Can you provide a procedure note for mechanical removal of a dense cerumen impaction in a 45‑55‑year‑old adult presenting with unilateral hearing loss and ear fullness, with an intact tympanic membrane and no history of chronic otitis media, recent ear surgery, or bleeding disorders?

Procedure Note for Mechanical Removal of Cerumen Impaction

Pre-Procedure Documentation

Document the following elements before beginning the procedure:

• Indication for removal: Cerumen impaction causing unilateral hearing loss and ear fullness, preventing adequate examination of the tympanic membrane 1
• Laterality: Specify which ear (right or left) 1
• Pre-procedure otoscopic findings: Dense cerumen impaction with [complete/partial] occlusion of the external auditory canal; tympanic membrane not visualized due to cerumen 1
• Modifying factors assessed: Intact tympanic membrane confirmed by history (no prior perforation, no tympanostomy tubes, no recent ear surgery), no diabetes mellitus, no immunocompromised state, no anticoagulant therapy, no bleeding disorders 1, 2
• Patient symptoms: Hearing loss, ear fullness [document any additional symptoms such as tinnitus, pain, or dizziness if present] 1

Procedure Details

Equipment and technique used:

• Visualization method: Direct otoscopy with handheld otoscope [or binocular microscope if available—microscopy has ~90% success rates with no reported canal trauma in studies] 1
• Instruments employed: Cerumen curette [and/or alligator forceps, right-angle hook, or microsuction as applicable] 1, 3
• Technique: Manual removal under direct visualization using [specific instrument], with gentle traction to extract cerumen fragments without contacting canal walls 1
• Patient positioning: Seated upright with head tilted away from affected ear 1
• Anesthesia/preparation: None required [or document if cerumenolytic pretreatment was used] 1, 2

Intra-Procedure Findings and Events

• Cerumen characteristics: Dense, impacted cerumen [describe color, consistency] 1
• Complications during procedure: None [or document any bleeding, pain, dizziness, or canal trauma if occurred] 1
• Patient tolerance: Procedure well-tolerated without significant discomfort 1

Post-Procedure Assessment

Two critical assessments must be documented for patient safety and medicolegal purposes 1:

1. Otoscopic Re-Examination

• Post-removal visualization: External auditory canal now clear of cerumen; tympanic membrane fully visualized and appears intact with normal landmarks [describe tympanic membrane appearance: pearly gray, light reflex present, no perforation, no effusion] 1
• Complications from removal: No evidence of otitis externa, bleeding, canal laceration, or tympanic membrane perforation 1

2. Symptom Resolution Assessment

• Hearing: Patient reports immediate improvement in hearing [or document if hearing loss persists] 1
• Ear fullness: Resolved 1
• Other symptoms: [Document resolution or persistence of any presenting symptoms] 1

Clinical Decision-Making

The impaction is considered resolved when both criteria are met 1:

1. The clinician can adequately examine the ear and tympanic membrane without cerumen interference 1
2. Associated symptoms have resolved 1

If symptoms persist despite complete cerumen removal, alternative diagnoses must be considered: sensorineural hearing loss, serous otitis media, otosclerosis, cholesteatoma, eustachian tube dysfunction, or other middle ear pathology 1. In this case, further audiometric evaluation or ENT referral would be warranted 1, 4.

Post-Procedure Instructions

• Ear care: Avoid cotton-tipped swabs in the ear canal 4, 2
• Follow-up: Return if symptoms recur or new symptoms develop 1
• Prevention counseling: [Document any patient education provided regarding cerumen management] 1

Procedure Outcome

• Success: Complete removal of cerumen impaction achieved with resolution of symptoms and full visualization of tympanic membrane 1
• Complications: None 1
• Disposition: Patient discharged with above instructions 1

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Common pitfalls to avoid in documentation:

• Never omit the post-procedure otoscopic examination—this is essential for medicolegal protection, as complications including tympanic membrane perforation, bleeding, and canal trauma can occur even with careful technique 1
• Always document symptom resolution or persistence—if hearing loss persists after confirmed cerumen removal, this indicates an alternative diagnosis requiring further workup 1
• Document modifying factors assessed—failure to identify contraindications like tympanic membrane perforation could lead to inappropriate treatment selection 1, 2