Cerumen: Insights and Management

Cerumen is an amalgam of secretions from the cerumenous and sebaceous glands that line the lateral aspect of the external ear canal, and shed epithelial remnants and occasional extraneous material that finds its way into the external auditory canal. Although present in all age groups, cerumen may become particularly problematic in the elderly population and those residing in LTC facilities; impacted cerumen may lead to both worsening of an existing hearing deficit and unexpected cognitive and behavioral irregularities. Cerumen provides a number of vital services that contribute to the overall health of the external ear, yet removal is often required to assure proper examination prior to planned hearing testing, and to help in hearing aid performance. A number of techniques may be utilized to remove cerumen, and preference should depend upon a caregiver’s expertise, as well as a patient’s tolerance and receptivity to the approach under consideration. Annals of Long-Term Care: Clinical Care and Aging 2010;18[7]:39-42)
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The Department of Health and Human Services’ Administration on Aging predicts that by 2030, our aging (≥ 65 yr) population will number approximately 71.5 million, twice the number counted for the year 2000. The presence of cerumen or ear wax is one of the more common ear-related issues that can negatively impact an aging population. Although present in all age groups, those advanced in years are clearly more vulnerable to a number of attendant problems associated with the presence of impacted cerumen in the external auditory canal. Residents of long-term care (LTC) facilities are particularly disadvantaged when impacted cerumen contributes to compromised hearing in those patients already suffering from chronic illness, psychiatric disorders, or social isolation.¹

Although cerumen is generally considered beneficial for the overall health of the ear, removal must be entertained should the need arise to obtain adequate visualization of ear structures in preparation for planned hearing testing, or as a routine procedure to help assure proper hearing aid function. The potential for complications resulting from routine ear cleaning should reinforce the need for caution during cerumen extraction, especially in patients with lowered tolerance levels, states of confusion, increased excitability, and compromised immune status. Removal is not always uneventful, as mishaps may occur resulting in canal trauma, itching, infection, vertigo, pain, and perforation of the tympanic membrane. The frequent use of anticoagulants in this patient population may also elevate the risk of bleeding from inadvertent trauma to either the canal or tympanic membrane.

Although the terms cerumen and wax are often used interchangeably, cerumen constitutes a combination of secretions from both the cerumenous and sebaceous glands that line the lateral extent of the external auditory canal. Cerumenous glands are modified apocrine glands that function in concert with sebaceous glands to release a wide array of products that include long-chain fatty acids, alcohols, squalene, long-chained hydrocarbons, and cholesterol precursors,² which evidently provide lubrication to the ear canal and safeguard the canal’s cutaneous surface against potential undesirable consequences of exposure to water. The term ear wax, on the other hand, actually represents a variable admixture of cerumen together with contributions from the canal skin that include spent skin and hair and the occasional presence of extraneous items such as cotton fibers, airborne debris, and hair dyes and sprays, just to name a few. In spite of the obvious differences between the two, the term cerumen is customarily used throughout the literature and will be so utilized from here on in as well.

Becoming acquainted with the external auditory canal should enable the reader to gain an increased appreciation of cerumen’s function in the ear canal and how it is that this ongoing secretion becomes impacted in spite of the ear’s best efforts at its removal. Guest et al³ aptly describe the external auditory canal (Figure) as a “cul-de-sac of stratum corneum,” which because of its one way in and one way out construction employs a means by which to transport depleted sheets of stratum corneum out of the canal. This dead-end configuration requires that a mechanism be present for removal of spent epithelial debris in an outward direction and away from the interior of the canal. The system so utilized is commonly referred to as “migration,” a one-way transport system in which sheets of keratin debris are moved outward and away from the inner confines of the canal. Hawke⁴ proposed that the presence of impacted cerumen likely represents a deficiency in an agent referred to as keratinocyte attachment-destroying substance (KADS). This deficiency prevents corneocytes from separating from one another, and may thereby impede these attached sheets from joining the ongoing migratory process that carries squamous debris for disposal to the exterior. With epithelial sheets constituting up to 60% of impacted plugs,³ cerumen must be viewed not simply as an accumulation of secretory end products, but as an amalgam containing varying amounts of epithelial constituents as well.

The consistency, color, and amount of cerumen may vary from individual to individual, with ethnicity being associated with one’s predisposition to cerumen type. Two phenotypic types of cerumen, regulated by two autosomal alleles, have been described5 and are commonly identified as either “wet” or “dry.” The wet form, honey-colored and sticky in nature, is most frequently encountered in Caucasians and African Americans, while the dry form, brittle in consistency and gray or tan in color, is more common in Asians and Native Americans.^3,6 Differences in lipid content also serve to differentiate the wet form from the dry, with approximately 50% lipid content in the wet form and 20% lipid content in the dry.³ A more hardened cerumen typically may contain deposits of elongated sheets of epithelium, while the softer version likely possesses small epithelial remnants, which by their very nature fail to impart a firm consistency. Torchinsky and Davidson⁷ briefly touch upon the finding that seasonal change affects cerumen composition since the amount of triglyceride found in cerumen varies during winter and summer months. The constancy of temperature and humidity in many nursing homes and LTC facilities may perhaps impact upon cerumen content and consistency—a consideration that has garnered little attention in the literature and should seemingly deserve further investigation and study.

