Cerumen Impaction Removal

Michael G. Lamb, MD and Jeannette E. South-Paul, MD
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Subject: Cerumen Impaction Removal

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Introduction

Cerumen impaction is one of the most common problems one encounters in primary care medicine. It is estimated that 150,000 ear irrigations are done each day in the United States and 25,000 each day in the United Kingdom. One study reported that the average family doctor sees 108 patients a year with cerumen impactions. The incidence of cerumen impaction is nearly 28% in mentally retarded adults (i.e., patients with Down syndrome often have narrow ear canals). Almost 40% of nursing home residents have been shown to have cerumen impaction. Elderly adults with intellectual deterioration and those who wear hearing aids also get this problem more frequently. 
This problem is not only common but is also a cause of significant morbidity (i.e., otic pruritus, ear discomfort, recurrent external otitis, dizziness, vertigo, tinnitus, decreased hearing, hearing loss, social withdrawal, decreased cognition, poor work performance, and poor school performance). One study reported 80% improvement in hearing after the removal of impacted cerumen. Resolution of dizziness, vertigo, and tinnitus has been reported as well. Improvement in cognitive function has also been documented with successful treatment of cerumen impaction in selected groups. Overall, however, there have been few evidence-based studies in relation to outcomes data and the treatment of cerumen impaction. 
There are two major types of cerumen: wet and dry. The dry type of ear wax is gray-yellow, tan, or brown-yellow in color. It is difficult to remove by curettage but is easily flushed out with gentle irrigation. Wet cerumen is dark brown and sticky and has a higher concentration of lipids. It is relatively impervious to water and hence is best removed by manual curettage. Therefore, the type of ear wax involved in the impaction will determine the general approach to treatment (irrigation vs. curettage). There are a number of proprietary solvents that are touted as being effective in dissolving ear wax. For the most part, controlled studies do not show them to be any more effective than plain water. 
There is some controversy in regards to what is the best type of irrigation syringe to use. The “old-fashioned” metal syringe has been used for more than 2,000 years. Recently aural jet irrigation devices have become somewhat popular. Normal tympanic membranes in cadavers rupture at an overpressure between 0.5 and 2.0 atm. Atrophic tympanic membranes rupture between 0.3 and 0.8 atm. The tensile strength of the tympanum declines with advanced age. The standard metal syringe used in ear canal irrigation generates a maximum overpressure of 0.3 atm. When used gently, the pressure generated by this device is thus clearly less than the threshold for rupturing both normal and atrophic tympanic membranes. The authors of this chapter have performed more than 1,000 such irrigations without causing a perforation of the tympanum. The literature quotes a perforation rate of 1 in 1,000 patients when the standard metal syringe is used. In contrast, one study reported a perforation rate in cadavers of 6% with aural jet irrigation. It would seem that the standard metal syringe, when used properly, is safer than the aural jet devices. 
The patient must be informed of the potential complications of cerumen removal, especially bleeding, which is relatively common with curettage. Mild dizziness and a full feeling in the ear are somewhat common after irrigation. A tympanic membrane perforation should never occur in a cooperative patient, because the curette should not come anywhere close to the tympanic membrane. A good general rule is to never advance the curette greater than half the length of the external otic canal. There are several types of ear curettes. They can be composed of metal or plastic. A curette with a wirelike loop on the end is useful for removing dry cerumen. Hard cerumen plugs are best removed with a firm metal spoon-type curette with a slightly angled probe on the end. 

Equipment

  • Cerumen curettes: metal loop type, metal spoon type, metal angulated spoon type, or plastic loop type

  • Metal syringe with a piston-type mechanism (plastic types are also available)

  • Kidney-shaped metal or plastic basin (to catch irrigation water)

  • Standing gooseneck lamp (to illuminate the ear canal opening)

  • Protective drape (to cover the patient’s neck and shoulder)

  • Otoscope

Indications

  • Cerumen impaction. Because of the associated morbidity (especially in relation to decreased hearing), cerumen impaction should always be corrected if 50% or greater of the ear canal is occluded, providing that the patient can hold still or is able to be held still.

Contraindications

Curettage

  • Inability to cooperate, hold still, or be held still

  • Excessive cough reflex

  • Anticoagulation with warfarin (Coumadin)

  • Thrombocytopenia

  • Coagulopathy

  • Otitis externa

  • Otic bleeding

  • Suspected tympanic membrane perforation

  • Otic furuncle or pustule

  • Inability to adequately visualize (excess inner ear hair and unusual ear canal anatomy)

Irrigation

  • Prior ruptured tympanum

  • History of tympanostomy tubes

  • Acute otitis media

  • Acute, chronic, or recurrent otitis externa

  • Recurrent or chronic otitis media

  • Diabetes

  • Other immunosuppressed hosts

  • Inability to cooperate

  • Hemotympanum

  • Bloody discharge from the ear

  • Recent ear pain

  • Failure after five irrigation attempts to remove any significant amounts of cerumen

  • Recurrent vertigo

The Procedure

Irrigation for the Removal of Cerumen

Step 1
Several papers have been written recommending a specific protocol for cerumen removal. Although there are some common general considerations, there is no evidence-based consensus. Have an assistant bring kidney-shaped basins, curettes, and an irrigation syringe into the examination room. 
Step 2
Inspect the irrigation syringe and be sure that the piston mechanism moves smoothly. 
Step 3
Carefully examine the ears before irrigation. (If possible, check for intact tympanic membrane, look for any evidence of otitis media or otitis externa, and check for tragal tenderness, blood in the ear canal, and the type of cerumen.) 
Step 4
Check to be sure all fittings on the irrigation syringe are tight. 
Step 5
Fill a kidney-shaped basin with lukewarm water. 
Step 6
Fill the ear syringe with lukewarm water 
  • PITFALL: Using water that is too warm or too cold increases the risk of stimulation of the vestibular reflex and associated nystagmus and nausea.

