(Cerumen and Cerumen Impaction Physiology: Cerumen (“earwax’) is produced by the cerumen and sebaceous glands in the skin of the ear canal. Itforms a protective film in which fatty acids, ly- sozymes, and the creation of an acid milieu protect the skin of the ear canal. Self-cleansing of the ar canal, with natural removal of accumulated ceru- sens normally accomplished by epithelia migration from ‘th ‘the tympanic membrane toward the external Pathophysiology: Cerumen impaction may result from a disturbance of the normal self-cleansing mechanism or from excessive cerumen secretion. The cerumen plug consists mainly of secretions from the cerumen glands mixed with sebum, exfoliative debris, and con- taminants, Imprudent cleaning of the ear canal (espe- cially with cotton-tipped swabs!) can interfere with the self-cleansing mechanism and displace the ceru- ‘men toward the tympanic membrane. Obstruction of the ear canal by cerumen may be caused by the impaction or swelling of a cerumen plug. This often occurs after contact with water. With ageing, drying of the meatal skin and changes in secre- ‘tions can lead to the formation ofa hard cerumen that tends to be retained in the ear, especially with a nar- row canal, Symptoms: Cerumen impaction causes a pressure sen- sation in the ear with concomitant hearing loss. Some Patients complain of vertigo or tinnitus. Diagnosis: With a cerumen impaction, otoscopy may show obstruction of the ear canal by a yellowish brown to black material, The consistency of the ceru- Obtained, Need econ hisiry shoul be Particular attention is given to tympanic membrane perforations and previous temporal bone fractures orotologic surgery. Differential diognosis: An epithelial plug or crust can result from a cholesteatoma in the external ear canal. Occasionally the ear canal is obstructed by a thin skin flap, or cuticle. Tumors, foreign bodies, and crusted blood should also be excluded. ‘Complications: Otitis extema may develop, but gener- ally complications are very rare. ‘Treatment: Cerumen and cerumen phigs are removed with a small instrument (hook, curette) or by aural ir- rigation. ‘Instrumental cleaning of the ear canal is best done ‘under stereoscopic vision by a specialist using an ‘otomicroscope, ‘The lagram shows a transverse section through the ear canal. ‘Thelrigation jt is diected posteriorly and superioy. ‘Technique of aural irrigation: Inrigation is contraindicated in patients with a pos~ itive otologic history (see above). + Hard cerumen can be softened by pretreatment with hydrogen peroxide, a glycerin-containing agent, or other detergents for several days. = Theearis irrigated with bacteriologically pure wa- terat 37°C using an ear syringe with a blunt cannu- la © The water jet is directed posterosuperiorly; it is not trained directly on the tympanic membrane (ig.105). = Irrigation should be followed by otoscopy and a linical hearing test (tuning fork test). ‘(Contraindications (referral to a specialist): = Positive otologic history (see above) = Single hearing ear affected '* Restless, uncooperative patient = Foreign body Prophylaxis: The best preventive measure is to avoid Improper cleaning of the ear canal, paicalty the regular use of cotton-tipped swabs.