How To Remove Cerumen Manually and With Irrigation

Symptoms caused by impacted cerumen, such as decreased hearing, local pain and itching, vertigo, or a troublesome feeling of an ear blockage

Rarely, inability to view the tympanic membrane in a child with earache and fever

Irrigation and/or use of cerumenolytic agents are contraindicated if the patient has a non-intact tympanic membrane, which should be suspected if patients have history of mastoid surgery, history of ear tubes and it is unknown whether the tympanic membrane defect has completely healed, history of ear drainage, and/or history of ear pain when water gets in the ear

Anticoagulant therapy

Immunocompromised state

Diabetes mellitus

Prior radiation therapy to the head and neck

Ear canal stenosis, or exostoses

An uncooperative or very young patient who cannot remain still during the procedure

Scarring or distortion of the ear canal region, such as by previous surgery or radiation

Iatrogenic trauma to the ear canal or tympanic membrane, including perforation, which may cause infection. Tympanic membrane rupture may cause infection or other problems of the middle and inner ear, the mastoids, or the central nervous system.

Symptoms of caloric stimulation (eg, vertigo, bradycardia, nausea) may occur if irrigation water is not warmed to body temperature.

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If water is trapped behind retained cerumen, external otitis 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... read more can occur.

Otoscope or light source and aural speculum

Cerumenolytic agent (eg, over-the-counter docusate sodium, 5 to 10% sodium bicarbonate, 3% hydrogen peroxide, triethanolamine, olive oil)

Emesis basin

Absorbent pad, towel, or barrier drape

A 16-, 18-, or 19-gauge catheter with several cm of tubing (eg, plastic angiocatheter or butterfly catheter with the needle removed)

30- to 60-mL syringe

Irrigation solution: Sterile water or saline at body temperature or slightly higher

Sometimes, isopropyl alcohol, fluoroquinolone ear drops

Open procedural otoscope

Blunt, flexible plastic loop or cerumen curette, small right-angle hook, alligator forceps

Suction with thumb control tip (eg, Baron) size 5 Fr

Patients who are asymptomatic should not have cerumen removed.

Anesthetic drops are not effective in reducing discomfort from cerumen removal, and local anesthetic injection is very painful, so neither is used.

Dental jet devices (“water picks”) are used by some, but the stream from these (even on low settings) can rupture the tympanic membrane.

Proper lighting is essential for both the initial examination of the canal and the manual cerumen-removal procedure.

The irrigation method is preferred for mentally impaired adults because it does not require the patient to remain perfectly still.

Manual removal may be preferred in selected adults because it can be faster and is more effective in removing large, hardened accumulations. However, softening with a cerumenolytic and irrigation are often tried first and may facilitate manual removal.

Before and after attempting to remove cerumen, clinicians should consider doing a hearing assessment Evaluation Worldwide, about half a billion people (almost 8% of the world's population) have hearing loss ( 1). More than 10% of people in the US have some degree of hearing loss that compromises their... read more if the necessary equipment is readily available.

The tympanic membrane is 1 to 1.5 cm deep in the canal in children and 1.5 to 2 cm deep in most adults. Avoid instrumenting the ear more than 8 mm deep to prevent damage to the membrane.

The cerumen-producing glands are in the lateral external ear canal only and are present only in the hair-bearing skin. Cerumen deeper in the ear has typically been pushed there by the patient's use of a cotton swab or ear bud.

It is important to position yourself and your patient so that you have an optimal view into the ear canal and both of you are comfortable.

For irrigation, have the patient sit or semi-recline with the head supported. Have the patient or an assistant hold an emesis basin below the patient’s ear and against the neck and cheek.

For manual removal, position the patient supine or semi-reclined, with the head supported.

For instillation of a cerumenolytic, position the patient supine, with the head turned and the ear facing upward so the medication remains in the ear canal.

If the procedure was stopped due to pain, the patient should avoid getting water in the ear for 1 week and be given eardrops such as ofloxacin or a ciprofloxacin/corticosteroid suspension to use twice a day for 3 to 5 days with follow-up to reevaluate. Avoid eardrops containing neomycin, which causes contact dermatitis in up to 20% of patients.

Reexamine the ear to assess the canal and tympanic membrane.

Retest hearing.

If there is retained irrigation fluid but no suspected perforation, instill a few fluoroquinolone or acetic acid ear drops to provide prophylaxis against infection.

For a suspected perforation or if there was pain during the procedure, give a ciprofloxacin/corticosteroid suspension or another fluoroquinolone antibiotic and place the patient on water precautions until the ear is reevaluated.

Avoid excessive pressure during irrigation.

Avoid or stop the procedure if tympanic membrane perforation or injury is suspected during the procedure. Symptoms suggesting damage from the procedure are severe pain, vertigo Dizziness and Vertigo Dizziness is an imprecise term patients often use to describe various related sensations, including Faintness (a feeling of impending syncope) Light-headedness Feeling of imbalance or unsteadiness... read more , tinnitus Tinnitus Tinnitus is a noise in the ears. It is experienced by 10 to 15% of the population. Subjective tinnitus is perception of sound in the absence of an acoustic stimulus and is heard only by the... read more , sudden change in hearing or hearing loss Hearing Loss Worldwide, about half a billion people (almost 8% of the world's population) have hearing loss ( 1). More than 10% of people in the US have some degree of hearing loss that compromises their... read more , or bleeding from behind the cerumen.

Proper lighting and patient comfort are important.