Cerumen Management

with CARL

How best can we help you?

Recommended Equipment & Set Up

  • Your CARL (Basic or Pro)
  • Durable Ears Recommended for Cerumen Management
  • Different CARL anatomies
  • Otoscope
  • Illumination of your Choosing
  • Various Curettes
  • Various Irrigation Equipment with Basin
  • Various Suction Pumps
  • Simulated Cerumen (see below)

Specific Specialized Equipment:

  • Bionix Various Ear Care Products (https://bionix.com/products/frontline-care/ear-care.html)
  • Earway Pro (https://earwaysmedical.com/earway-pro/)
  • Otoset (https://otoset.com/)
  • Earigator (https://nupurtech.com/)

To set up your CARL for Cerumen Management, position the CARL as you would a patient for the technique you will explore. Ensure CARL can be positioned at eye-level for a realistic simulation.

Both CARL mounts are available which offer variable height mounting for proper clinical technique.

If irrigation is being used on your CARL, please ensure all electronics and wires are neatly packed away. If you are performing irrigation on your CARL Pro, please ensure the Durable ears are installed on CARL, the ear has been checked so there's no leakages from previous procedures, and cords are tucked away appropriately.

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

Ahead Recommended

Two Ingredient Play-Dough

Easy to find, cheap to purchase play-dough. Mix with lotion to increase viscosity.

Two approaches - pick a colour that will be very obvious in the ear (ex. Blue play-dough if using CARL Basic Camera) or pick a colour that will blend in for added challenge (ex. yellow)

CARL Competency Checks

The following competency checks can be used as checkpoints / tasks for standardized training of Cerumen Management on CARL:

  1. Explanation of Procedure
  2. Identify conditions required for when cerumen management is needed (i.e. fully occlusion)
  3. Identify type of wax
  4. Identify ideal technique/tool of removal
  5. Preparation and infection control
  6. Softening of wax
  7. Irrigation technique
  8. Curette technique
  9. Suction technique
  10. When to identify referral routes

Click on the menu items below to jump ahead or go back to sections

Technique Walkthrough

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”.


Important Considerations Before You Begin

  1. Determine the best treatment option which may include a combination of the following:
    • observation
    • cerumenolytics
    • manual removal
    • irrigation
    • medical referral

  2. Consider the risks. All techniques pose a risk to the patient especially when they are not used properly.

  3. 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
  • Low-tech
  • Inexpensive
  • Effective
  • Convenient
  • Portable
  • Low space requirement
  • Acceptable for the use in patients that have certain modifying factors that preclude the administration of other techniques
    • May reduce risk of infection by not exposing the ear to moisture (McCarter et al., 2007)
  • Tympanic membrane perforation
  • Hearing loss
  • Otalgia
  • Injury to ear canal
    • Laceration
    • Bleeding
    • Pain/Discomfort

Utilizing CARL Basic Camera for sticky tack with metal speculum and Bionix microloop curette

Aural Suction

Advantages Potential Risks/Drawbacks
  • Effective
  • Portable option available
  • Acceptable for the use in patients that have certain modifying factors that preclude the administration of other techniques
    • May reduce risk of infection by not exposing the ear to moisture (McCarter et al., 2007)
  • Expensive
  • Maintenance
  • Bulky
  • Injury to ear canal
    • Laceration
    • Bleeding
  • Perforated tympanic membrane
  • Nystagmus and vertigo (Schwartz et al., 2017)
  • Loud noise
  • Sound may startle patient
  • Pain/Discomfort

Irrigation

Advantages Potential Risks/Drawbacks
  • Various options
    • Manual or electric versions
  • Various cost options
  • Effective
  • Convenient
  • Portable
  • Minimal space requirement
  • Limitations in patients that have certain modifying factors
  • Tympanic membrane perforation
  • Patient discomfort with water in ears
  • Hearing loss
  • Otalgia
  • Temporal bone osteomyelitis
  • Injury to ear canal
    • Laceration
    • Bleeding
    • Pain/Discomfort
  • Tinnitus
  • Otitis externa
  • Otitis media
  • Vertigo

Bionix otoclear spray wash basin

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

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.

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

Technique Walkthrough Printable PDF

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Experience from the CARL Community

CARL has been a game-changer for our program. From hands-on learning labs to capstone projects to enhanced clinical skills, we use our CARL every semester in so many different ways. Our students appreciate the opportunity to see and do, while learning key concepts for becoming best practice audiologists. With CARL we practice: earmold impressions, earmold insertion/removal, cerumen management, transducer placement, hearing aid verification, otoscopy, RECD, SREM, pediatric fittings, and so much more.  Every year we come up with more reasons to use CARL. He’s part of our Program Family! 

Lauren Felton
Washington University in St. Louis, USA

CARL has been an integral part of clinical training at the University of South Florida.  USF AuD students use CARL in their every semester as they learn to hold the otoscope and as they continue learning  how to take earmold impressions, perform probe mic measures, measure earmold tubing on a patient’s ears, and learn cerumen management techniques.  Having CARL is a way for students to comfortably practice skills and allows during learning labs for instructors and students to not always have to serve as the “test” ears.  We currently have 2 CARLs at USF and are always excited to know what AHead will develop next in the way of simulation learning tools.

Devon Weist
University of South Florida, USA

We have been working with Carl for over a year now. This is very useful for our audiology students because it allows them to practice real-ear measurements, ear impressions and cerumen extraction independently and safely. We also use Carl during practical exams, which provides a standardized testing condition for all our students. Carl is a very valuable addition to our lab!

Mathieu Hotton
Laval University, Canada

CARL is a game changer! Helped us to deliver and practice ear moulds impression and insertion, Real Ear Measurements and aural care. We can't wait to work with the next generation.

Giulio Speccia
South Devon College, UK

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