Chapter 166. Cerumen Impaction Removal

Removal of impacted cerumen is one of the most common otolaryngologic procedures performed by nonotolaryngologists.1 This procedure is also believed to be the most common cause of iatrogenic otolaryngologic complications referred to specialists.2 Approximately 8 million ears are irrigated annually in the United States to remove cerumen.3,4

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 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.6 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 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 assisted by chewing movements.7,8

There are many reasons for cerumen to become impacted.4,6,7 The most common is self-cleaning with cotton-tipped applicator swabs that can push cerumen further into the EAC. The abundant hairs in the EAC, more common in males than females, can obstruct cerumen migration. A small (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, 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.

Recently, the term “impaction” has been defined more clearly as cerumen that causes patient symptoms or prevents a necessary examination of the EAC or TM.4 The primary indication for removal of cerumen is symptomology of impaction.2,4 The most common complaint is hearing loss, which is often abrupt and expressed as a “blocked ear.” Hearing remains normal or nearly so as long as there is a small space in the EAC through which sound can pass and cause vibration of the TM. The hearing loss becomes subjectively significant when the canal is completely obstructed or when the TM is compressed by cerumen and cannot freely move.4,6,8 Other typical symptoms of cerumen impaction include fullness, itching, odor, pain, tinnitus, vertigo, unsteady gait, or reflex cough due to vagus nerve stimulation.4,6,7 Other indications for removing cerumen include the need to examine the ear canal and TM or to test hearing.4,8,9 Cerumen can cause feedback sound loops in those with hearing aids or damage the appliance.4

There are several general contraindications to cerumen removal. An uncooperative patient or young patient that cannot follow instructions or be safely restrained can suffer an iatrogenic injury. Previous ear surgery with scarring of the EAC or TM risks iatrogenic injury. A known or suspected cholesteatoma is a contraindication to cerumen removal. Do not attempt removal if the anatomy of the EAC or TM cannot be clearly defined or is distorted.

The remaining contraindications to cerumen removal are specific to each removal technique. Nearly all cerumen can be safely removed by using one of the techniques listed. Often, two or more techniques can be used together with increased success.6,9

The most important contraindication for EAC irrigation is an acute or chronically ruptured TM.4,7–12 Fluid forced into the middle ear can lead to otitis media, labyrinthitis, mastoiditis, disruption of the ossicles, and loss of balance or hearing.4,10,12 Some authors recommend alternate methods for any patient who has never had an ear exam to document the integrity of the TM.9,10 Most patients can provide the information of having a history of a ruptured TM. A relative contraindication is moderate to severe otitis externa.4,7,8

The major contraindication to instrument removal is a patient, usually pediatric, who is so uncooperative that injury to the EAC or TM is likely to occur with movement.6,12,13 The second contraindication is cerumen pushed directly against the TM. In these circumstances, the TM can be abraded or perforated during cerumen removal with instruments.

The major contraindication to suction removal is a single, hard, irregular, and impacted cerumen plug. Suction will be unsuccessful. Suction works best if there are multiple tiny cerumen fragments or very soft cerumen.9

Cerumen softening or cerumenolytic agents should not be used if the patient has a ruptured TM. Other contraindications to softening agents are an allergy to the agent or an otitis externa.4,7,14,15

Anesthesia

• Local anesthetic solution or suspension (e.g., viscous lidocaine, lidocaine solution, or Auralgan)
• 3 mL syringe

Irrigation

• 10 to 20 mL syringe
• Butterfly catheter with any size needle
• Kidney basins
• Chux or other water barrier
• Tap water or saline at or slightly above body temperature5,6

Alternate Irrigation Equipment4

• Plastic portion of 18 gauge angiocatheter
• Oral jet irrigation (Water-Pik); no longer recommended (see “Complications,” below)
• DeVilbiss irrigator and a compressed air source
• Metal ear syringe

Instruments to Separate and Loosen Cerumen (Figures 166-1, 166-2, 166-3 and 166-4)

• Ear curettes or cerumen spoon, metal or disposable plastic
• Wire loop
• Blunt or ball right-angle hook

Instruments to Grasp Cerumen Directly (Figures 166-1 & 166-3)

• Alligator forceps
• Hartman forceps
• Lighted forceps (Bionix Medical Technologies, Toledo, OH)

