Cerumen is a naturally occurring substance produced in the cartilaginous portion of the external auditory meatus.
Excessive or occluding earwax is found in:
- 13% of Canadian adults (Feder et al., 2015)
- 11% of 20-39 year olds and 21% among 70-79 year olds (Feder et al., 2015)
- 17% of Canadian children and adolescents (Feder et al., 2016)
Symptoms of cerumen impaction include tinnitus, aural fullness, otalgia, cough, and hearing loss (Schwartz et al., 2017).
Cerumen management is the act of removing cerumen or ear wax from the external auditory canal. The presence of cerumen can impact various tests including otoscopy, immittance, audiometry, electrocochleography, auditory brainstem response, caloric testing, and real-ear measures (Schwartz et al., 2017). Cerumen can also impact earmold impressions, earmold fittings, and hearing aid fittings.
There are several techniques that can be used to remove cerumen. These techniques can be found in subsequent “Quick Guides”.
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Simulated Cerumen
What can be used to simulate cerumen?
Product
Qualities
Pros/Cons
Possible Uses
Playdough (Recommended by AHead)
-Very soft
-Hardened by exposing to air
-Homemade and store
bought options
-Inexpensive
-Irrigation
Sticky Tack
-Soft and pliable
-More structure than
playdough
-Commonly found in clinics
-Inexpensive
-Curette
-Irrigation
Banana
-Firmness depends on
ripeness
-Inexpensive
-Suction
-Irrigation
Slime
-Semi-liquid
-Homemade and store
bought options
-Fairly inexpensive
-May not always turn out in
homemade version
-Suction
-Irrigation
Pre-Made Cerumen
-Thin paste-like
consistency
-Pre-made
-Costly
-Shipping wait times
-Suction
-Irrigation
What can be used to simulate cerumen?
| Product | Qualities | Pros/Cons | Possible Uses |
|---|---|---|---|
| Playdough (Recommended by AHead) |
-Very soft -Hardened by exposing to air |
-Homemade and store
bought options -Inexpensive |
-Irrigation |
| Sticky Tack |
-Soft and pliable -More structure than playdough |
-Commonly found in clinics -Inexpensive |
-Curette -Irrigation |
| Banana | -Firmness depends on ripeness |
-Inexpensive |
-Suction -Irrigation |
| Slime | -Semi-liquid |
-Homemade and store
bought options -Fairly inexpensive -May not always turn out in homemade version |
-Suction -Irrigation |
| Pre-Made Cerumen | -Thin paste-like consistency |
-Pre-made -Costly -Shipping wait times |
-Suction -Irrigation |
Homemade Cerumen
Two Ingredient Play-Dough
-Recommended by AHead
Ingredients
- Corn starch
- Baby lotion OR hair conditioner OR dish soap
- Food coloring (optional)
Directions
In a bowl, mix the first two ingredients.
Experiment with portions; more cornstarch will make it more crumbly.
Optional: Add few drops of food coloring so it shows up better on the camera
Note: this will dissolve if used for irrigation
Two ingredient playdough with extra corn starch makes the consistency soft and crumbly
Soft Sticky Tack
Ingredients
- Sticky Tack
- Lotion OR foaming hand soap
Directions
Add a small amount of lotion or hand soap to the sticky tack and combine
Add more lotion to make the sticky tack softer and stretchy
Optional: Add beads or other elements to give texture
Sticky Tack Softened with Lotion
Cream of Wheat Added for Texture
Important Considerations Before You Begin
- Determine the best treatment option which may include a combination of the following:
- observation
- cerumenolytics
- manual removal
- irrigation
- medical referral
- Consider the risks. All techniques pose a risk to the patient especially when they are not used properly.
- Before you begin, it is important that you and your patient are positioned/seated comfortably.
Cerumen Management Methods
Manual Removal: Curette, Forceps, & Hook
| Advantages | Potential Risks/Drawbacks |
|---|---|
|
|
Proceed to the guide; Cerumen Management: Curette for more information.
Sticky tack with metal speculum and Bionix microloop curette
Manual Removal: Aural Suction
| Advantages | Potential Risks/Drawbacks |
|---|---|
|
|
Proceed to the guide; Cerumen Management: Suction for more information.
Irrigation
| Advantages | Potential Risks/Drawbacks |
|---|---|
|
|
Bionix otoclear spray wash basin
Proceed to the guide; Cerumen Management: Irrigation for more information.
Guide To
Curette
If you are new to cerumen management, make sure to review the lesson, Intro to Cerumen Management, for important background information
Step 1: Place simulated cerumen into CARL’s ear. Select a light source to conduct an ear examination and a curette, forceps, and/or hook based on the consistency and degree of cerumen impaction.
Step 2: For an adult, gently pull the pinna up and back to straighten the canal. Using the same hand as the ear you are assessing, carefully remove the cerumen while bracing one or two fingered against the cheek.
