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1. CERUMEN IMPACTION

Cerumen is a protective secretion produced by the outer portion of the ear canal. In most persons, the ear canal is self-cleansing. Recommended hygiene consists of cleaning the external opening only with a washcloth over the index finger. Cerumen impaction is most often self-induced through ill-advised cleansing attempts by entering the canal itself. It may be relieved by the patient using detergent ear drops (eg, 3% hydrogen peroxide; 6.5% carbamide peroxide) and irrigation, or by the clinician using mechanical removal, suction, or irrigation. Irrigation is performed with water at body temperature to avoid a vestibular caloric response. The stream should be directed at the posterior ear canal wall adjacent to the cerumen plug. Irrigation should be performed only when the tympanic membrane is known to be intact.

Use of jet irrigators (eg, WaterPik) should be avoided since they may result in tympanic membrane perforations. Following irrigation, the ear canal should be thoroughly dried (eg, by the patient using a hair blow-dryer on low-power setting or by the clinician instilling isopropyl alcohol) to reduce the likelihood of external otitis. Specialty referral is indicated if impaction is frequently recurrent, if it has not responded to routine measures, or if there is tympanic membrane perforation or chronic otitis media.

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Schwartz  SR  et al. Clinical Practice Guideline (Update): Earwax (cerumen impaction). Otolaryngol Head Neck Surg. 2017 Jan;156(1 Suppl):S1–29.
[PubMed: 28045591]

2. FOREIGN BODIES

Foreign bodies in the ear canal are more frequent in children than in adults. Firm materials may be removed with a loop or a hook, taking care not to displace the object medially toward the tympanic membrane; microscopic guidance is helpful. Aqueous irrigation should not be performed for organic foreign bodies (eg, beans, insects), because water may cause them to swell. Living insects are best immobilized before removal by filling the ear canal with lidocaine.

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Friedman  EM. Videos in clinical medicine. Removal of foreign bodies from the ear and nose. N Engl J Med. 2016 Feb 18;374(7):e7.
[PubMed: 26886547]
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Karimnejad  K  et al. External auditory canal foreign body extraction outcomes. Ann Otol Rhinol Laryngol. 2017 Nov;126(11):755–61.
[PubMed: 28954532]
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Shunyu  NB  et al. Ear, nose and throat foreign bodies removed under general anaesthesia: a retrospective study. J Clin Diagn Res. 2017 Feb;11(2):MC01–4.
[PubMed: 28384894]

3. EXTERNAL OTITIS

ESSENTIALS OF DIAGNOSIS

  • Painful erythema and edema of the ear canal skin.

  • Purulent exudate.

  • In diabetic or immunocompromised patients, osteomyelitis of the skull base (“malignant external otitis”) may occur.

General Considerations

External otitis presents with otalgia, frequently accompanied by pruritus and purulent discharge. There is often a history of recent water exposure (ie, swimmer’s ear) or mechanical trauma (eg, scratching, cotton applicators). External otitis is usually caused by gram-negative rods (eg, Pseudomonas, Proteus) ...

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