Suction

• Frazier suction catheters
• Suction source
• Connection tubing
• Hemostat

Cerumen Softening Agents

• Warm tap water
• Hydrogen peroxide
• Olive, mineral, vegetable, or almond oil
• 5%, 10%, or 15% sodium bicarbonate solution
• Commercial agents (e.g., Cerumenex, Cerumol, Auralgan, and Waxsol)
• Colace
• Glycerine
• Alcohol
• Propylene glycol

Pediatric Immobilization

• Sheets
• Commercial immobilization device (e.g., Papoose board)

Explain the procedure and potential complications to the patient and/or their representative. The discussion should include discomfort, dizziness, minor bleeding, postprocedural otitis externa, and TM perforation. Discuss the importance of remaining still during the procedure. Warn the patient that they may experience an occasional loud noise, especially if suction is used. The most convenient position for adult patients is to remain seated with the ear facing the Emergency Physician. Children can sit on the lap of a parent or attendant with the affected ear facing the Emergency Physician. The parent or attendant should wrap one arm around the child's arms and body while the stabilizing the head with their other arm.16 Smaller children can be swaddled in a papoose made from sheets and tape or a commercial immobilization device.16

Turn the affected ear toward the ceiling and fill the EAC with 5 to 10 mL of local anesthetic solution or suspension using the syringe tip, an angiocatheter, or a butterfly catheter with the needle cut off. This will result in substantial but short-lived topical anesthesia for the procedure.17 If the effect wears off before the procedure is complete, the topical application of local anesthetic can be repeated as needed or longer-acting agents may be used. All cerumen removal techniques require the EAC to be straightened. In the adult, this is accomplished by pulling the pinna slightly up and back while simultaneously pulling it straight out from the head.6 In the small child, pull the pinna down, back, and slightly out from the head.6,18

Precautions for Using Instruments in the EAC

There are two major precautions the Emergency Physician must take to avoid pushing cerumen further into the EAC or causing damage to the EAC and TM. First, the procedures must be performed under direct vision.6 Second, the hand holding the instrument must remain firmly in contact with the patient's head at all times to stabilize the hand and avoid scrapping the canal wall or puncturing the TM should the patient move.6,15 Even a very cooperative patient may move due to an involuntary reflex cough.18

Irrigation

Irrigation is the safest and easiest method of removing cerumen, and is usually successful.2,4,6,10,15 It is less likely to lacerate or damage the EAC or TM than other techniques. It is also the technique most commonly used by nonotolaryngologists.

Place a kidney basin under the affected ear and against the patient's cheek to catch the exiting irrigation solution and cerumen. Instruct the patient or an assistant to hold the basin in place. This author's favorite device for irrigating is to cut the needle and most of the tubing off a butterfly needle, leaving only 1 to 2 cm of tubing (Figure 166-5).13 This remaining tubing will usually be curved, which is optimal for precisely directing the irrigation stream. Others use a 14 or 16 gauge plastic angiocatheter.12 It is important to remember that wider diameter instruments deliver fewer pounds per square inch of pressure with reduced chance of injury.12 Attach the irrigation tubing or angiocatheter onto a 10 or 20 mL syringe. Draw up body temperature normal saline or tap water into the syringe. Insert the butterfly tubing or angiocatheter 1 cm into the EAC with the tip aimed in a direction opposite to the location of the cerumen8 (Figure 166-5). This will cause the water to shoot past the cerumen, bounce off the TM, and force the cerumen out of the EAC along with the irrigating solution.10 If there is no obvious break in the cerumen, direct the stream superiorly or slightly anterior and superiorly.4,10

Care must be taken to make sure that the irrigation stream can easily exit the EAC, to prevent an increase in hydrostatic pressure, which could damage the TM.9 Use only body temperature, or slightly warmer, fluid to avoid caloric stimulation symptoms.4 Irrigation will often have to be repeated numerous times, but persistence is usually rewarded with success.6 Irrigation will sometimes have to be combined with either cerumen softening agents, manual separation of cerumen from the EAC wall, or direct grasping of a partially dislodged cerumen plug.4,6

Many physicians have used mechanical dental irrigation devices (e.g., Water-Pik) to irrigate the EAC and remove cerumen. These devices shoot a stream of fluid from its tip. While they will often remove the cerumen, the direct fluid stream can rupture a TM.3,4,12,20

The OtoClear Ear Irrigation Tip (Bionix Medical Technologies, Toledo, OH) is an improvement for EAC irrigation (Figure 166-6). This device is designed as disposable and single patient use. It attaches to the Luer hub of a syringe. The OtoClear tip can also be attached to a spray bottle or dental irrigating device, allowing these devices to be safely used. When inserted into the EAC, its flared base fits snugly and prevents it from being inserted too far. Holes in the base allow for the egress of irrigation fluid and cerumen into the kidney basin held against the skin. The OtoClear tip directs fluid toward the walls of the EAC (Figure 166-6). This prevents damage to the TM.

