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Elizabeth A Dinces, MD
Section Editor
Daniel G Deschler, MD, FACS
Deputy Editor
H Nancy Sokol, MD


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.


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].


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'.)


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Literature review current through: Sep 2016. | This topic last updated: Jul 30, 2015.
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  1. Roland PS, Smith TL, Schwartz SR, et al. Clinical practice guideline: cerumen impaction. Otolaryngol Head Neck Surg 2008; 139:S1.
  2. Lum CL, Jeyanthi S, Prepageran N, et al. Antibacterial and antifungal properties of human cerumen. J Laryngol Otol 2009; 123:375.
  3. Jabor MA, Amedee RG. Cerumen impaction. J La State Med Soc 1997; 149:358.
  4. Moore AM, Voytas J, Kowalski D, Maddens M. Cerumen, hearing, and cognition in the elderly. J Am Med Dir Assoc 2002; 3:136.
  5. Guest JF, Greener MJ, Robinson AC, Smith AF. Impacted cerumen: composition, production, epidemiology and management. QJM 2004; 97:477.
  6. Mitka M. Cerumen removal guidelines wax practical. JAMA 2008; 300:1506.
  7. Kelly KE, Mohs DC. The external auditory canal. Anatomy and physiology. Otolaryngol Clin North Am 1996; 29:725.
  8. Ijaz, Ahmad, Lee, WC, Binnington, JD. External Auditory Canal Measurements: Localization of the Isthmus. Otorhinolaryngol Nova 2000; 10:183.
  9. Donaldson JA, Duckert LG. Anatomy of the Ear. In: Otolaryngology, 3rd, Paparella MM, Shumrick DA, Gluckman JL, Meyerhoff WL (Eds), WB Saunders, Philadelphia 1991. p.23.
  10. LITTON WB. Epithelial migration over tympanic membrane and external canal. Arch Otolaryngol 1963; 77:254.
  11. Campos A, Arias A, Betancor L, et al. Study of common aerobic flora of human cerumen. J Laryngol Otol 1998; 112:613.
  12. Burkhart CN, Burkhart CG, Williams S, et al. In pursuit of ceruminolytic agents: a study of earwax composition. Am J Otol 2000; 21:157.
  13. Meador JA. Cerumen impaction in the elderly. J Gerontol Nurs 1995; 21:43.
  14. Memel D, Langley C, Watkins C, et al. Effectiveness of ear syringing in general practice: a randomised controlled trial and patients' experiences. Br J Gen Pract 2002; 52:906.
  15. Oron Y, Zwecker-Lazar I, Levy D, et al. Cerumen removal: comparison of cerumenolytic agents and effect on cognition among the elderly. Arch Gerontol Geriatr 2011; 52:228.
  16. Wright T. Ear wax. BMJ 2015; 351:h3601.
  17. Keane EM, Wilson H, McGrane D, et al. Use of solvents to disperse ear wax. Br J Clin Pract 1995; 49:71.
  18. Clegg AJ, Loveman E, Gospodarevskaya E, et al. The safety and effectiveness of different methods of earwax removal: a systematic review and economic evaluation. Health Technol Assess 2010; 14:1.
  19. Burton MJ, Doree C. Ear drops for the removal of ear wax. Cochrane Database Syst Rev 2009; :CD004326.
  20. Hand C, Harvey I. The effectiveness of topical preparations for the treatment of earwax: a systematic review. Br J Gen Pract 2004; 54:862.
  21. Browning GG. Ear wax. BMJ Clin Evid 2008; 2008.
  22. Aung T, Mulley GP. Removal of ear wax. BMJ 2002; 325:27.
  23. Mandel EM, Dohar JE, Casselbrant ML. Aural irrigation using the OtoClear Safe Irrigation System in children. Int J Pediatr Otorhinolaryngol 2004; 68:1295.
  24. McCarter DF, Courtney AU, Pollart SM. Cerumen impaction. Am Fam Physician 2007; 75:1523.
  25. Leong AC, Aldren C. A non-randomized comparison of earwax removal with a 'do-it-yourself' ear vacuum kit and a Jobson-Horne probe. Clin Otolaryngol 2005; 30:320.
  26. Pevsner J. Removal of cerumen from ear canal using lighted curettes. Am Fam Physician 2007; 76:32.
  27. Pothier DD, Hall C, Gillett S. A comparison of endoscopic and microscopic removal of wax: a randomised clinical trial. Clin Otolaryngol 2006; 31:375.
  28. Food and Drug Administration. Advice for patients: Ear candles. Available at: www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PatientAlerts/ucm200896.htm (Accessed on February 10, 2011).
  29. Sørensen VZ, Bonding P. Can ear irrigation cause rupture of the normal tympanic membrane?: an experimental study in man. J Laryngol Otol 1995; 109:1036.
  30. Sharp JF, Wilson JA, Ross L, Barr-Hamilton RM. Ear wax removal: a survey of current practice. BMJ 1990; 301:1251.
  31. Driscoll PV, Ramachandrula A, Drezner DA, et al. Characteristics of cerumen in diabetic patients: a key to understanding malignant external otitis? Otolaryngol Head Neck Surg 1993; 109:676.
  32. Weinroth SE, Schessel D, Tuazon CU. Malignant otitis externa in AIDS patients: case report and review of the literature. Ear Nose Throat J 1994; 73:772.
  33. Saloranta K, Westermarck T. Prevention of cerumen impaction by treatment of ear canal skin. A pilot randomized controlled study. Clin Otolaryngol 2005; 30:112.