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Summary Table

Feature	Details
Risk Factors	Cotton swab use (most common cause), hearing aid users, elderly patients with narrow or tortuous canals, excessive cerumen production, eczema or psoriasis of the ear canal, anatomic abnormalities (exostoses, stenosis)
Etiology	Accumulation of cerumen that fully occludes the external auditory canal, often driven by impaction from foreign objects (cotton swabs, earplugs) rather than overproduction
Patient Presentation	Gradual conductive hearing loss, aural fullness, otalgia, tinnitus, occasionally dizziness or cough (Arnold nerve reflex)
Classic Physical Exam	Otoscopy reveals a mass of cerumen (yellow-brown to dark brown) partially or completely obstructing the canal; tympanic membrane is obscured and cannot be visualized
Key Diagnostic Results	Clinical diagnosis by otoscopy; audiometry shows conductive hearing loss if tested; Weber lateralizes to the affected ear, Rinne is negative (bone > air) on the affected side
Management	Cerumenolytic agents (sodium bicarbonate, hydrogen peroxide, docusate sodium), ear irrigation with warm water, or manual removal by curette under direct visualization
Keywords	"Ear fullness," "gradual hearing loss," "unable to visualize the tympanic membrane," "cotton swab use," "conductive hearing loss that resolves after removal"

1. Pathophysiology

Cerumen is a mixture of secretions from the ceruminous glands (modified apocrine glands) and sebaceous glands located in the cartilaginous (outer one-third) portion of the external auditory canal. It combines with desquamated epithelial cells and hair to form a waxy substance that serves several protective functions: it traps debris, repels water, and maintains an acidic pH (~5) that inhibits bacterial and fungal growth.

Under normal conditions, the ear canal is self-cleaning. The epithelium of the canal migrates laterally from the tympanic membrane outward, carrying cerumen and trapped debris toward the meatus in a natural conveyor belt mechanism. This process is aided by jaw movement during chewing and talking, which deforms the cartilaginous canal and helps propel cerumen outward.

Impaction occurs when this self-cleaning mechanism is disrupted. The most common cause is repeated insertion of cotton swabs, which pushes cerumen deeper into the canal past the cartilaginous portion and into the bony (medial two-thirds) segment where there are no ceruminous glands and no migratory epithelium to clear it. Once cerumen is compacted against the bony canal or the tympanic membrane, it hardens and becomes progressively more difficult to expel naturally.

The resulting occlusion produces conductive hearing loss because the cerumen plug physically blocks sound transmission through the canal to the tympanic membrane. The degree of hearing loss depends on the completeness of the occlusion; even a small residual gap between the cerumen and the canal wall preserves near-normal hearing. This is why patients often report sudden hearing loss after showering or swimming: water causes the cerumen to swell and close that remaining gap, converting a partial obstruction into a complete one.

Otalgia from cerumen impaction is typically dull and pressure-like, resulting from direct contact of hardened cerumen against the sensitive skin of the bony canal or the tympanic membrane. Occasionally, patients report a vagal cough reflex (Arnold nerve reflex) triggered by stimulation of the auricular branch of the vagus nerve (CN X) that innervates the posterior and inferior canal wall. This reflex is worth remembering because it can also be triggered during ear irrigation or examination, and a vignette describing chronic cough that resolves after cerumen removal is a classic presentation.

2. Classification and Clinical Manifestations

Type	Description	Clinical Features
Partial impaction	Cerumen narrows the canal but does not fully occlude it	Mild aural fullness, minimal hearing loss, tympanic membrane may still be partially visible on otoscopy
Complete impaction	Cerumen fully occludes the canal lumen	Conductive hearing loss (up to 40-45 dB), pronounced aural fullness, tympanic membrane cannot be visualized
Hard (desiccated) cerumen	Dry, dark brown to black, firmly adherent to canal walls	More common in elderly patients; difficult to irrigate without prior softening; higher risk of canal trauma during removal
Soft (wet) cerumen	Golden-yellow, moist, pliable consistency	More common in certain ethnic populations (Caucasian, African descent); easier to remove by irrigation or suction

Clinical Manifestations

Symptom	Mechanism
Conductive hearing loss	Physical blockage of sound wave transmission to the TM
Aural fullness / pressure	Occlusion creates a closed air column with altered pressure dynamics
Tinnitus	Contact of cerumen with the TM can produce low-frequency humming or buzzing
Dizziness / vertigo	Caloric effect from cerumen pressing on the TM or during irrigation with non-body-temperature water
Chronic cough	Arnold nerve reflex (auricular branch of CN X stimulation)
Otalgia	Pressure of hardened cerumen against the bony canal periosteum or TM

