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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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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.

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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. 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) or fungi (eg, Aspergillus), which grow in the presence of excessive moisture. In diabetic or immunocompromised patients, persistent external otitis may evolve into osteomyelitis of the skull base (so-called malignant external otitis). Usually caused by Pseudomonas aeruginosa, osteomyelitis begins ...

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