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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 and no hygiene measures are recommended. Cerumen impaction is most often self-induced through ill-advised cleansing attempts by entering the canal itself, eg, digital trauma or use of a cotton-tip applicator. 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 otitis externa. 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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Horton  GA  et al. Cerumen management: an updated clinical review and evidence-based approach for primary care physicians. J Prim Care Community Health. 2020;11:2150132720904181.
[PubMed: 31994443]  

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 or mineral oil. Lidocaine should never be used in a patient with a possible tympanic membrane perforation as this may result in a profound vestibular response.

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Kim  KH  et al. Clinical characteristics of external auditory canal foreign bodies in children and adolescents. Ear Nose Throat J. 2020;99:648.
[PubMed: 31814447]  

3. OTITIS EXTERNA

ESSENTIALS OF DIAGNOSIS

  • Otalgia.

  • Erythema, edema, and purulence of the external auditory canal skin.

  • Diabetic or immunocompromised patients are at risk for “malignant” otitis externa (osteomyelitis of the skull base).

General Considerations

Otitis externa, often called “swimmer’s ear,” presents with otalgia with associated external auditory canal edema and purulent discharge. There is often a history of recent water exposure or mechanical trauma (eg, scratching, cotton applicators). Otitis externa is usually caused by gram-negative rods (eg, Pseudomonas, Proteus) or fungi (eg, Aspergillus), which grow in the presence of excessive ...

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