3. Diagnostic Workup

Test	Role	Key Findings
Otoscopy	Best initial and usually only test needed	Cerumen mass occluding the canal; TM not visualizable; canal skin may be erythematous from irritation
Tuning fork tests (Weber and Rinne)	Bedside assessment of hearing loss type	Weber lateralizes to the affected ear; Rinne shows bone conduction > air conduction (negative Rinne) on the affected side
Pure tone audiometry	Objective quantification if hearing loss persists after removal	Conductive hearing loss pattern with air-bone gap; should normalize completely after successful cerumen removal
Tympanometry	Adjunctive if TM integrity is in question post-removal	Type B (flat) tracing when canal is fully occluded; normalizes (Type A) after removal if the middle ear is healthy

Cerumen impaction is a clinical diagnosis made by direct otoscopic visualization. No laboratory tests or imaging are required. The key finding is an obstructing mass of cerumen that prevents adequate visualization of the tympanic membrane.

The reason otoscopy matters beyond simply confirming cerumen is that the tympanic membrane must be assessed once the cerumen is removed. A vignette may describe a patient who presents with hearing loss attributed to cerumen, but after removal the hearing does not improve, prompting further evaluation for an underlying sensorineural or middle ear pathology. Always think of cerumen impaction as a diagnosis that requires you to see through to the TM before you can close the case.

Tuning fork tests are the most commonly tested bedside maneuvers in this context. In cerumen impaction:

The Weber test (512 Hz fork placed on the vertex) will lateralize to the affected ear because the conductive blockage enhances bone-conducted sound perception on that side, analogous to the effect of plugging one ear with a finger.

The Rinne test (fork on the mastoid then held near the ear canal) will be negative on the affected side, meaning bone conduction is perceived as louder than air conduction. This confirms a conductive hearing loss of at least 15 to 20 dB.

A critical teaching point: if the Weber test lateralizes to the opposite ear, this suggests sensorineural hearing loss on the affected side rather than conductive loss, and the diagnosis of simple cerumen impaction should be reconsidered.

Audiometry is not routinely needed but is indicated when hearing loss persists after complete cerumen removal or when there is a clinical suspicion of coexisting sensorineural pathology, particularly in elderly patients where presbycusis and cerumen impaction commonly coexist.

4. Management and Treatment

Clinical Scenario	Treatment	Details
Soft cerumen, partial impaction	Cerumenolytic drops alone	Sodium bicarbonate drops, hydrogen peroxide 3%, or docusate sodium; instill 5 to 10 drops, let sit for 15 to 30 minutes, then allow natural drainage; repeat for 3 to 5 days
Hard cerumen, complete impaction	Cerumenolytic softening followed by irrigation	Soften with drops for 15 to 30 minutes (or for several days if very hard), then irrigate with body-temperature water (~37 C) using a syringe directed at the posterosuperior canal wall
Impaction with canal edema or failed irrigation	Manual removal under direct visualization	Curette or wire loop under otoscope or microscope guidance; suction aspiration is an alternative
TM perforation known or suspected	Manual removal only; avoid irrigation	Water entering the middle ear risks infection, vestibular stimulation, and worsening of hearing
Recurrent impaction	Prophylactic cerumenolytic drops	Mineral oil or olive oil drops 1 to 2 times per week to soften cerumen and facilitate natural migration

Step 1: Determine whether removal is necessary. Asymptomatic cerumen that does not obstruct the canal or prevent clinical examination does not require treatment. Removal is indicated when cerumen causes symptoms (hearing loss, pain, fullness) or when it prevents adequate examination of the tympanic membrane in a patient who needs otoscopic evaluation.

Step 2: Soften the cerumen. For hard, desiccated cerumen, pre-treatment with a cerumenolytic agent improves the success rate of subsequent irrigation. Commonly used agents include sodium bicarbonate drops, hydrogen peroxide 3%, docusate sodium (a stool softener repurposed as a cerumenolytic), and commercial preparations containing carbamide peroxide. No single cerumenolytic has been shown to be clearly superior. The drops are instilled with the affected ear facing upward, left in place for 15 to 30 minutes, and then drained. For very hardened cerumen, softening over 3 to 5 days may be needed before attempting removal.

