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An 80 year old patient presents to clinic with complaints of markedly impaired hearing, made worse after attempting to clean out his ears with a Q-tip the prior week.He states that soundsseem dull and distant, and that he cannot differentiate speech well in a crowded restaurant.Clinical exam reveals bilateral impaction of cerumen in the middle third of his external auditory canal.Which of the following is the next appropriate step?
A. Physician guided Q-tip cerumen removal
B. Recommendation for candling at home
C. Carbamide peroxide twice daily followed by irrigation
D. Direct irrigation with refrigerated saline
Annotated Answer: C. Carbamide peroxide twice daily followed by irrigation The same admonitions for patients using a Q-tip apply to providers. Any entry into the auditory canal should be done only under direct visualization. Candling is a homeopathic remedy based on the notion that a candle will melt cerumen and create a wicking action. Direct saline irrigation may be difficult if the cerumen is impacted and not amenable to breakup. Refrigerated saline would just induce a cold calorics test for nystagmus.
Which of the following is associated with a reduced incidence of cerumen impaction?
A. Cotton tip applicator manipulation
B. Wide canals
C. Hair in the lateral canal
D. Hearing aid or earplug use
Annotated Answer: B. wide canals. Cerumen tends to thicken with age. Narrow external ear canals predispose to cerumen impaction and the increase in lateral canal hair also increases the difficulty in natural drainage and cerumen migration. Manipulation, directly with applicators, or indirectly through repeated use of earplugs or hearing aides, will force the cerumen further into the canal.
Use of cerumenolytic agents is most reasonable in which patient?
A. 40 year old with tympanostomy tubes and impacted overlying cerumen
B. 50 year old with tympanic membrane barotrauma and occlusive cerumen
C. 70 year old with cerumen directly impacting the tympanic membrane
D. 80 year old with burrowing insect in the ear canal
Annotated Answer C. c. 70 year old with cerumen directly impacting the tympanic membrane. As long as the tympanic membrane is intact, cerumenolytic agents are reasonable choices. Perforation is a contraindication, and insects should first be drowned with mineral oil before attempting removal or irrigation. When in doubt, consult an otolaryngologist or cerumen removal clinic.