COURSE: MEDICAL SURGICAL NURSING 111

COURSE CODE: NSC 421

NAME OF LECTURER: MAAM CHUKWU

TOPIC: CERUMEN IMPACTION

NSC/20/1653: OBIUNU .O. MIRACLE

NSC/20/1654: UNEGBU CHIOMA GENEVIEVE
NSC/20/1655: ENYOLU CHIOMA VIVIAN
NSC/20/1656:UGWUOKE EMILIA CHIDERA
NSC/20/1657: ONYEMA SUCCESS ONYEDIKACHI
NSC/20/1659: OGUNMERU KHADIJAT IFEOLUWA
CERUMEN IMPACTION
Definition: Cerumen or earwax is a combination of glandular
secretions and desquamated epithelial cells that cleans, protect and
lubricates the external auditory canal. Cerumen is typically expelled
from the ear canal spontaneously via a self-cleaning mechanism that
is assisted by jaw movements during talking and eating.
Cerumen impaction which is commonly known as earwax
blockage is defined as an accumulation of cerumen that causes
symptoms or prevents assessment of the ear canal, tympanic
membrane or audiovestibular system; complete obstruction is not
required for required for a diagnosis.

CAUSES OF CERUMEN IMPACTION

Cerumen impaction can be caused by;
 Producing more earwax or a type of earwax that is susceptible
to impaction: some people get ear wax build up simply because
they naturally produce more earwax or producing a type of
earwax that is distinct and more prone to impaction
 Misshapen ear canal that interfere with natural wax removal
 Developmental disabilities affecting the ear
 Dry or hard earwax
 Lots of hair in the ear canal
 Lifestyle: frequent use of earplugs or hearing aids
NB: certain skin conditions like eczema and other factors like old
age make individuals more susceptible to having ear impaction.

TYPES OF CERUMEN IMPACTION

Audiologist classify cerumen impaction into four categories;
 Type 1: no visible cerumen: no soft or hard wax is seen and
complete tympanic membrane can be visualized during
otoscope examination but patient experiences symptoms of
cerumen impaction, this is usually an indication of other
problems of the ear.
  Type 2: non-occluding cerumen: otoscope examinations shows
some soft and/or hard wax. However wax is non-occluding and
two-third of the tympanic membrane can be visualized
 Type 3: occluding cerumen: otoscope examinations show
occluding soft and/or hard wax with very little or no
visualization of the tympanic membrane. However, some gap
can be seen between the ear wax and ear canal wall.
 Type 4: Fully occluding cerumen and debris: ear canal is
completely blocked with soft or hard wax and also with debris.
No visualization of tympanic membrane.

SYMPTOMS OF CERUMEN IMPACTION

 Earache
 Tinnitus: ringing or noises in the ear
 Feeling of fullness in the ear
 Hearing loss
 Dizziness
 Cough
 Itchiness in the ear
 Otorrhea: discharge from the ear

DIAGNOSTIC PROCEDURE
1) History taking: questions would be asked on;
 Medical history: this includes history of any previous ear
infections or problems as well as present symptoms
experienced by the patient
 Family history of cerumen impaction and other related ear
problems
 Surgical history: history of any ear surgery
History taking would include questions on lifestyle such as;
 Amount of time spent using earphones
 Previous use of hearing aids
 Ear hygiene habits including methods used for cleaning
  Unhygienic practices like use of cotton swabs frequently, ear
candling and olive oil drops or sprays
2) Physical assessment: this involves the use of an otoscope to
check the external ear, earwax build up, and eardrum so as to
visualize and determine the method of management required
Assessment also helps in determining the cause of cerumen
impaction as well as treatment method to be considered.

PATHOPHYSIOLOGY OF CERUMEN IMPACTION

Pathophysiology of cerumen impaction is largely dependent on the
cause and type of cerumen impaction;
1) Cerumen impaction caused by prolonged use of
earphones: the earphones act as a physical barrier which
prevents the normal removal of earwax from the ear, it could
also be recognized as a foreign object by the ear thereby
stimulating the cerumen glands leading to excessive cerumen
production as well as keratin which causes the dryness and
hardness of cerumen.
2) Cerumen impaction caused by misshapen or narrow ear
canals: the size or shape of the ear canals can interfere with
the natural wax removal, in cases where the ear canal is too
narrow, even though production of earwax is normal, due to
the size of the ear canal, it is unable to be removed effectively
and this leads to an accumulation of cerumen in the ear which
could eventually cause occlusion and more accumulation
leading to impaction
3) Cerumen impaction caused by overproduction of cerumen
or due to type of earwax produced:genetics may cause you
to produce more earwax than is necessary. People with 1 or 2
copies of the C variant in the ABCC11 gene(which is
responsible for determining the type of earwax) have more fat
in their earwax, making it wet and sticky, which usually causes
occluding cerumen impaction, while those with 2 copies of the
T variant have less fat in their earwax making it dry and flaky,
 this usually makes it harder for natural removal eventually
leading to non-occluding cerumen impaction

