The ear canal may be obstructed by cerumen (earwax), scar tissue, a tumor, a foreign body, or an insect. Itching, pain, and temporary conductive hearing loss may result. Most causes of obstruction are readily apparent during otoscopic examination. Treatment is careful manual removal using adequate lighting and appropriate instruments.
Diagnosis of external ear obstructions is usually obvious based on physical examination.
Before and after attempting to remove cerumen or a foreign body from the ear canal, clinicians should consider doing a hearing assessment if they have the necessary equipment readily available. Hearing loss (compared with the unaffected ear) that does not improve after removal of the obstruction could indicate that the foreign body (or prior attempts to remove it) has damaged the middle or inner ear. Hearing that worsens after removal of the obstruction could indicate damage caused by the removal process. However, clinicians who cannot formally assess hearing need not defer removal of common, easily removable obstructions. An in-office tuning fork test may also document hearing status.
Cerumen
In general, cerumen impaction that is severe enough to prevent visualization of the eardrum should be managed by an otolaryngologist, when practical.
chronic otitis media and cause an acute otitis media. Irrigation is also not done if patients have diabetes mellitus, immunocompromise, or certain ear canal abnormalities or have had radiation therapy to the head and neck or if patients are taking anticoagulants.
(See also American Academy of Head and Neck Surgery Practice Guidelines on management of cerumen.)
Foreign bodies in the ear
Foreign bodies are common, particularly among children, who often insert objects, particularly beads, erasers, and beans, into the ear canal. Foreign bodies may remain unnoticed until they provoke an inflammatory response, causing pain, itching, infection, and foul-smelling, purulent drainage.
In general, foreign bodies that appear easy to grasp and remove (eg, paper, an insect wing) can be removed with alligator forceps by most practitioners (1). However, forceps tend to push round, smooth objects (eg, beads, beans) deeper into the canal. Patients with such objects should be referred to an otolaryngologist if the object cannot be easily removed with a curette or alligator forceps. If a smooth, round foreign body is lateral to the isthmus (bony-cartilaginous junction), it should be removed by reaching behind the object with a small right-angle instrument and rolling it out. For foreign bodies medial to the isthmus, an otolaryngologist should remove the object using a microscope for guidance. Unless a microscope is used, a foreign body lying at or medial to the isthmus (the bony cartilaginous junction of the external auditory canal) is difficult to remove without injuring the delicate canal skin, tympanic membrane, or ossicular chain. Referral to an otolaryngologist is also indicated when a child is uncooperative and may require sedation or when attempts at removal are unsuccessful.
Irrigation is not recommended for removing a foreign body; hygroscopic foreign bodies (eg, beans or other vegetable matter) swell when water is added, complicating removal.
Pearls & Pitfalls
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When a patient cannot remain still or removal is difficult, a general anesthetic or deep sedation may be needed to prevent injury to the tympanic membrane or ossicles. If manipulating a presumed foreign body results in bleeding, further attempts at removal should stop, and an otolaryngologic should be consulted immediately. Bleeding may indicate that the canal skin is lacerated or that the foreign body is actually a middle ear polyp.
Insects
General reference
1. Curry SD, Maxwell AK: Management of foreign bodies in the ear canal. Otolaryngol Clin North Am 56 (5):881–889, 2023. doi: 10.1016/j.otc.2023.06.002 Epub 2023 Jul 27.
