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• 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.

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.

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.

For both irrigation and manual removal

• Otoscope or light source and aural speculum

• Cerumenolytic agent (eg, over-the-counter docusate sodium, 5 to 10% sodium bicarbonate, 3% hydrogen peroxide, 6.5% carbamide peroxide, triethanolamine, olive oil)

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

• 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.

• 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.

• 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.

• If the procedure was stopped due to pain, the patient should avoid getting water in the ear for 1 week and be given eardrops such as ofloxacin or a ciprofloxacin/corticosteroid suspension to use twice a day for 3 to 5 days with follow-up to reevaluate. Avoid eardrops containing neomycin, which causes contact dermatitis in up to 20% of patients.

• Reexamine the ear to assess the canal and tympanic membrane.

• Retest hearing.

• If there is retained irrigation fluid but no suspected perforation, instill a few fluoroquinolone or acetic acid ear drops to provide prophylaxis against infection, especially if the patient is immunocompromised.

• For a suspected perforation or if during the procedure there was iatrogenic injury to the external canal or significant pain, give a ciprofloxacin/corticosteroid suspension or another fluoroquinolone antibiotic and place the patient on water precautions until the ear is reevaluated.

• 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.

• Proper lighting and patient comfort are important.