MANAGEMENT OF CERUMEN IMPACTION

Management of cerumen impaction typically involves removing the
impacted cerumen and reducing the risk of recurrence.
Methods used for the removal of cerumen impaction include:
1) Irrigation: irrigation involves the use of a stream of water to
flush out the cerumen, a standard oral jet irrigator with or
without a modified tip is commonly used for aural irrigation.
Pretreatment with a topical preparation improves the
effectiveness of irrigation. Irrigation can be done with or
without cerumenolytic pretreatment. Irrigation is not
advisable in patients with a perforated tympanic membrane
and care is advised in use in persons with diabetes because the
PH in these persons is higher and that may facilitate the
growth of pathogens hence care must be taken to minimize
trauma, the use of eardrops to acidify the ear canal after
irrigation should also be considered.
NB: irrigation should not be performed in patients with a
history of ear surgery or in those with anatomic abnormalities
of the ear canal.
2) Manual removal: manual removal of impacted cerumen
requires an instrument for visualization (e.g. handheld
speculum or otoscope, headlamp, binocular microscope) and
one for removal (e.g metal and plastic loop or spoon, alligator
forceps, curette). Manual instrumentation is often preferred
for hard cerumen as well as cerumen impaction in patients
with perforated tympanic membrane.
3) Micro suction with the use of cerumenolytic agents:
Microsuction involves the aspiration of cerumen with a suction
tip attached to a negative-pressure pump, usually after
cerumen has been softened by a cerumenolytic agent.
 4) It can also be managed by just the use of cerumenolytics
which exist in three forms;
 Water based cerumenolytics: which induce hydration and
subsequent fragmentation of cerumen. examples include:
acetic acid, hydrogen peroxide, sodium bicarbonate,
sterile saline solution
 Oil based cerumenolytics: which are not true
cerumenolytics, they soften and lubricate cerumen but
they do not disintegrate it. Examples include; almond oil,
arachis oil, olive oil, earex( which is composed of arachis
oil, rectified camhor oil and almond oil)
 Non-water, non-oil based cerumenolytics: their
mechanism of action is not known. Examples include;
Debrox(carbamide peroxide), Audax(choline salicylate
and glycerine).

COMPLICATIONS OF CERUMEN IMPACTION

There are several potential complications that can occur as a result
of cerumen impaction. These include;
 Hearing loss
 Tinnitus (ringing in the ears)
 Ear pain
 Vertigo (dizziness)
 Ear infection

These complications can occur as a result of the physical blockage

of the ear canal, as well as the accumulation of fluid and bacteria
in the ear in some cases.

REHABILITATION OF CERUMEN IMPACTION

Rehabilitation after cerumen impaction is focused on restoring
hearing and preventing recurrence. This may involve;
 Wearing hearing aids or other assistive listening devices, as
well as using hearing protection when exposed to loud noises.
  Education about proper ear cleaning techniques and the
avoidance of irritants is also important. In some cases,
rehabilitation may also involve working with a speech-
language pathologist to improve communication
 It also includes education of clients on the effects of unhealthy
ear cleaning practices such as the use of cotton tipped swabs,
and olive oil drops or sprays
 In addition, aural rehabilitation may include cognitive
rehabilitation such as training to improve memory and
attention.

GERONTOLOGICAL CONSIDERATION
From a gerontological perspective, cerumen impaction can be
particularly challenging for older adults. This is because the risk of
cerumen impaction increases with age due to factors such as;
 Decreased motility
 Dry skin
 Medications that can affect cerumen production like
antidepressants, sedative drugs, anticholinergic and other
drugs that are commonly used among the elderly
 Changes in the structure of their ear canal as a result of ageing
 Oil glands that produce wax begin to atrophy, and the wax
becomes drier and more prone to impacting
 In addition, older adults may have difficulty cleaning their own
ears or recognizing the signs and symptoms of cerumen
impaction. Therefore, it’s important for older adults to have
regular hearing screenings and to seek medical attention if
they experience any changes in their hearing.