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Removal of impacted cerumen (Figure 198-1) is one of the most common otolaryngologic procedures performed by physicians who are not Otolaryngologists.1 It is also a common cause of iatrogenic otolaryngologic complications with medical malpractice suits that frequently result in payment.2 Approximately 150,000 ears are irrigated weekly and 8 million annually in the United States to remove cerumen.3,4

FIGURE 198-1.

Cerumen from the external auditory canal on a cotton-tipped applicator. (Used from


The S-shaped external auditory canal (EAC) is 2.5 cm long in adults.5 The lateral or distal third is cartilaginous, with thicker skin, more hair follicles, glands, and more subcutaneous tissue than the medial or proximal two-thirds which is bony and has a thinner, more fragile layer of skin.5,6 The narrowed isthmus is located between the cartilaginous and bony portions.5 The canal ends medially at the tympanic membrane (TM) which is situated obliquely to increase the surface area for carrying sound energy to the middle ear.5 The anteroinferior EAC is 0.6 mm longer than the posterosuperior portion.5 Auriculotemporal branches of cranial nerves V, VII, IX, and X and the greater auricular nerve of the cervical plexus supply sensation to the EAC.5

Cerumen (Figure 198-1) is a mixture comprising secretions of the ceruminous glands of the lateral two-thirds of the EAC, the pilosebaceous glands located at the roots of EAC hairs, and sloughed squamous epithelial cells.5,7 Cerumen forms a barrier against infection, has antimicrobial activity, and protects the skin of the EAC as it is water repellant. It is expelled naturally by migration and assisted by chewing movements.7,8

There are many reasons for cerumen to become impacted.4,7 The most common is self-cleaning with cotton-tipped applicator swabs that can push cerumen further into the EAC (Figure 198-1). The abundant hairs in the EAC, more common in males than females, can obstruct cerumen migration. A small (e.g., especially in children), tortuous, or scarred EAC will obstruct cerumen migration. Some people produce large quantities of cerumen. Diseases such as Parkinson’s can alter the consistency of the cerumen and inhibit its migration. Hearing aids, earbud headphones, stethoscope earpieces, or any other object in the EAC may compact the cerumen. Deficits in the substances that cause sloughed squamous epithelial cells to separate will inhibit the movement of cerumen. Nonimpacted cerumen exposed to water can swell and obstruct the EAC.


The term “impaction” is defined as cerumen that causes patient symptoms or prevents a necessary examination of the EAC or TM, even without complete obstruction of the canal.4 The primary indication for removal of cerumen is the symptomology ...

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