Step 3: Remove the cerumen. The three main removal techniques are:

Irrigation is the most commonly used method in primary care. Body-temperature water (~37 C) is delivered into the canal using a large syringe or electronic irrigator. The stream should be directed at the posterosuperior canal wall, not directly at the cerumen plug or the TM, to allow water to flow behind the plug and push it outward. Using water that is too cold or too warm can induce a caloric response (vertigo and nystagmus) by stimulating the lateral semicircular canal through the TM, which is an important complication to recognize.

Manual removal with a curette is preferred when irrigation is contraindicated or has failed. It is performed under direct visualization using an otoscope or operating microscope. This method carries a higher risk of canal abrasion and is typically performed by trained clinicians.

Suction aspiration uses a fine-tipped suction catheter under microscopic guidance and is the method of choice in ENT settings, particularly for soft cerumen.

Contraindications to irrigation are a critical testing point:

Known or suspected tympanic membrane perforation (water entering the middle ear causes infection and caloric vertigo)
Tympanostomy tubes in place
History of mastoid surgery or middle ear surgery
Only hearing ear (risk of complications affecting the patient's sole source of hearing)

After removal, the canal and tympanic membrane should be inspected. If the TM is intact and hearing has normalized, no further workup is needed. If hearing loss persists, audiometry is the next step.

5. Differential Diagnosis and Distractors

Differential	Why It Is Similar	Key Discriminator
Foreign body in the ear canal	Both cause unilateral conductive hearing loss and aural fullness with an obstructed canal on otoscopy	Otoscopy reveals a non-cerumen object (bead, insect, cotton tip); history often includes a witnessed insertion event (especially in children)
Otitis externa	Both present with ear pain, fullness, and a canal that is difficult to visualize	OE has pain with tragal pressure/pinna traction, canal wall erythema and edema with purulent discharge; cerumen impaction has no canal wall inflammation
Cholesteatoma	Both can cause conductive hearing loss and a mass-like appearance on otoscopy	Cholesteatoma shows a pearly white mass or retraction pocket medial to or involving the TM, often with foul-smelling discharge; cerumen is lateral to the TM and has a waxy appearance
Canal exostosis / osteoma	Both can narrow the canal and trap cerumen, causing conductive hearing loss	Exostoses appear as bony hard, smooth protrusions of the canal wall (associated with cold water exposure, "surfer's ear"); the narrowing is skeletal, not waxy
Keratosis obturans	Both produce a plug of material that fills the canal	Keratosis obturans involves accumulation of desquamated keratin (not cerumen) that expands the bony canal, causing widening visible on CT; associated with bronchiectasis and sinusitis
Presbycusis	Both present with hearing loss in elderly patients	Presbycusis produces bilateral, symmetric, high-frequency sensorineural hearing loss; Weber lateralizes away from the worse ear; Rinne remains positive bilaterally

6. Traps and High-Yield Pearls

The most common trap with cerumen impaction involves the tuning fork interpretation. A vignette will describe an elderly patient with gradual hearing loss, and otoscopy reveals cerumen blocking the canal. Students must correctly predict that Weber will lateralize to the affected ear (conductive loss) and Rinne will be negative on that side (bone > air). The classic mistake is confusing this with sensorineural hearing loss, where Weber lateralizes away from the affected ear and Rinne remains positive. If you remember nothing else: conductive loss lateralizes toward the problem, sensorineural loss lateralizes away from it.

A second important trap is the contraindication to irrigation. When a vignette describes a patient with cerumen impaction and includes a subtle mention of tympanostomy tubes, prior ear surgery, or known TM perforation, the correct answer shifts from irrigation to manual removal under direct visualization. Choosing irrigation in these settings is the designed wrong answer.

Third, watch for the vignette where cerumen is removed but hearing does not improve. This is a two-step question: the first step tests whether you can identify and manage cerumen impaction, and the second step tests whether you recognize that an underlying pathology (presbycusis, otosclerosis, middle ear effusion) was masked by the cerumen. The next best step is audiometry, not reassurance.

Finally, the Arnold nerve reflex appears occasionally as a vignette describing chronic unexplained cough that resolves after cerumen removal. This tests your knowledge that the auricular branch of CN X innervates the ear canal and that its stimulation can trigger a vagal cough reflex. If a question describes chronic cough with a normal chest X-ray and normal pulmonary function tests, consider looking in the ear.

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