As noted, cerumen has been assigned a number of pivotal roles that include removing desquamated skin and other extraneous items that find their way into the canal, serving as a lubricant and protective barrier that prevents water from negatively impacting on the ear canal’s epithelial layer. Whether or not cerumen contains any bactericidal activity has been bandied about in the literature, with some reports concluding that cerumen provides little, if any, bactericidal activity,^8,9 while others take an opposite view based on respective studies that do indeed indicate the presence of antibacterial properties.^2,5,10

A number of regional and systemic disorders, notably psoriasis, cystic fibrosis, and Parkinson’s disease, have been noted to contribute to alterations in the amount and consistency of cerumen.⁶ Osteomas and exostoses commonly result in surface irregularities that may not only modify the ear canal’s efficiency in expelling accumulated cerumen via migration, but may also serve as a potential physical impediment while attempting to remove accumulated cerumen.

Age-related changes such as coarser, elongated canal hair, decreased glandular function, and exostotic changes of the canal have been documented by Torchinsky and Davidson⁷ as giving rise to a drier, less mobile plug that may be unable to traverse an aging constricted canal. The presence of impacted cerumen has taken on added significance because an accumulation of this nature can easily impact on an existing hearing deficit, particularly in individuals confined to LTC facilities. The specter of hearing loss and the likelihood of associated social isolation in this population requires that cerumen be removed for proper examination, adequate audiometric testing, and proper hearing aid utilization.

Clinical Guidelines

The American Academy of Otolaryngology-Head and Neck Surgery released clinical guidelines relative to cerumen impaction based on evidence-based management criteria, including information relevant to residents of LTC facilities.¹¹ The following is a summary of its recommendations:

1. Diagnose cerumen impaction when accumulated cerumen coincides with symptoms or precludes adequate evaluation of the ear. Factors that may modify management include alterations in the anatomical dimensions of the ear canal, integrity of the tympanic membrane, diabetes mellitus, compromised immune status, and anticoagulant therapy.
2. Nonimpacted cerumen may be observed if there is no related symptomatology and adequate evaluation is not hampered.
3. Cerumen impaction should be treated when related symptoms are voiced by the patient or when required examination is impeded. The elderly and cognitively impaired have been found to have a higher incidence of cerumen impaction and may be unaware of the impaction’s presence, or incapable of voicing complaints or offering appropriate symptoms to caregivers.
4. Patients with hearing aids should be examined for the presence of impacted cerumen, which may result in a diminution of hearing aid performance.
5. Cerumen impaction may be removed by a number of means that include irrigation, cerumenolytic products, or manual extraction other than irrigation.
6. Patients should be assessed following treatment for impacted cerumen, and the status of resolution should be documented. If resolution is not complete, additional treatment protocols should be utilized. In the event that symptomatology persists in spite of removal, other diagnoses should be entertained.
7. Patients may be advised of available measures to help in preventing cerumen from accumulating.³

Adverse Effects of Impacted Cerumen

In “Clinical Practice Guideline: Cerumen Impaction,” Roland et al¹¹ make emphatic mention of a number of cerumen-related impediments commonly experienced by elderly and developmentally delayed individuals. Impacted cerumen is a common finding, having been estimated to occur in over 33% of residents of LTC facilities, many of whom lack the ability or inclination to communicate relevant symptoms to their healthcare providers. The mere presence of cerumen will likely prove inconsequential, but as the canal begins to occlude, a variety of symptoms and complaints may occur, including diminished hearing, aural fullness, tinnitus, disequilibrium, itching, cough, and discomfort. An alteration in mental function or emotional stability in the elderly and LTC residents may arise as a result of impacted ear canals,⁷ a matter of particular concern when these residents remain silent or detached as their attention to personal needs may have started to recede and sensory deficits have become more pronounced.

Healthcare professionals need to be ever more vigilant and should recommend that appropriate examination, testing, and treatment be instituted in spite of a resident’s possible lack of interest or inability to communicate. Innovative approaches may be required when patients are found to be poor historians, confused, combative, or simply unwilling or incapable of participating in their own care and well-being.¹²

How much of a hearing loss should be anticipated when impacted cerumen is detected in an ear canal? Roland et al¹¹ offer a range of a 5 to 40 decibel loss, which will logically be dependent upon the extent of cerumen impaction within the canal. Adding this loss to an existing hearing deficit may well lead to social isolation, despondency, acting out inappropriately, depression, and paranoia.¹³ Because hearing loss is quite common amongst residents of LTC facilities, the presence of occlusive cerumen should support the need for cerumen removal so as to prevent impacted cerumen from exacerbating an existing hearing loss. Moore and colleagues1 found that a marked improvement in hearing and mental status took place following removal of impacted cerumen from residents confined to a skilled nursing facility. Cerumen removal is obviously required for those individuals who present with ear-related symptoms, but must also be entertained if clinical suspicion is aroused in LTC residents whose silence or inappropriate conduct serve to delay needed intervention.

