INTRODUCTION Cerumen, commonly known as ear wax, is a hydrophobic protective covering in

the ear canal. It acts to shield the skin of the external canal from water damage, infection, trauma, and
foreign bodies [1,2]. Accumulation of cerumen is usually asymptomatic but can occasionally cause
bothersome symptoms, such as hearing loss and ear discomfort.
This topic will focus on the indications and techniques for cerumen removal.
EPIDEMIOLOGY Cerumen accumulation can affect up to 6 percent of the general population and
a much higher percentage of persons with cognitive impairment [3,4]. Excessive or impacted cerumen
is present in approximately 1 in 10 children, 1 in 20 adults, and 1 in 3 older adults [1,5]. In the United
States, cerumen accumulation leads to 12 million patient visits and 8 million cerumen removal
procedures annually [6].
ANATOMY Cerumen is found in the external auditory canal (EAC), which begins at the meatus of
the auricle and ends at the tympanic membrane (figure 1) [7]. The lateral one-third of the EAC
(cartilaginous EAC) consists of hair and glandular-bearing skin on top of fibrocartilaginous tissue. The
sebaceous and ceruminous glands within the skin appendages found in the cartilaginous EAC are
responsible for the components of cerumen. The medial two-thirds of the EAC (bony EAC) consist of
thin skin adherent to the periosteum of the temporal bone. The canal narrows in most individuals at
the isthmus, which is located at the junction of the bony and fibrocartilaginous portions of the canal
[8]. Cerumen trapped medial to the isthmus tends to become impacted and cause hearing loss.
At the most medial end of the external canal is the tympanic membrane. The lateral layer of the
tympanic membrane consists of keratinizing squamous epithelium that is in continuity with the
epithelium of the external canal [9,10]. Lateral epithelial migration allows for removal of sloughing
squamous epithelial cells. Further description of the ear canal and discussion of its relationship to
external ear canal disease are presented elsewhere. (See "External otitis: Pathogenesis, clinical
features, and diagnosis", section on 'Anatomy' and "External otitis: Pathogenesis, clinical features,
and diagnosis", section on 'Pathogenesis and risk factors'.)
CERUMEN ACCUMULATION Cerumen is composed of secretions of both sebaceous and
ceruminous glands located in the lateral one-third of the ear canal. These secretions mix with
desquamated skin, the bacteria of normal skin flora, and occasional depilated hair to form cerumen
[5,11,12]. Any water trapped in the ear canal also mixes with cerumen. Accumulation of cerumen that
causes bothersome symptoms and/or prevents a needed assessment of the ear canal is termed
cerumen impaction [1].
The migratory pattern of the epithelium lining the ear canal is from medial to lateral. This skin
migration along with movement of the soft tissues around the temporal-mandibular joint serve to
eliminate excess cerumen from the ear canal [7,10]. Cerumen accumulates when this system is
thwarted, breaks down, or is inadequate.
The main reasons that cerumen accumulates in the ear canal include [3]:
Obstruction due to ear canal disease Ear canal disease can occur within the bone, soft
tissues, or skin of the ear canal. Bony obstructions can be congenital or acquired, and may be
related to head and neck malformations. Bony obstructions due to Paget disease or fibrous
dysplasia are examples of acquired disease. Bony growths within an otherwise normal canal (a
single osteoma or multiple exostoses) are not uncommon (picture 1 and picture 2). Infectious
and dermatologic diseases (eg, otitis externa, eczema) can be found in the ear canal, as well as
cutaneous manifestations of systemic disease (eg, systemic lupus erythematosus, Crohns

disease, Sjogrens syndrome). These disorders tend to cause excess exfoliation of the canal
skin and atrophy or hypertrophy of the ceruminous and sebaceous glands.
Narrowing of the ear canal Anatomic variations of the ear canal are common. A particularly
tortuous canal or an ear canal with excess narrowing at the isthmus may tend to accumulate
cerumen. Soft tissue stenoses of the ear canal can occur in patients with multiple or severe
infections of the ear canal, or after surgery on the ear. Tumors of the tissues in or around the ear
canal also cause generalized narrowing. Excessive ear canal hair can trap cerumen at the
meatus. Another source of obstruction is collapse of the cartilage that makes up the lateral onethird of the ear canal (eg, trauma).
