Cerumen can be removed manually (using various instruments) or by irrigation of the ear canal.
Non-otolaryngologists more often start with the irrigation method. Sometimes both methods are needed. Pre-procedure cerumenolytic agents may facilitate either method but are routinely used with irrigation.
Indications for Cerumen Removal
Symptoms caused by impacted cerumen, such as decreased hearing, local pain and itching, vertigo, or a troublesome feeling of an ear blockage
Rarely, inability to view the tympanic membrane in a child with earache and fever
Cerumen helps to acidify the ear canal and moisturize the ear canal skin. Both of these functions help to reduce the risk of infection and are important for external ear canal health. Frequent removal of cerumen is discouraged for this reason.
Contraindications to Cerumen Removal
Absolute contraindications
Irrigation and/or use of cerumenolytic agents are contraindicated if the patient has a non-intact tympanic membrane, which should be suspected if patients have history of mastoid surgery, history of ear tubes and it is unknown whether the tympanic membrane defect has completely healed, history of ear drainage, and/or history of ear pain when water gets in the ear
Anticoagulant therapy
Immunocompromised state
Diabetes mellitus
Prior radiation therapy to the head and neck
Ear canal stenosis, or exostoses
Cerumenolytics are contraindicated if there is allergy to the agent.
Relative contraindications
An uncooperative or very young patient who cannot remain still during the procedure
Scarring or distortion of the ear canal region, such as by previous surgery or radiation
Referral to an otolaryngologist is indicated if general anesthesia or deep sedation may be needed or when removal is difficult.
Complications of Cerumen Removal
Cerumen removal is often done by non-otolaryngologists and is a common cause of iatrogenic complications.
Iatrogenic trauma to the ear canal or tympanic membrane, including perforation, which may cause infection. Tympanic membrane rupture may cause infection or other problems of the middle and inner ear, the mastoids, or the central nervous system.
Symptoms of caloric stimulation (eg, vertigo, bradycardia, nausea) may occur if irrigation water is not warmed to body temperature.
Particularly in patients with diabetes, necrotizing external otitis can occur.
If water is trapped behind retained cerumen, external otitis can occur.
Equipment for Cerumen Removal
For both irrigation and manual removal
Otoscope or light source and aural speculum
For irrigation
Emesis basin
Absorbent pad, towel, or barrier drape
A 16-, 18-, or 19-gauge catheter with several cm of tubing (eg, plastic angiocatheter or butterfly catheter with the needle removed)
30- to 60-mL syringe
Irrigation solution: Sterile water or saline at body temperature or slightly higher
Sometimes, isopropyl alcohol, fluoroquinolone ear drops
For manual removal
Open procedural otoscope
Blunt, flexible plastic loop or cerumen curette, small right-angle hook, alligator forceps
Suction with thumb control tip (eg, Baron) size 5 Fr
Additional Considerations for Cerumen Removal
Patients who are asymptomatic should not have cerumen removed.
Anesthetic drops are not effective in reducing discomfort from cerumen removal, and local anesthetic injection is very painful, so neither is used.
Dental jet devices (“water picks”) are used by some, but the stream from these (even on low settings) can rupture the tympanic membrane.
Proper lighting is essential for both the initial examination of the canal and the manual cerumen-removal procedure.
The irrigation method is preferred for patients who are not able to remain still.
Manual removal may be preferred in selected adults because it can be faster and is more effective in removing large, hardened accumulations. However, softening with a cerumenolytic and irrigation are often tried first and may facilitate manual removal.
Before and after attempting to remove cerumen, clinicians should consider doing a hearing assessment if the necessary equipment is readily available.
Relevant Anatomy for Cerumen Removal
The tympanic membrane is 1 to 1.5 cm deep in the canal in children and 1.5 to 2 cm deep in most adults. Avoid instrumenting the ear more than 8 mm deep to prevent damage to the membrane.
The cerumen-producing glands are in the lateral external ear canal only and are present only in the hair-bearing skin. Cerumen deeper in the ear has typically been pushed there by the patient's use of a cotton swab or ear bud.
Positioning for Cerumen Removal
It is important to position yourself and your patient so that you have an optimal view into the ear canal and both of you are comfortable.
For irrigation, have the patient sit or semi-recline with the head supported. Have the patient or an assistant hold an emesis basin below the patient’s ear and against the neck and cheek.
For manual removal, position the patient supine or semi-reclined, with the head supported.
For instillation of a cerumenolytic, position the patient supine, with the head turned and the ear facing upward so the medication remains in the ear canal.
Step-by-Step Description of Cerumen Removal
General considerations
Consider doing a pre-procedure screening bedside hearing assessment.
Advise the patient not to move the head, to minimize any trauma that could result from a sudden movement while an instrument is in the ear canal.
During an examination of the canal or cerumen removal, gently pull (or have an assistant pull) the pinna up and backward (for adults) or down and backward (for children), to straighten the canal as needed.
Patients may experience some discomfort, but you must stop the procedure if the procedure becomes painful and reexamine the ear for signs of injury.
Effective use of instruments
Soft cerumen is removed effectively using irrigation and/or spoonlike instruments, or curettes.
Hard cerumen is more easily removed with cerumen loops and small ear hook instruments.
Suction removal is useful for very soft cerumen and small cerumen fragments but not for a large, hard, or impacted cerumen plug.
Irrigation
Irrigation is done only if there are no risk factors for perforation.
Instill a cerumenolytic and allow it to work for 15 to 30 minutes.
Fill the syringe with irrigation solution.
Insert the irrigation tubing only about 0.5 cm into the canal and not beyond the hair-bearing skin that defines the cartilage-bone (of the skull) junction.
Have an assistant or the patient hold the emesis basin snugly under the ear to catch the irrigant.
Direct a moderate-pressure stream of water around the cerumen or superiorly; the cerumen can then be propelled out by the water accumulating behind it.
You may need to make multiple attempts.
If you can see the tympanic membrane and it is intact with some retained irrigant, you can instill a few drops of isopropyl alcohol after irrigation to hasten water evaporation.
Manual removal
If there are no risk factors for perforation, consider instilling a cerumenolytic and allowing it to work for 15 to 30 minutes.
Use instruments under direct visualization; insert them through the procedure head of the otoscope and speculum.
Remove cerumen using suction or a curette (for soft cerumen) or a loop or hook (for firm cerumen). If needed, extract cerumen using an alligator forceps.
Aftercare for Cerumen Removal
Reexamine the ear to assess the canal and tympanic membrane.
Retest hearing.
Warnings and Common Errors for Cerumen Removal
Avoid excessive pressure during irrigation.
Avoid or stop the procedure if tympanic membrane perforation or injury is suspected during the procedure. Symptoms suggesting damage from the procedure are severe pain, vertigo, tinnitus, sudden change in hearing or hearing loss, or bleeding from behind the cerumen.
Tips and Tricks for Removing Cerumen
Proper lighting and patient comfort are important.
