* This is the Professional Version. *
External Ear Obstructions
The ear canal may be obstructed by cerumen (earwax), a foreign object, or an insect. Itching, pain, and temporary conductive hearing loss may result. Most causes of obstruction are readily apparent during otoscopic examination. Treatment is manual removal.
Before and after attempting to remove cerumen or a foreign body, clinicians should consider doing a hearing assessment (see Evaluation of Hearing Loss) if they have the necessary equipment readily available. Hearing loss (compared to the unaffected ear) that does not improve after removal of the obstruction could indicate that the foreign body (or prior attempts to remove it) has damaged the middle or inner ear. Hearing that worsens after removal of the obstruction could indicate damage caused by the removal process. However, practitioners who cannot formally assess hearing need not defer removal of common obstructions. An in-office tuning fork test may also document hearing status.
Cerumen may be pushed farther into the ear canal and accumulate during patients' attempts to clean the ear canal with cotton swabs, resulting in obstruction. Cerumen solvents (hydrogen peroxide, carbamide peroxide, glycerin, triethanolamine, or mineral oil) may be used to soften very hard wax before direct removal. However, the prolonged use of these agents may lead to canal skin irritation or allergic reactions.
Cerumen is removed by rolling it out of the ear canal with a blunt curet or loop or removing it with a suction tip (eg, Baron, size 5 or 7 French). These methods are quicker, safer, and more comfortable for the patient than irrigation, which is typically not recommended. Irrigation is contraindicated if the patient has a history of otorrhea or perforation of the tympanic membrane; water entering the middle ear through a perforation may exacerbate chronic otitis media.
Foreign bodies are common, particularly among children, who often insert objects, particularly beads, erasers, and beans, into the ear canal. Foreign bodies may remain unnoticed until they provoke an inflammatory response, causing pain, itching, infection, and foul-smelling, purulent drainage. A rounded foreign body in the ear canal is best removed by reaching behind it and rolling it out with a small, blunt hook, preferably under microscopic guidance. Objects with an edge (eg, paper) can be removed with alligator forceps, but forceps tend to push round, smooth objects deeper into the canal. Without a microscope, a foreign body lying medial to the isthmus (the bony cartilaginous junction of the external auditory canal) is difficult to remove without injuring the tympanic membrane and ossicular chain. Irrigation is not recommended for foreign body removal; hygroscopic foreign bodies (eg, beans or other vegetable matter) swell when water is added, complicating removal. A general anesthetic or deep sedation may be needed when a child cannot remain still or when removal is difficult, threatening injury to the tympanic membrane or ossicles. Further, if manipulating a presumed foreign object results in bleeding, immediate otolaryngologic consultation should be sought. Bleeding may indicate a mucosal polyp originating in the middle ear, which may be attached to the ossicles or facial nerve.
Insects in the canal are most annoying while alive. Filling the canal with viscous lidocaine kills the insect, which provides immediate relief and allows the immobilized insect to be removed with forceps by grasping a wing or leg.
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* This is a professional Version *