Failure of epithelial migration As part of the normal aging process, the glands of the ear
canal skin tend to atrophy, producing a harder, less fluid cerumen that migrates much more
slowly out of the ear canal [13]. In addition, chronic changes of the skin of the ear canal can lead
to a loss of the normal migratory pattern of the epithelium [3]. Impaired epithelial migration and
elimination of cerumen in the ear canal can also occur as a result of foreign objects placed in the
ear canal (eg, cotton). Inappropriate attempts at removal are a common reason for cerumen
accumulation in an otherwise healthy young adult or child. Cotton-tipped applicators (eg, Q-tips,
cotton buds) tend to push cerumen deeper into the ear canal and over time can cause complete
obstruction in some individuals. Hearing aids, ear plugs, and swim molds also obstruct the ear
canal and, with prolonged use, contribute to cerumen accumulation.
Overproduction Some individuals produce a volume of cerumen that overcomes the ear
canal's ability to eliminate it in the absence of ear canal disease. This can occur as a response
to local trauma, as a result of retained water in the ear canal, or can be idiopathic.
CLINICAL PRESENTATION Cerumen accumulation is usually asymptomatic. However, in some
patients, accumulation of cerumen may lead to one or more of the following symptoms [6]:
Hearing loss
Earache
Ear fullness
Itchiness
Reflex cough
Dizziness
Tinnitus
Cerumen is identified in the ear canal on otoscopic examination. Cerumen varies widely in
appearance and texture from almost liquid to rock hard. Appearance may depend on the percentage
of its different components, time spent in the ear canal (harder cerumen is usually present for longer
periods of time), and the amount of desquamated skin. Color ranges from a deep, dark red to black to
off-white. A given individual may have different color cerumen in each ear. The color of the cerumen
reflects its composition, but does not necessarily depict normalcy or the health of the external canal.
CERUMEN REMOVAL In 2008, the American Academy of Otolaryngology-Head and Neck Surgery
published clinical practice guidelines for cerumen impaction [1]. The following recommendations are
largely consistent with these guidelines.
Indications for removal Cerumen removal is indicated for patients with symptoms due to cerumen
(eg, hearing loss, earache, ear fullness, or itchiness) [1]. A systematic review, including observational
studies and randomized trials, found that symptomatic patients with cerumen accumulation who
underwent cerumen removal experienced improved hearing compared to those who were observed
without treatment [1]. In one randomized trial included in the systematic review, 116 patients seeking

cerumen removal for a variety of reasons (78 percent with blocked ears and 72 percent with hearing
problems) were randomly assigned to irrigation or no treatment. A significantly greater proportion of
patients in the treatment group had a 10 decibel (dB) improvement in hearing threshold (34 versus 1.6
percent) [14].
Cerumen removal should also be considered in patients who may not be able to express symptoms,
such as young children and patients with cognitive impairment [15]. One prospective study of elderly
nursing home patients found that patients with cerumen impaction had improved hearing and
cognitive function following cerumen removal, compared to controls [4].
Patients who are asymptomatic should not have cerumen removed [1,16]. Many asymptomatic
patients will clear cerumen without any intervention [17]. Furthermore, cerumen can serve as a
protective layer for the skin of the ear canal, preventing against infection and trauma. Lastly, cerumen
removal can result in rare adverse outcomes. (See 'Complications' below.)
Removal methods Cerumen removal should be performed with the proper methods and tools;
improper removal can lead to complications. There are three recommended therapeutic options:
cerumenolytic agents, irrigation, and manual removal [1]. There are no head-to-head trials comparing
the individual methods for cerumen removal. Systematic reviews have not found superiority of one
method over another [1,18]. Selection of cerumen removal method should be based on provider
experience [6]. Availability of time, equipment (eg, irrigation system, curettes), and ancillary staff also
may influence choice of removal method.
