Gordon H. Sun, MD, MS

Disclosures

February 15, 2017

Choosing an Intervention

Certain comorbidities, medications, radiation exposure, and anatomical features directly influence the type of intervention most suitable for cerumen impaction. Patients with compromised immune systems (those with diabetes mellitus, HIV/AIDS, or renal failure, or those receiving chemotherapy or immunosuppressive agents) can be at higher risk for otitis externa after debridement of cerumen, especially with the use of aural irrigation.[2] Irrigation can cause trauma to the external canal skin and alter the pH of the ear canal, and pathogens can breach the injured area and cause infection. Tap water irrigation can increase the risk for necrotizing external otitis or osteomyelitis of the ear canal.[14,15,16,17]

If irrigation is used, the provider must minimize trauma, strongly consider using an acidifying ototopical medication (eg, vinegar or acetic acid) after the procedure, and monitor the patient closely. Intrinsic coagulation disorders and use of anticoagulation medications can increase the risk for bleeding during removal of cerumen. A history of head and neck radiation can alter the external auditory canal architecture, resulting in canal stenosis, atrophy of ceruminous glands, and accumulation of squamous debris.[18]

Narrowing of the external auditory canals, whether intrinsic or due to such lesions as exostoses and osteomas, can obstruct visualization and make debridement of cerumen more technically challenging. Irrigation may be more difficult to perform in stenotic ear canals. This anatomical finding alone is not an absolute contraindication to debridement in an office setting, although specialized equipment or referral to an experienced otolaryngologist or other consultant may be necessary.

A nonintact tympanic membrane, whether due to perforation, tympanostomy tube, previous ear surgery, barotrauma, or other causes, is an indication for cerumen removal using techniques other than irrigation. Aural irrigation in a patient with a tympanic membrane perforation can produce vertigo, and several cerumenolytic agents have ototoxic effects.[2]

Third Case: Office-Based Treatment of Cerumen Impaction

A 48-year-old teacher with intermittent aural fullness and itchiness over the past 2 months was evaluated by his family physician. The patient had no significant medical history.

Physical examination demonstrated normal-sized external auditory canals with semi-solid cerumen impaction. Pneumatic otoscopy demonstrated partially visible tympanic membranes, with no clinical suspicion of perforation.

The patient had not attempted any treatments for the cerumen impaction. The provider, who was very experienced with cerumen removal, had at her disposal a large irrigation syringe with sterile saline and distilled water, otoscopes with and without open heads, and a selection of regular ear curettes and suction tips.

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