Removal of cerumen and FB from the ear

Question 1

What is the goal of cerumen/fb removal?

Answer 1

To remove cerumen impaction or foreign bodies from the
auditory canal while observing standard precautions and with the
minimal degree of risk to the patient.

Question 2

What is the function of cerumen?

Answer 2

1. Cerumen serves as protective coating, trapping fine dust and repelling
   water away from the tympanic membrane.
2. The acidic nature of cerumen is
   not suitable for bacterial growth, thus aiding in prevention of otitis externa
   development.

Question 3

How does the body remove cerumen from the the EAC?

Answer 3

Fine hair located in the auditory canal moves the cerumen out
of the external meatus, preventing obstruction.

Question 4

What can prevent the body from naturally removing cerumen from the ear?

Answer 4

1. narrowed auditory canal or external meatus, overproduction of
   cerumen, or use of cotton-tipped applicators in the canal

Question 5

What is the mc cause of hearing impairment?

Answer 5

Cerumen impaction

Question 6

What can cerumen impaction lead to?

Answer 6

1. Tinnitus
2. Vertigo
3. Ear fullness/pain

Question 7

What are the indications for cerumen removal/fb removal?

Answer 7

1. Symptomatic pt
2. cerumen impaction visualized on exam that prevents visualization of tm
3. Presence of any fb

Question 8

What are the contra indications for cerumen removal/fb removal?

Answer 8

1. Refer to otolaryngologist for:
   A. Uncooperative patient
   B. Suspected tympanic membrane rupture
   C. Inability to visualize the tympanic membrane when rupture is suspected
   D. Contact of the foreign body with the tympanic membrane

Question 9

What are the potential complications to the removal?

Answer 9

1. Tympanic membrane perforation
2. Ossicle damage
3. Abrasion of the canal
4. Movement of the foreign body further into the canal
5. Temporary vertigo
6. Tinnitus

Question 10

What material are needed for cerumen/fb removal?

Answer 10

1. Syringe (metal ear syringes are available but any 30- to 60-mL
   syringe will work)
2. Otoscope
3. Body temperature water
4. Cerumen spoon
5. Cerumen loop or right-angle hook
6. Alligator forceps
7. Lidocaine or mineral oil for live insects
8. Cup-shaped forceps for round foreign bodies
9. Small-diameter suction tip if suction is available
10. Magnet if the foreign body is metal
11. Cyanoacrylate glue (super glue) and a wooden cotton swab

Question 11

How is the pt prepped for the procedure?

Answer 11

1. Discuss the proposed procedure with the patient, including the
   associated risks.
2. Advise the patient to remain still during the procedure.
3. Warn the patient that the procedure may be uncomfortable but if it
   becomes painful the removal attempt will be stopped.
4. The patient should be placed in an upright and comfortable position.
5. Discuss any concerns the patient expresses regarding the procedure.

Question 12

What is the cerumen removal procedure?

Answer 12

1. After confirming the presence of cerumen
   impaction with an otoscopic examination,
   place the patient in an upright,
   comfortable position.
2. Place a waterproof barrier–backed
   absorbent pad across the patient’s
   neck and shoulder, on the side of the
   affected ear.
3. Fill the large syringe with body
   temperature water.
4. Have the patient or an assistant hold a
   basin under the affected ear to collect
   the fluid during irrigation unless using
   an ear wash system with suction built in.
5. Place the syringe tip (you also may attach
   an 18-gauge intravenous catheter or
   butterfly catheter tubing to the syringe)
   into the lateral canal (Fig. 32-4).
6. Irrigate, targeting the superior canal
   surface, allowing the fluid to flow behind
   the impaction and pushing it toward the
   canal orifice.
7. The canal and tympanic membrane
   should be inspected frequently during
   the procedure for injury or rupture.
8. Repeat as needed until the impaction is
   removed or the patient voices pain.
9. If irrigation is not successful, manual
   removal with a cerumen spoon may be
   attempted. This is generally more
   uncomfortable for the patient.
10. Using the otoscope to visualize the
    cerumen, place the cerumen spoon into
    the canal. Your aim is to put the spoon
    at one edge of the impaction and pull it
    distally. It is vital the patient remain still
    during this maneuver to prevent
    tympanic membrane rupture or abrasion
    of the canal.
11. If the cerumen does not dislodge easily,
    reattempt irrigation after inspection.
    Frequently the manual attempt loosens
    the impaction, allowing irrigation to be
    successful.
12. After the cerumen is removed, a final
    inspection of the canal and tympanic
    membrane is mandated.

Question 13

How is a FB removed?

Answer 13

1. After confirming the presence of a foreign
   body with an otoscopic exam, place the
   patient in a comfortable position.
2. The foreign body type drives the approach
   for removal. Irrigation is not an option
   for absorbent material (e.g., beans).
3. If a live insect is present, warm oil or
   lidocaine may be dropped into the canal
   to immobilize or kill the insect Lidocaine may also provide an
   anesthetic effect.
4. Insert the cerumen loop or right-angle
   hook into the canal through the otoscope.
   Caution: Do not make a blind insertion.
5. Aim the instrument at the superior edge
   of the foreign body, sliding it behind and
   then pulling the material toward the
   external orifice.
6. Alligator forceps are useful for items that
   are soft and easily grasped (e.g., cotton).
7. Round material (e.g., beads) are
   removed more easily with cup-shaped
   forceps to prevent movement of the
   body toward the tympanic membrane.
8. If suction is available, a small-diameter
   suction tip may be placed against the
   object for removal.
9. Metal objects may be removed with a
   magnet (Hall, 2003).
10. Skilled clinicians have used cyanoacrylate
    glue (super glue) applied to the wooden
    end of a cotton swab. Insert the wooden
    tip into the canal, placing it against the
    foreign body until the glue dries, and
    then withdraw the swab and foreign body
    together.
11. After the foreign body is removed, a final
    inspection of the canal and tympanic
    membrane is mandated to evaluate for
    canal or tympanic membrane damage.

Question 14

What are the special considerations for the procedure?

Answer 14

1. Any infection should be treated promptly, but the tympanic membrane
   may appear slightly erythematous immediately following irrigation.
2. There are commercial ear irrigation systems available that provide
   irrigation with simultaneous suction.
3. Home dental irrigation units have been used but are not recommended.
   A. The narrow irrigation stream may cause a tympanic membrane rupture.
   B. Backsplash is also increased with these units.

Question 15

What is the follow-up care for cerumen/fb removal?

Answer 15

1. If tympanic membrane rupture occurs, otolaryngologist evaluation
   should be scheduled within 1 to 2 weeks; treat for pain and provide
   reassurance (Tintinalli, 2004).
2. To decrease the risk of development of resultant otitis externa, dry the
   auditory canal after the irrigation by placing 2 or 3 drops of isopropyl
   alcohol into the canal (in the absence of tympanic membrane
   perforation) or using a warm blow dryer on a low setting (Jacker, 2005).
3. If the patient had decreased hearing due to cerumen impaction,
   improved hearing is usually noted immediately following removal of the
   cerumen.
4. The patient should be instructed to report any signs or symptoms of
   infection to the clinician as soon as they are noted. These include, but
   are not limited to, localized pain, erythema, and swelling.