For providers with expertise and equipment (usually otolaryngologists), we suggest manual removal
because this involves direct visualization during the removal process, minimizing damage to the ear
canal skin and/or tympanic membrane. However, in the primary care setting where equipment and
experience with manual removal may not be available, we suggest cerumenolytics rather than
irrigation as no equipment is necessary and there is less risk of tympanic membrane perforation. If
cerumenolytics fail, we suggest follow-up with irrigation.
Cerumenolytics Cerumenolytics are safe to use in patients with no history of infections,
perforations, or otologic surgery. Cerumenolytics should be avoided if tympanic membrane damage is
suspected. If a patient has a history of drainage from the ear, ear pain, or frequent ear infections
earlier in life, then the tympanic membrane may be impaired and cerumenolytics should not be
employed.
Clinicians can apply cerumenolytics or instruct patients to use at home, but patients should be
followed-up with direct otoscopy. Retention of cerumenolytic drops behind the cerumen may occur,
which can result in irritation or damage to the skin of the external auditory canal. Instructions on
cerumenolytics typically recommend no more than three to five days of use for this reason.
In one high quality randomized controlled trial comparing cerumenolytics with no therapy, 97 people
(155 ears) with impacted cerumen were treated using a cerumenolytic for five days or received no
therapy [17]. Use of a cerumenolytic increased the likelihood of an ear being cleared of cerumen
compared with no treatment (53 versus 32 percent, respectively). Of note, one-third of untreated ears
cleared during the five days.
A systematic review including nine randomized trials of 11 cerumenolytics found that ear drops were
better than no treatment, but there was no significant difference in efficacy between the types of drops
[19]. Water and saline solution were also used and found to be similarly efficacious to other
cerumenolytics. The most commonly used cerumenolytics are preparations of mineral oil or hydrogen
peroxide, both available over-thecounter. Patients with dryness or excessive exfoliation of the ear

canal skin should avoid preparations containing hydrogen peroxide as this may exacerbate cerumen
accumulation. Plain mineral oil and liquid docusate sodium are effective for these individuals.
In addition to cerumenolytics, patients with hard impaction or ear canal disease may require irrigation
or manual removal under direct visualization with an otoscope or microscope in the office. Systematic
reviews have found that use of a cerumenolytic may improve success of subsequent irrigation;
however, it remains unclear which cerumenolytic agent is superior for this purpose [18,20]. In our
practice, we use carbamide peroxide in our patients as it is safe and generally effective. We ask
patients to apply 5 to 10 eardrops twice daily up to four days, keeping drops in ear for several minutes
by keeping head tilted and placing cotton in ear. To prevent complications, treatment duration should
not exceed more than four days. (See 'Complications' below.)
Irrigation Irrigation is one of the most widely practiced forms of cerumen removal. Expert
consensus supports irrigation as an effective and safe method for removing cerumen [1]. In one
randomized trial of 116 patients seeking care for a variety of reasons (78 percent with blocked ears
and 72 percent with hearing problems), patients randomly assigned to irrigation were more likely to
have an improvement in several symptoms including hearing on the phone, ear pain, and feeling of
blocked ears [14].
We typically perform gentle irrigation of the ear canal with a large syringe (200 mL) and warm water
treated with a bacteriostatic agent (such as dilute hydrogen peroxide1:10). However, saline or tap
water may be just as effective [21]. Irrigation can be performed by the physician or other trained
clinical staff. Direct visualization of the ear canal is not necessary for safe and effective irrigation. The
ear canal should be straightened as much as possible by pulling up and posteriorly on the auricle. The
tip of the syringe should not be placed past the lateral one-third of the ear canal (usually no more than
8 mm into the canal). By directing the stream of irrigant upwards in the ear canal, the widened area of
the ear canal next to the tympanic membrane can be cleared as well [13]. Irrigation tends not to be
effective for hard impaction. One systematic review found that application of a cerumenolytic agent
may assist with irrigation [20], but this is not usually necessary in most cases. Direct otoscopy is
performed after irrigation to evaluate the success of the procedure (figure 2).
(See 'Cerumenolytics' above.)