Step 7
Express any air from the syringe and refill by aspirating more water into the syringe (this prevents a loud gurgling noise from occurring, which is obviously not pleasant for the patient). 
Step 8
Drape the patient’s shoulder and lateral neck with a protective barrier and direct the light from a standing gooseneck lamp onto the patient’s ear. 
Step 9
Have your assistant gently retract the pinnae to open the ear canal. 
Step 10
Grasp the nipple of the syringe between the second and third fingers. Place the thumb of the opposite hand over the plunger. 
Step 10
Step 10
Step 11
Place only the tip of the syringe in the canal. 
Step 11
Step 11
Step 12
Have an assistant hold the kidney-shaped basin under the ear to catch the irrigation water. 
Step 12
Step 12
Step 13
Gently irrigate the ear by pressing with only mild force on the irrigation piston. If significant resistance is encountered, re-evaluate the ear canal. Re-examine the ear with an otoscope to ascertain progress, and repeat the irrigation procedure until the cerumen is removed. 
Step 13
Step 13

Cerumen Removal by Curette

Step 1
A bright light should be shined on the ear while an assistant gently retracts the earlobe to open the canal as much as possible. The patient should be sitting and should be informed that this is an uncomfortable but not painful procedure. He or she must be told to be very still. Putting up the back of the exam table may help the patient hold still. The patient need only to say “stop” to halt the procedure. This should be the case if any pain is being produced. Choose the type of curette to be used. 
Step 2
The angled curette usually works best in most adult cerumen impactions. 
Step 3
Holding the otoscope in the inferior aspect of the ear canal, gently advance the curette above the plug for no more than 0.50 to 0.75 cm. The curette is then anchored in the cerumen plug, and the plug is gently extracted. Quite often the entire plug may be removed whole. On other occasions, repeated attempts are needed to remove all the cerumen. One should never try to remove cerumen that is close to the tympanic membrane with a curette. This is because such proximity increases the chance of a perforation. Occasionally removing some hard cerumen with a curette will allow for an easier irrigation of the ear canal to complete the wax removal. Patients should also be told before the procedure that placing a probe in the ear does induce a cough reflex in some people. 

Complications

Irrigation Technique

  • Perforated tympanic membrane (1 in 1,000 incidence)

  • Minor bleeding from the ear canal

  • Ear canal laceration

  • Otitis media

  • External otitis

  • Vertigo

  • Tinnitus

  • Hemotympanum

  • Malignant external otitis (in diabetics)

Curettage Technique
  • Perforated tympanic membrane

  • Minor bleeding from the ear canal

  • Ear canal laceration

Pediatric Considerations

Adolescents are usually able to cooperate well with either ear cleaning procedure. This is usually not the case with infants and children. These patients often must be held in a “fetal position” by an assistant while the cerumen is removed with a curette. Because cerumen in infants and children is usually of the dry type, a plastic loop curette is recommended. This curette also is less likely to scratch or abrade the ear canal (an important consideration in a potentially uncooperative patient). A trained assistant is preferred over enlisting a parent to hold the child. Irrigation is difficult in infants and small children. It is probably done best with a 3- to 5-cc non-Luer-tip plastic syringe. Obviously this must be done as gently as possible. 

Postprocedure Instructions

Patients should be informed that a full or stuffy feeling in the ear is common after irrigation. The presence of ear pain, tinnitus, fever, vertigo, or bloody drainage from the ear should be immediately reported because these can be signs of significant complications. In general, if one is careful and follows the appropriate guidelines, complications related to cerumen impaction treatment are quite rare. 

Coding Information and Supply Sources

  • Otoscopes, ear curettes, emesis or ear basins, gooseneck lamps, and ear syringes can be obtained from medical supply houses.

  • Cerumen-softening agents such as mineral oil, triethanolamine (Cerumenex), carbamide peroxide (Debrox), or cresyl acetate (Cresylate) may be obtained from pharmacies.

Bibliography

Bird S. The potential pitfalls of ear syringing: minimizing the risks. Aust Fam Physician .  2003;(March):150–151.
Eckhof J. A quasi randomized trial of water as a softening agent of persistent ear wax. Br J Gen Pract .  2001;51:635–637.
Guest J, Greenier M, Robinson A, et al. Impacted cerumen: composition, production, epidemiology and management. QJM.  2004;97(8):477–488. [View Abstract]
Hedgard-Jansen J, Bonding P. Experimental pressure induced rupture of the tympanic membrane in man. Acta Otolaryng .  1993;109:62–67.
Memel D, Langley C, Watkins C. Effectiveness of ear syringing in general practice. Br J Gen Pract .  2002;(Nov.): 906–911.
Sharp J, Wilson J. Ear wax removal: a survey of current practice. Br Med J .  1990;301:1251–1253. [View Abstract]
Sorensen VZ, Bonding P. Can ear irrigation cause rupture of the normal tympanic membrane? J Laryngol Otol .  1991;101:75–78.
Zikk D, Lane B, Birchall M, et al. Invasive external otitis after removal of impacted cerumen by irrigation. N Engl J Med.  1991;325(13):969–970. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’sPhysicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.2007.
 
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