]

Possible complications [2]

Ear canal irrigation [2][4]

  • Can be performed in the office by a health care provider or at home by the patient or caregiver
  • Consider using a cerumenolytic agent 15 minutes before irrigation. [7]

Avoid jet irrigators for at-home irrigation as they could potentially damage the TM. [2][4]


Water or saline that is close to body temperature is used to flush cerumen out of the EAC using a syringe (manual irrigation) or an electronic irrigator.

  • Straighten the EAC by gently pulling the external ear in an upward and backward direction.
  • An assistant holds a receptacle (e.g., a kidney tray) under the patient's ear to catch the irrigant.
  • Gently instill the irrigant in the EAC, directing the fluid stream toward the wall of the EAC rather than toward the TM; limit irrigation to < 30 minutes.
  • Perform an otoscopy to ensure cerumen clearance and assess for complications.
  • After irrigation, consider instilling hydrogen peroxide or acetic acid in the EAC to reduce the risk of infection (e.g., in individuals with diabetes). [2][3][4]

Avoid using cold or warm irrigation fluids, as this may trigger caloric nystagmus and vertigo. [2]

In individuals with diabetes, avoid using tap water for irrigation as it may increase the risk of malignant otitis externa. [2]


If an intact tympanic membrane cannot be verified, do not irrigate the ear canal. [2]

Potential complications

Manual cerumen removal [2][4]

Should be performed in the office performed by a trained health care provider


  • Consider using a cerumenolytic agent 15 minutes before manual removal.
  • An instrument (e.g., curette, forceps, angulated suction tip) is inserted into the ear canal to physically remove cerumen. [8]
  • Use an external light source to directly visualize the ear canal and cerumen during removal. [2]


Potential complications

Reassessment and further management [2][4]

Prevention of recurrence [2][4]

Recurrent cerumen impaction may be prevented with any of the following measures: [2]

Advise against ear candling, olive oil drops, cotton-tipped swabs, and home use of jet irrigators as they are ineffective and can increase the risk of injury. [2]

Primary prevention of cerumen impactiontoggle arrow icon

  • Reassure individuals that cerumen production and removal is a normal physiological process.
  • Routine cleaning of the EAC is unnecessary; scheduled cleaning may be considered in individuals with risk factors for cerumen impaction.
  • Instruct all individuals to:
  • For early identification of cerumen accumulation in individuals using hearing aids, recommend:
    • Regular ear examinations every 3 or 6 months
    • An office evaluation if hearing aid performance decreases

Referencestoggle arrow icon

  1. Schwartz SR, Magit AE, Rosenfeld RM, et al. Clinical Practice Guideline (Update): Earwax (Cerumen Impaction). Otolaryngol Head Neck Surg. 2017; 156 (S1).doi: 10.1177/0194599816671491 . | Open in Read by QxMD
  2. Horton GA, Simpson MTW, Beyea MM, Beyea JA. Cerumen Management: An Updated Clinical Review and Evidence-Based Approach for Primary Care Physicians. J Prim Care Community Health. 2020; 11: p.215013272090418.doi: 10.1177/2150132720904181 . | Open in Read by QxMD
  3. $Contributor Disclosures - Cerumen impaction. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  4. Michaudet C, Malaty J. Cerumen Impaction: Diagnosis and Management. Am Fam Physician. 2018; 98 (8): p.525-529.
  5. McCarter DF, Courtney U, Pollart SM. Cerumen Impaction. Am Fam Physician. 2007; 75 (10): p.1523-1528.
  6. Aaron K, Cooper TE, Warner L, Burton MJ. Ear drops for the removal of ear wax. Cochrane Database Syst Rev. 2018; 2018 (10).doi: 10.1002/14651858.cd012171.pub2 . | Open in Read by QxMD
  7. Meyer F, Preuß R, Angelow A, Chenot JF, Meyer E, Kiel S. Cerumen Impaction Removal in General Practices: A Comparison of Approved Standard Products. Journal of Primary Care & Community Health. 2020; 11: p.215013272097382.doi: 10.1177/2150132720973829 . | Open in Read by QxMD
  8. Shope TR, Chen CP, Liu H, Shaikh N. Randomized Trial of Irrigation and Curetting for Cerumen Removal in Young Children. Front Pediatri. 2019; 7.doi: 10.3389/fped.2019.00216 . | Open in Read by QxMD

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