There are several mechanical jet irrigators available, some with a special irrigator tip that allows for
better control of water pressure and direction of spray. However, their efficacy and safety have not
been tested in randomized trials with conventional manual irrigation [22,23].
In immunocompromised patients, acidification of the ear canal should follow irrigation with water (eg,
2 percent acetic acid otic drops or boric acid powder) [1]. Moisture retained in the ear canal tends to
encourage bacterial growth in the wet desquamated skin, made more likely in a higher pH
environment. Use of sterile water or saline rather than tap water can also help reduce the risk of
infection from trapped water behind retained cerumen.
Manual removal Manual removal is often quicker than cerumenolytics and irrigation, and does not
expose the ear to moisture. Manual removal should be performed by clinicians with adequate
experience and appropriate equipment. Manual removal requires adequate visualization, usually with
an otoscope or binocular microscope. Instruments used for removal of cerumen include curettes
(probes with loops), spoons, forceps, right-angled hooks, straight applicator with applied wisps of
cotton, and suction (usually with angulated suction tips). Manual removal may be preferred for
patients with abnormal otologic findings (eg, perforated tympanic membrane) or patients with
immunodeficiency that may be predisposed to infection if moisture is introduced into the ear canal via
cerumenolytics or irrigation.

There are no randomized trials evaluating the efficacy of manual removal techniques in comparison to
no treatment. There are small case series that have found manual removal to be effective in removing
cerumen [24,25]. There are no data investigating the efficacy of curettes or spoons in comparison to
other manual methods for cerumen removal.
In our experience, manual devices are most effective for removing cerumen in the lateral one-third of
the ear canal. They should be used under direct visualization only and require the patient to be able to
remain still during removal. Lighted curettes are plastic, disposable curettes that attach to a light
source and can be helpful in visualizing the ear during cerumen removal [26]. Curette technique for
cerumen removal is not effective in uncooperative patients, when cerumen is impacted against the
tympanic membrane, or when the cerumen is very hard.
Suction with direct visualization is an effective adjuvant to the removal techniques mentioned above.
Suction is usually performed on soft cerumen. When suctioning is required deep in the external
auditory canal (past the isthmus), binocular magnification is essential to prevent inadvertent injury to
the tympanic membrane or canal.
Other methods
Endoscopy has been used to successfully remove cerumen, but this method is most
appropriate for specialty use and is not used in the primary care setting [27].
There are several home methods of cerumen removal that have not been well-studied. These
home methods include irrigation, manual removal (eg, cotton swabs, bobby pins), and ear
vacuum kits [25]. They have not shown efficacy and should not be performed.
Ear candling, also called ear coning or thermal auricular therapy, involves lighting one end of a
hollow candle and placing the other end in the ear canal. Ear candling has NOT been shown to
be an effective method of cerumen removal, and has the potential to injure the ear, as well as
cause facial burns. The US Food and Drug Administration and various practice guidelines
recommend that patients avoid the use of ear candles for cerumen removal [1,28].
Complications Complications vary between different removal procedures [1]. Cerumenolytics can
lead to allergic reactions, otitis externa, earache, transient hearing loss, and dizziness. A common
adverse effect of irrigation is retention of water behind incompletely removed cerumen, resulting in
maceration of the skin and potential infection [19]. Tympanic membrane perforation, hearing loss,
tinnitus, pain, and vertigo can also occur, particularly after aggressive irrigation for cerumen
accumulation [29,30]. The most common adverse effects with manual removal of cerumen include ear
pain, bleeding, laceration, and perforation of the tympanic membrane.
Certain patient populations are prone to complications with cerumen removal. Narrowing of the ear
canal (eg, in patients with congenital narrowing) may limit visualization, making both irrigation and
manual instrumentation difficult to perform. Patients with diabetes, AIDS, or other
immunocompromised states may be at increased risk of malignant otitis externa due to cerumen
removal [31,32]. In addition, patients receiving anticoagulant therapy are at higher risk of hemorrhage
or subcutaneous hematomas. Care should be taken to minimize trauma in all of these populations,
and close follow-up should be provided. (See "Malignant (necrotizing) external otitis".)