Cerumen Removal

When preparing to remove cerumen (Table), healthcare providers should be cognizant of and prepared for anatomical variations of the canal, as well as the possibility of unexpected findings within the external ear canal structure. Foreign bodies, which often include the end of a cotton swab or pieces of paper, occasionally are coated with cerumen and may easily mimic a typical cerumen impaction. Individual differences in size and orientation of the canal, along with disparities in hair and glandular density, may lead to confusion, extraction difficulties, and unanticipated trauma to the canal or adjoining structures. Any history of previous otologic surgery may result in significant anatomical alterations and should therefore raise a precautionary flag so that any planned manipulation of the ear in question is performed by a consulting otolaryngologist. Irrigation, cerumenolytics, and instrumentation have all been utilized to remove cerumen, and any planned technique should be tailored to suit each patient’s particular needs. A small, insignificant amount of cerumen need not raise concern unless hearing assessment, providing a proper environment for hearing aids, and adequate visualization for both treatment and evaluation necessitate that cerumen removal be performed.

Conclusions

Impacted cerumen occurs at all ages but is more widespread in the elderly and those residing in LTC facilities. The latter represents a more vulnerable and challenging group who may be suffering from assorted sensory deficits and behavioral idiosyncrasies that may be exacerbated by the presence of impacted cerumen. Hearing testing, adequate physical examination, and the need to maintain a proper milieu for hearing aid usage all require that cerumen be eliminated from the ear canal. Removal of cerumen must be individualized so as to meet each patient’s particular needs, limitations, and deficits. Irrigation, cerumenolytics, and instrumentation are all commonly utilized, and preference logically will depend upon a caregiver’s competence, a patient’s tolerance to cerumen removal, and any relevant past medical history that could impact on extraction. Routine hearing testing in concert with impaction removal should be entertained in LTC facilities as a means to improve hearing acuity and offset the occasional emotional and cognitive issues associated with the presence of impacted cerumen.

The author reports no relevant financial relationships. Dr. Hersh is at the Department of Surgery/Otolaryngology, New York Hospital Queens, Flushing, NY.

References

1. Moore AM, Voytas J, Kowalski D, Maddens M. Cerumen, hearing and cognition in the elderly. J Am Med Dir Assoc 2002;3:136-139.

2. Burkhart CN, Burkhart CG, Williams S, et al. In pursuit of ceruminolytic agents: A study of earwax composition. Am J Otol 2000;21:157-160.

3. Guest JF, Greener MJ, Robinson AC, Smith AF. Impacted cerumen: Composition, production epidemiology and management. QJM 2004;97:477-488.

4. Hawke M. Update on cerumen and ceruminolytics. Ear Nose Throat J 2002;81(8 suppl 1):23-24.

5. Lum CL, Jeyanthi S, Prepageran N, et al. Antibacterial and antifungal properties of human cerumen. J Laryngol Otol 2009;123:375-378. Published Online: August 11, 2008.

6. Hanger HC, Mulley GP. Cerumen: Its fascination and clinical importance: A review. J R Soc Med 1992;85:346-349.

7. Torchinsky C, Davidson TM: Cerumen impaction. In: Calhoun KH, Eibling DE, eds. Geriatric Otolaryngology. New York: Taylor & Francis Group; 2006:43-57.

8. Campos A, Betancor L, Arias A, et al. Influence of human wet cerumen on the growth of common and pathogenic bacteria of the ear. J Laryngol Otol 2000;114:925-929.

9. Pata YS, Ozturk C, Akbas Y, et al. Has cerumen a protective role in recurrent external otitis? Am J Otolaryngol 2003;24:209-212.

10. Chai TJ, Chai TC. Bactericidal activity of cerumen. Antimicrob Agents Chemother 1980;18:638-641.

11. Roland PS, Smith TL, Schwartz SR, et al. Clinical practice guideline: Cerumen impaction. Otolaryngol Head Neck Surgery 2008;139(3 suppl 2):S1-S21.

12. Van Vuuren PAC, Kagan SH, Chalian AA. Geriatric otolaryngology toolbox: What you and your nurse can do to improve outcomes for older patients. Ear Nose Throat J 2009;88(10):1162-1168.

13. Mahoney DF. Cerumen impaction. Prevalence and detection in nursing homes. J Gerontol Nurs 1993;19:23-30.