Instrument Removal: Separation of Cerumen from the EAC Wall

This technique is a useful adjunct to irrigation and/or instrument removal.15 Sometimes the cerumen is firmly pressed against the EAC wall in all visible directions. Irrigation will not work or may even worsen the situation by pushing the cerumen further into the EAC. Use either cerumen curettes (Figures 166-2, 166-3, and 166-4), loops (Figure 166-1A), right-angle hooks (Figure 166-1B), or wires to gently separate the cerumen from the EAC wall and compress it into the center of the lumen.9

The EasiEar Disposable Comfort Curette (Splash Medical Devices LLC, Atlanta, GA) is an improvement to the standard disposable plastic curette (Figure 166-4). It is a stainless steel, single patient use, and disposable curette. The rounded wire head is smooth. It lacks the jagged and sharp plastic edges that are often found on molded plastic curettes. The EasiEar has no abrasive edges, seams, or surfaces to potentially abrade the EAC. This design may prevent painful cerumen removal, EAC abrasions and lacerations, and procedure-related bleeding. The spring wire shaft provides some flexibility and enhanced maneuverability when compared to molded plastic curettes, making the cerumen removal process easier.

The best place to start is superiorly. The cerumen should not be pulled out with the same movement, as this can abrade the EAC.15 Once there is a visible passage to the TM, irrigation as described above is highly successful and safe. Alternatively, separation of the cerumen from the EAC wall can be performed circumferentially, all the way around the cerumen plug. This results in a cerumen plug freely suspended in the EAC, which can easily be removed by irrigation, pulled out with a right-angle hook, or grasped with forceps.15

Instrument Removal: Sliding Cerumen Out with Instruments from Behind

This technique requires either a cerumen spoon (Figure 166-1A), a wire loop for small cerumen particles, a right-angle hook (Figure 166-1B) for larger quantities, or an EasiEar curette (Figure 166-4). Separate the cerumen from the EAC wall as described above. Position the instrument with the loop or hook in the same plane as the EAC wall. Insert the tip of the instrument into the EAC above and just beyond the cerumen to be removed. Rotate the instrument 90° to bring the loop or hook behind and directly in contact with the back (medial) side of the cerumen. Gently pull the instrument out of the EAC, pulling the cerumen out with it.6 Take care not to abrade the EAC wall with the instrument.

Instrument Removal: Grasping Cerumen with Forceps for Removal

To be successful, there must be sufficient space for the jaws of the forceps on both sides between the EAC wall and the cerumen, or a lateral leading edge that can be grasped. Separate the cerumen from the EAC wall as described above. Insert the forceps into the EAC. Grasp the cerumen with the jaws of the Hartman (Figure 166-7A) or alligator forceps (Figure 166-7B). Gently withdraw the forceps, taking care not to abrade the EAC wall. If the cerumen is located too far medially or instrumentation would cause pain or damage to the TM, irrigation can move the cerumen plug laterally for subsequent grasping with a forceps.

For an optimal outcome, one may need to alternate irrigation and instrument removal to remove all of the cerumen plug safely and completely.4,6 For example, irrigation may gently soften or loosen the plug. A cerumen loop or curette can then be used to separate it from the EAC wall. Irrigation can be used again to move it more laterally. Finally, a forceps or hook can be used to remove the cerumen plug from the EAC.

Suction Removal

This technique requires soft cerumen or multiple small flakes.9 Use the same preparations and precautions described above. Attach the Frazier suction catheter or suction tubing to the suction source. Turn on the suction source. Insert the suction catheter into the EAC. Gently advance the suction catheter until the tip is in contact with the cerumen (Figure 166-8). If using a Frazier suction catheter, place the thumb over the hole on the catheter shaft to direct the suction through the tip of the Frazier catheter. Gently advance the Frazier catheter until its tip is in contact with the cerumen. Withdraw the suction catheter or Frazier catheter and cerumen from the EAC. Usually the tip must be withdrawn and cleaned continuously, because most cerumen will plug the suction tip. For additional safety, insert the suction catheter through a plastic otoscope speculum and withdraw both together.

