Use of jet irrigators designed for cleaning teeth (eg, WaterPik) for wax removal should be avoided since they may result in tympanic membrane perforations. Following irrigation, the ear canal should be thoroughly dried (eg, by instilling isopropyl alcohol or using a hair blow drier on low-power setting) to reduce the likelihood of inducing external otitis. Specialty referral for cleaning under microscopic guidance is indicated when the impaction has not responded to routine measures or if the patient has a history of chronic otitis media or tympanic membrane perforation.

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.

External otitis presents with otalgia, frequently accompanied by pruritus and purulent discharge. There is often a history of recent water exposure 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.

Examination reveals erythema and edema of the ear canal skin, often with a purulent exudate. Manipulation of the auricle often elicits pain. Because the lateral surface of the tympanic membrane is ear canal skin, it is often erythematous. However, in contrast to acute otitis media, it moves normally with pneumatic otoscopy. When the canal skin is very edematous, it may be impossible to visualize the tympanic membrane. Fundamental to the treatment of external otitis is protection of the ear from additional moisture and avoidance of further mechanical injury by scratching. Otic drops containing a mixture of aminoglycoside antibiotic and anti-inflammatory corticosteroid in an acid vehicle are generally very effective (eg, neomycin sulfate, polymyxin B sulfate, and hydrocortisone). Purulent debris filling the ear canal should be gently removed to permit entry of the topical medication. Drops should be used abundantly (5 or more drops three or four times a day) to penetrate the depths of the canal. When substantial edema of the canal wall prevents entry of drops into the ear canal, a wick is placed to facilitate entry of the medication.

dermatologic conditions such as seborrheic dermatitis and psoriasis, most cases are self-induced either from excoriation or by overly zealous ear cleaning. To permit regeneration of the protective cerumen blanket, patients should be instructed to avoid use of soap and water or cotton swabs in the ear canal. Patients with excessively dry canal skin may benefit from application of mineral oil, which helps to counteract dryness and repel moisture. When an inflammatory component is present, topical application of a corticosteroid (eg, 0.1% triamcinolone) may be beneficial. It is axiomatic in persistent pruritus that the patient must cease scratching the ear. In stubborn cases, the fingernails must be kept short and the patient may need to wear cotton gloves at night to avoid manipulation during sleep. Symptomatic reduction of pruritus may be obtained by use of oral antihistamines (eg, diphenhydramine, 25 mg orally at bedtime). Topical application of isopropyl alcohol promptly relieves ear canal pruritus in many patients.