Note: If the wax is not occluding, place the tip of the curette into the opening and gently remove debris laterally. If the wax is occluding, try to create an opening by breaking off pieces of wax using a hook. During cerumen removal, you may need to switch to a different size or type of curette, or a different technique. It is important to avoid too much pressure and dragging the instrument along the canal wall as this would be uncomfortable/painful to a real patient.
Tip: A metal speculum can be used to focus light into the canal² and to improve accuracy.³ Don’t forget to check-in with your client to make sure they are still comfortable.
Step 3: Repeat procedure with next side. Document procedure, as outlined by your licensing body.
Step 4: Proceed to the next guide; Cerumen Management: Irrigation.
Guide To
Irrigation
If you are new to cerumen management, make sure to review the lesson, Intro to Cerumen Management, for important background information
Step 1: Place simulated cerumen into CARL’s ear and perform otoscopy.
Step 2: Place the basin directly under the ear and against the head. Put a towel under to absorb any spills.
Step 3: Place the tip of the irrigation tool into the ear and gently irrigate using warm water to prevent a caloric-reflex.
Note: Do not direct the stream at the eardrum and do not insert the tip too far so, that the water may drain out properly and to prevent pressure from building up.
Step 4: Check progress every 20-30 seconds³ using otoscopy and continue to assess whether an alternative technique/approach is required.
Tip: Don’t forget to check-in with your client to make sure they are still comfortable.
Step 5: Repeat the procedure with the next side.
Step 6: Document the procedure as outlined by your licensing body.
Step 7: Proceed to the next guide; Cerumen Management: Suction.
Guide To
Suction
If you are new to cerumen management, make sure to review the lesson, Intro to Cerumen Management, for important background information
Materials
- CARL
- CARL ears
- Illumination
- Simulated cerumen
- Suction machine and tips with thumb valve (i.e. Baron size 5 Fr)
- Warm water to unclog instrument
Consent
Prior to engaging in any procedure, you must obtain informed consent from the client. For more information, consult with your licensing body.¹
Step 1: Place simulated cerumen into CARL’s ear and perform otoscopy using a preferred light source.
Note: Suction is best for very soft or semi-liquid cerumen and small pieces.
Tip: A metal speculum can be used to focus light into the canal² and to improve accuracy.³
Step 2: Inform client that the suction pump is noisy and will make squeaky noises as the wax is suctioned out.
Step 3: Insert suction tip with the valve uncovered.
Step 4: Carefully contact the piece of cerumen and cover the thumb valve to initiate suctioning.
Note: Do not come into contact with the canal wall as this would be uncomfortable to an actual patient. Don’t forget to check in with your client to make sure they are still comfortable. Continue to assess whether an alternative technique/ approach is required.
Step 5: Repeat procedure with next side.
Step 6: Document procedure, as outlined by your licensing body.
Step 7: Proceed to the next guide; Cerumen Management: Case Studies.
Resources
For review of the Cerumen Management Equipment used in this example visit:
Bionix:
https://bionix.com/products/frontline-care/ear-care.html
Other unique Cerumen Management tools:
These Tools used on CARL:
Earigator used on CARL
References
Feder, K., Michaud, D., McNamee, J., Fitzpatrick, E., Ramage-Morin, P., & Beauregard, Y. (2016). Prevalence of hearing loss among a representative sample of Canadian children and adolescents 3 to 19 years of age. Ear & Hearing, 38(1), 7-20.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5181131/pdf/aud-38-007.pdf
Feder, K., Michaud, D., Ramage-Morin, P., McNamee, J., & Beauregard, Y. (2015). Prevalence of hearing loss among Canadians aged 20 to 79: Audiometric results from the 2012/201 Canadian health measures survey. Health Reports vol. 26, no.7. Statistics Canada Catalogue no. 82-003. p. 18-25. https://www150.statcan.gc.ca/n1/en/pub/82-003-x/2015007/article/14206-eng.pdf?st=6rE6qz66
McCarter, D.F., Courtney, A.U., & Pollart, S.M. (2007). Cerumen Impaction. American Family Physician, 75(10), 1523-1528. https://www.aafp.org/afp/2007/0515/afp20070515p1523.pdf
Schwartz, S. R., Magit, A. E., Rosenfeld, R. M., Ballachanda, B. B., Hackell, J. M., Krouse, H. J., Lawlor, C. M., Lin, K., Parham, K., Stutz, D. R., Walsh, S., Woodson, E. A., Yanagisawa, K., & Cunningham, E. R. (2017). Clinical practice guideline (update): Earwax (cerumen impaction). Otolaryngology–Head and Neck Surgery, 156(1_suppl), S1–S29.
https://doi.org/10.1177/0194599816671491
¹Obtaining consent by the College of Audiologists and Speech-Language Pathologists (CASLPO) http://www.caslpo.com/sites/default/uploads/files/GU_EN_Obtaining_Consent_for_Services.pdf
² Purdy, J. (2002). Managing Cerumen. https://www.audiologyonline.cm/articles/managing-cerumen-1159
³Wilson, P.L. & Roeser, R.J. (1997). Cerumen management: Professional issues and techniques. Journal of the American Academy of Audiology, 8, 412-430.