Removal of Cerumen Impaction
Ronnie S. Fuerst
Introduction
Removing cerumen from the external auditory canal of pediatric patients is a procedure that is performed daily in the emergency department (ED) and a variety of other medical settings. Authorities estimate that cerumen removal by syringing occurs 150,000 times per week. Visualization of the tympanic membrane is critical for completing a physical examination in pediatric patients presenting with symptoms where the underlying cause may involve the middle ear or tympanic membrane (see also Chapter 52).
The two basic methods for cerumen removal are syringing and débridement. Syringing (irrigation) uses an emulsifying agent to soften and break up cerumen, followed by irrigation. Débridement (curettage) is performed using either a blind technique or by direct visualization with a light source.
Anatomy and Physiology
As shown in Chapter 52, the ear is divided into internal, middle, and external portions (see Figs. 52.1 and 52.2). The internal ear is composed of a system of tubes and spaces called the “membranous labyrinth,” and these are contained within the bony labyrinth. The middle ear is composed of three ossicles. From lateral to medial, they are the malleus, incus, and stapes. All three are contained within the tympanic space, but only the malleus contacts the tympanic membrane. The border separating the middle ear and the external ear is the tympanic membrane. The external auditory canal and the auricle comprise the external ear. The external canal is divided into two parts: the superficial segment, which is supported by cartilage, and the deep segment, which is supported by bone. The deeper bony segment has significantly greater sensitivity to pain.
Cerumen is a mixture of desquamated keratin, dust and debris, hair, and secretions from ceruminous and sebaceous glands in the ear canal (1,2,3,4,5). Long-chain fatty acids, alcohols, squalene, and cholesterol form the major organic components of cerumen (2). Cerumen type is an inherited trait. Wet cerumen is autosomal dominant and is found in most African Americans and Caucasians. It is soft, sticky, and yellow-gold in color. Dry cerumen is common among Asians. It crumbles easily and is light gray. The lysosomes, immunoglobulins, and proteins contained in cerumen, as well as its acidic pH, are believed to have bacteriostatic or bacteriocidal activity (1,4,5).
Indications
Visualization of the tympanic membrane is indicated for any complaint that may stem from middle ear pathology. In children, this would most commonly be otitis media or tympanic membrane perforation. Symptoms may include ear pain or fullness, hearing difficulty, drainage from the ear canal, and headache. Fever, vomiting, diarrhea, poor appetite, ear pulling, cough, and irritability are nonspecific symptoms that may be seen in infants and toddlers with middle ear infections. Symptoms of cerumen impaction alone include vertigo, hearing loss, cough, tinnitus, ear pain, and fullness (1,4,5,6,7).
Syringing and débridement with direct visualization work best in older, cooperative pediatric patients. Blind débridement, although sometimes necessary in the older patient, is normally best used for infants and toddlers. Syringing is a less painful procedure than blind débridement and has fewer iatrogenic risks but is frequently unsuccessful. Débridement by direct visualization can often be accomplished without pain. The advantages of débridement are that it is less time consuming and has a higher success rate.
A suspected perforated tympanic membrane, tympanostomy tubes, and an uncooperative patient are contraindications to cerumenolytics and syringing. A history of otitis
externa, a single hearing ear, and previous ear surgery are relative contraindications to syringing (8). Bleeding disorders are a relative contraindication to blind débridement. Syringing is the preferred method for patients with a bleeding disorder because trauma to the ear canal is avoided.
externa, a single hearing ear, and previous ear surgery are relative contraindications to syringing (8). Bleeding disorders are a relative contraindication to blind débridement. Syringing is the preferred method for patients with a bleeding disorder because trauma to the ear canal is avoided.
TABLE 53.1 Cerumenolytics | |
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Equipment
Items and materials that may be useful for removal of a cerumen impaction are listed in Tables 53.1, 53.2, 53.3.
Otoscope
Emulsifying agents. Several compounds can be used to emulsify and lubricate cerumen and thereby facilitate its removal from the ear canal. Sodium bicarbonate 10% and saline are popular noncommercial products. The most popular commercial products are paradichlorobenzene 2%, chlorbutol 5%, oil of terebinth 5% (Cerumol), triethanolamine polypeptide oleate-condensate 10%, docusate sodium, and chlorbutanol 0.5% in propylene glycol (Cerumenex).
Irrigant: room temperature saline or tap water. A recent study found commercial products had no advantage over normal saline in visualizing the tympanic membrane when syringing was used for disimpaction (9).
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