External Ear Obstructions

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 or impaction. Cerumen solvents (hydrogen peroxide, carbamide peroxide, glycerin, triethanolamine, liquid docusate sodium, 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.

In general, cerumen impaction that is severe enough to prevent visualization of the eardrum should be managed by an otolaryngologist, when practical.

Cerumen can be removed by rolling it out of the ear canal with a blunt curet or loop or a small, blunt right angle hook, or by removing it with a suction tip (eg, Baron, size 5 French). Proper lighting is essential. These methods, particularly when done by an experienced practitioner, can be quicker and safer than irrigation. Irrigation is often done in the emergency department or primary care setting and should be done carefully to avoid complications. Irrigation may also be combined with cerumenolytic agents, such as liquid docusate sodium. Irrigation is contraindicated in patients with a known tympanic membrane perforation or with a suspected infection. Water entering the middle ear through a tympanic membrane perforation may exacerbate chronic otitis media Otitis Media (Chronic Suppurative) Chronic suppurative otitis media is a persistent, chronically draining (> 6 weeks), suppurative perforation of the tympanic membrane. Symptoms include painless otorrhea with conductive hearing... read more and cause an acute otitis media Otitis Media (Acute) Acute otitis media is a bacterial or viral infection of the middle ear, usually accompanying an upper respiratory infection. Symptoms include otalgia, often with systemic symptoms (eg, fever... read more .

(See also American Academy of Head and Neck Surgery Practice Guidelines on management of cerumen.)

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.

In general, foreign bodies that appear easy to grasp and remove (eg, paper, an insect wing) can be removed with alligator forceps by most practitioners. However, forceps tend to push round, smooth objects (eg, beads, beans) deeper into the canal. Patients with such objects should be referred to an otolaryngologist if the object cannot be easily removed with a curette. If a smooth, rounded, or spherical foreign body is lateral to the isthmus (bony-cartilaginous junction), it should be removed by reaching behind the object and rolling it out. Foreign bodies medial to the isthmus should be removed under operating microscope guidance by a specialist. Without a microscope, a foreign body lying at or medial to the isthmus (the bony cartilaginous junction of the external auditory canal) is difficult to remove without injuring the delicate canal skin, tympanic membrane, or ossicular chain. Referral to an otolaryngologist also is indicated for an uncooperative child, who may require sedation, or for failed attempts at 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, further attempts at removal should stop and immediate otolaryngologic consultation should be sought. Bleeding may indicate a laceration of the canal skin or that the foreign body is actually a middle ear polyp.

Insects in the canal are most annoying while alive. Filling the canal with viscous lidocaine (or alcohol if the eardrum is intact) kills the insect, which provides immediate relief and allows the immobilized insect to be removed with forceps by grasping a wing or leg.