PREVENTION OF CERUMEN ACCUMULATION Most patients with conditions predisposing to
cerumen accumulation (eg, eczema, otitis externa) cannot prevent recurrent episodes of cerumen
accumulation and the need for cerumen removal.
Among individuals without predisposing conditions, routine use of topical emollients appears to
prevent accumulation of cerumen. In a randomized trial of 39 children and adults with recurrent
cerumen impaction, patients randomly assigned to a topical emollient were less likely to have a

recurrence of cerumen impaction compared to those assigned to no treatment (23 versus 61 percent)
[33]. Treatment with topical emollient involved weekly instillation for one year with 2 mL of a
preparation mixture of paraffinum liquidum, cyclomethicone, and buxus chinensis. The topical
emollient used in this study is not readily available in pharmacies.
In our practice, we suggest that patients with a history of recurring symptomatic cerumen impaction
(>once per year despite cerumen removal) and otherwise normal ears use a cotton ball dipped
in mineral oil and place in the external canal for 10 to 20 minutes once per week (combined with eight
hours of not using a hearing aid overnight, if applicable). This helps to liquefy the cerumen and aid the
normal elimination mechanisms, thereby potentially reducing the number of visits per year for
cerumen removal.
Routine cleaning of the ears by a health professional every 6 to 12 months is also suggested [1].
Patients should be instructed that chronic use of cotton swabs or cerumenolytics should not be
performed.
REFERRAL Referral to an otolaryngologist for cerumen in the ear canal is seldom necessary.
Referrals should be made in the following circumstances:
History of chronic cerumen impaction, perforated tympanic membrane, or ear surgery
Purulence or necrotic tissue in the ear canal
Persistence of otologic complaints after removal of cerumen
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The
Basics and Beyond the Basics. The Basics patient education pieces are written in plain language,
at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might
have about a given condition. These articles are best for patients who want a general overview and
who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer,
more sophisticated, and more detailed. These articles are written at the 10 th to 12th grade reading level
and are best for patients who want in-depth information and are comfortable with some medical
jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on patient info and the keyword(s) of interest.)
Basics topics (see "Patient information: Age-related hearing loss (presbycusis) (The
Basics)" and "Patient information: Ear wax impaction (The Basics)")
SUMMARY AND RECOMMENDATIONS
The main causes for cerumen accumulation include obstruction due to ear canal disease,
narrowing of the ear canal, failure of epithelial migration, and cerumen overproduction.
(See 'Cerumen accumulation' above.)
Cerumen accumulation is usually asymptomatic. However, in some patients, accumulation of
cerumen may lead to hearing loss, ear pain, ear fullness, itching, cough, dizziness,
vertigo, and/or tinnitus. Cerumen is identified by visual inspection of the ear canal with otoscopic
examination. (See 'Clinical presentation' above.)
In asymptomatic patients with cerumen accumulation, we recommend NOT removing cerumen
(Grade 1B). Removal of cerumen obstructing the ear canal should be considered in patients
who cannot express symptoms (eg, those with cognitive impairment). (See 'Indications for
removal' above.)

In patients with symptoms due to cerumen accumulation, options for cerumen removal include
cerumenolytic agents, irrigation, and mechanical removal methods. For providers with expertise
and equipment (usually otolaryngologists), we suggest manual removal over cerumenolytics and
irrigation (Grade 2C). However, in the primary care setting where equipment and experience
with manual removal may not be available, we suggest cerumenolytics rather than irrigation
(Grade 2C). (See'Indications for removal' above and 'Removal methods' above.)
In patients with recurrent cerumen impaction and no significant ear disease, we suggest using
a cotton ball dipped in mineral oil and placing in the external canal once per week to help liquefy
cerumen and aid the normal elimination mechanisms (Grade 2C). (See 'Prevention of cerumen
accumulation' above.)
Patients with cerumen impaction should be referred to an otolaryngologist in the following
situations: history of chronic cerumen impaction, perforated tympanic membrane, or ear surgery;
purulence or necrotic tissue in the ear canal; and persistence of otologic complaints after
removal of cerumen. (See 'Referral' above.)
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