Cerumen Softening Agents

If the cerumen is so impacted and hard that the above techniques are likely to cause pain and/or injury or if the cerumen cannot be removed, apply a “cerumenolytic” or cerumen softening agent. After the cerumen has softened, it can be removed using the techniques described above. Many studies have compared different agents and most are surprisingly comparable in their effectiveness.1,4,7,14 In fact, even water or saline is effective for cerumen softening and disintegration.1,4,7,14 This may explain why persistent irrigation is so frequently successful. The more commonly available agents in the Emergency Department are listed in the “Equipment” section.

Fill the EAC with one of the cerumen softening agents. Insert a cotton ball into the opening of the EAC to prevent the agent from leaking out. Apply the agent to the contralateral EAC if indicated. An alternative is to place the patient lying on their side with the affected ear facing upward. Insert the agent into the EAC. The agent will not leak out if the patient remains in this position. The disadvantage of placing the patient on their side is that only one ear can be worked on at a time.

Most authors recommend waiting 15 to 30 minutes after the application of the cerumen softening agent before attempting to remove the cerumen.8 Some recommend using the agents at home for up to a week before further removal attempts.8,9 Prolonged exposure to these agents can precipitate an otitis externa, allergic reactions, or a contact dermatitis in the EAC. These agents must be removed and the canal thoroughly dried after their use.4,6

After cerumen has been removed, it is critical to reexamine the ear to confirm that the EAC, TM, and hearing are all normal.2,4 Remove all remaining water and softening agents to prevent an otitis externa.4,6

Many authors recommend prescribing several days of topical otic drops to prevent or treat subclinical otitis externa, which is frequently present in these patients. Often recommended are topical combinations of antibiotics and steroids in solution or suspensions. Commonly prescribed agents include otic quinolones, Corticosporin Otic, Otic Domeboro, Otobiotic, Pediotic suspension, and VoSol to name a few. Consult an Otolaryngologist for patients with injuries, hearing deficits, severe otitis externa, or in whom cerumen removal was unsuccessful. Otherwise, the patient can receive follow-up with their Primary Care Physician in 48 to 72 hours. Instruct the patient in the proper application of ear drops. They should return to the Emergency Department if they develop ear pain, ear discharge, fever, decreased hearing, vertigo, headache, or a stiff neck. They should also be cautioned against future use of cotton swabs or other instruments in the EAC.

Numerous complications can result from the removal of cerumen from the EAC.2,3,4,7,9,12,13,19,20 The complication rate for irrigation is 1 per 1000 cases.2,4,7 It is higher for all other techniques. Irrigation can push cerumen further into the EAC. Irrigation fluid must be body temperature or slightly warmer. Cold fluid can cause caloric stimulation resulting in vertigo, vomiting, bradycardia, or syncope. Middle ear debris can be forced through a preexisting or iatrogenic TM defect, resulting in an otitis media, ossicle damage, labyrinthitis, mastoiditis, loss of hearing and balance, or a central nervous system infection. Otitis externa can result from abrasions to the EAC or retained fluids. Butterfly tubing is less likely than an angiocatheter to damage the EAC or TM because of its more pliable nature, larger diameter, and curved tip.

It is known that mechanical dental irrigation devices, even at low pressures, can rupture the TM. For this reason, they are not recommended for cerumen removal.3,4,12,20

Instrumentation and suction should be used with caution to prevent secondary injury. This includes lacerations or abrasions of the EAC, rupture of the TM, pushing foreign bodies further into the EAC, and disruption or removal of the ossicles. Abrasions or lacerations to the EAC can result in an otitis externa.

Cerumen softening agents can cause a contact dermatitis in the EAC, which may lead to an otitis externa. If the TM is not intact, these agents may cause permanent middle ear damage. Do not use these agents if the TM is ruptured acutely or the history suggests a potential defect.

Successful cerumen removal will often require using multiple techniques in sequence, adapted to the individual patient's situation. With adequate anesthesia, careful planning of the procedural sequence, and gentle handling, those who have been relieved of cerumen impaction will be among your most grateful patients.