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Cerumen Impaction Removal

Overview

Removal of cerumen (wax) from the ear forms a significant part of the workload of an otolaryngologist and is, therefore, an essential skill to master.
However, general practitioners, emergency department staff, nurses, audiologists, audiological physicians, and alternative medicine practitioners may all be confronted with the scenario of excess ear wax that causes difficulty in examination, hearing loss, or discomfort.

Cerumen impaction is defined as an accumulation of cerumen that causes symptoms, prevents assessment of the ear, or both.

In an evaluation of 279 children with acute otitis media with effusion, ear wax needed to be removed to visualize the tympanic membrane in 29% of consultations.

Many options are available to attempt to clear ear wax. These include the following:

Conservative approach

Advising the patient to avoid the use of cotton tip applicators for routine cleaning. Normal external ear canal skin will desquamate in such a way  that wax tends to be pushed to the outside. Regular “cleaning” with cotton tip applicators may be pushing wax deeper into the canal.

Wax-softening drops

A multitude of over-the-counter and commercially available products are sold. Opinion varies on which is the most effective. These products can usually be divided into wate- based (such as peroxide ear drops), oil-based  (such as olive oil), and non-water non-oil based (such as carbamide peroxide and glycerol-combination preparations).

Wax-softening drops are intended to soften the wax over a period of hours to days. It is often prescribed for 2 weeks for maximal effect. The drops may be enough to clear obstruction as the ear canal skin will assist in pushing out the wax over time. However, these may also worsen the patient symptoms in the short term by converting a partial obstruction to a complete blockage. In these cases, mechanical wax removal under vision (micro-suctioning) or irrigation of the ear may need to be considered to improve symptoms.

Ear irrigation

This procedure involves the use of warm (ideally body temperature) water under pressure directed into the ear canal to mechanically remove the wax. While a seemingly simple procedure it has a significant risk of damaging the tympanic membrane (ear drum) and middle ear structures, which led to it being a common reason for litigation in general practice in the past. Pressure-controlled devices limit the risk but tympanic membranes vary in strength from patient to patient and the risk of damage remains. Ear irrigation should not be undertaken without undergoing specific training, taking a full otological history, otological examination, seeking informed consent from the patient, and with the correct pressure-limited instrumentation.

Mechanical wax removal under vision

This is typically done using an operating microscope with the patient awake. The operating microscope affords depth perception and allows accurate targeting of the wax. The wax may be removed with small suction tips (micro-suction), small forceps (called crocodile forceps), blunt instruments (for example, Jobson Horne Probes), or small cotton tip applicators.

Correct patient and care provider positioning is i

Correct patient and care provider positioning is important and improves visualization of the external canal and tympanic membrane.

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