Cerumen Impaction Removal

CHAPTER 72 Cerumen Impaction Removal



Michael McHenry


Cerumen impaction is one of the most common otologic problems encountered by primary care clinicians (approximately 150,000 ears are irrigated per week in the United States to remove cerumen). Cerumen is a naturally occurring lubricant and protectant of the external auditory canal. The predominant form is a wet, sticky, honey-colored wax that can darken, but a dry, scaly form occurs in some patients. Normally cerumen is carried from inside the canal to the outside by tiny cilia. Accumulation of cerumen can cause decreased hearing, tinnitus, vertigo, infection, or a sensation of increased pressure. The hearing loss is usually quite sudden when the cerumen seals off the canal and is often described by the patient as a “blocked ear.” Accumulation is common in elderly patients and in patients working in dusty environments. Patients often do a poor job of removing cerumen with cotton-tipped sticks or over-the-counter preparations, leaving the clinician to complete the procedure. In fact, overzealous use of these applicators frequently disrupts the natural ciliary cleaning process. For removal by the clinician, topical anesthesia may be desired; foreign bodies may also need to be removed (see Chapter 76, Removal of Foreign Bodies from the Ear and Nose, which also describes a technique for injecting anesthetic for external canal field block). The overall goal of this procedure is to remove cerumen under direct visualization or by irrigation without causing injury. The risk of injury is not to be taken lightly because ear irrigation is one of the more common causes of iatrogenic injuries cared for by otolaryngologists. Asymptomatic cerumen buildup does not require removal; rather, the patient should be taught how to perform his or her own ear irrigation to clean the ears.



Indications



• Tympanic membrane or ear canal obscured by cerumen with otologic complaint

• Patient complaint of decreased hearing, otalgia, tinnitus, vertigo, or unsteady gait associated with cerumen

• External otitis associated with cerumen (the ear should be dried meticulously after the procedure)

• Clinician needs to examine an ear canal or tympanic membrane obscured by cerumen

• Patient needs hearing tested and ear canal(s) obscured by cerumen


Contraindications



• Uncooperative patient or infant who cannot be adequately restrained.

• Clinician unfamiliar with or unable to define anatomy of the external auditory canal.

• Patient with distorted anatomy (e.g., prior or current injury obscuring normal anatomy), although this is a relative contraindication.

• Previous ear surgery with resultant scarring and increased risk of perforation (relative contraindication).

• Known or suspected cholesteatoma.

• The affected ear is the only hearing ear (relative contraindication, but referral should be considered).

• For irrigation, acute otitis media or known/suspected perforation of the tympanic membrane is a contraindication. In these situations, the curette or suction catheter should be used under direct visualization.


Equipment



• Equipment necessary for clinician to observe universal blood and body fluid precautions (gloves, mask, goggles)

• Ear curette
• Metal: rigid, Buck, Shapleigh, or Yankauer; flexible, Billeau flexible earloop

• Plastic: Flex-loop ear curette, disposable ear curette, or infant ear scoop

• Otoscope with moveable posterior lens or shield, or ear speculum and light source

• Ear forceps

• Ball-tipped ear hook

• Local anesthetic solution or suspension (e.g., lidocaine solution)

• For suction: Various ear suction catheters with suction source (Fig. 72-1)

image

image

Figure 72-1 Suction catheters (including Frazier) (A) and basic suction pump (B) can assist in managing ear canal obstruction.


NOTE: Hollow ear candles have been found ineffective.


• For irrigation
• Ear syringe (large stainless steel syringe with irrigant deflector), or a commercially available jet irrigator (on “ENT table units,” or an oral Waterpik [Water Pik, Inc., Fort Collins, Colo]), or a 22-gauge butterfly intravenous catheter tubing (with needle and butterfly removed) and a 20- to 50-mL syringe. An 18-gauge Angiocath type IV catheter can also be used with a syringe.

• Lukewarm tap water (“lukewarm” is confirmed when a drop placed on the inner forearm of the examiner is comfortable, similar to testing baby formula).

• Towels, Chux, or plastic drape.

• Cotton gauze strip.

• Emesis or ear basin to collect irrigant.

• Aqueous-based ceruminolytics, in contrast to the traditional organic or oil-based preparations, have been found to be most effective in in vitro studies. Distilled water can be used, but 3% hydrogen peroxide or 5% to 10% sodium bicarbonate was superior in studies. Olive oil was not useful. Sialic acid took twice as long as distilled water to dissolve cerumen. The sodium bicarbonate solution can be made at home by dissolving image teaspoon sodium bicarbonate (baking soda) in 10 mL of water.


Preprocedure Patient Preparation



• For curette and suction removal, discuss the chance of perforation and minor trauma to the ear canal associated with pain.

• For irrigation removal, discuss the risk of perforation and potential dizziness during the irrigation. Local discomfort may also be experienced, especially when the ear syringe is used.

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Cerumen Impaction Removal

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