Cerumen Removal Procedure Note

Date: [Date and time per local policy]

Patient: [Patient name and identifiers per local policy]

Clinician: [Clinician name and credentials]

Setting: [office / urgent care / ED / other]

Procedure Performed

Procedure: Cerumen removal
Laterality: [right / left / bilateral] (If laterality unclear, state "Laterality unclear—clarification required.")
Primary approach: [irrigation/lavage / manual instrumentation (curette, suction, forceps) / combined approach] (If bilateral with different approaches, specify per ear below.)

Indication

(Document at least one clinical rationale.)

• [Symptoms attributable to cerumen: decreased hearing / fullness / otalgia / tinnitus / vertigo] (Include duration/severity if provided; brief patient quote acceptable.)
• [Cerumen obstructing visualization of tympanic membrane or external auditory canal required for clinical evaluation]
• [Need for audiologic/vestibular testing or hearing aid assessment]
• [Denies symptoms] or [Removal required for adequate examination] (Use if asymptomatic.)

Pre-procedure Assessment

(Include only treated ear(s). TM visualization status required for each.)

Right ear

• Relevant modifying factors: [suspected non-intact TM / prior tubes or ear surgery / otorrhea / pain with water entry / canal stenosis or exostoses / dermatitis / suspected infection or inflammation / anticoagulation / diabetes or immunocompromise / cooperation concerns] (Omit line entirely if none present.)
• Otoscopic exam: [Cerumen amount: scant / moderate / copious]; [Character: soft / dry / hard]; [Impacted/obstructive: yes / no]. [EAC abnormalities if present: erythema / edema / abrasion]. TM status: [TM visualized—intact / tube present / abnormalities noted / TM partially visualized / TM not visualized due to cerumen obstruction] (Never leave blank; if not visible, state reason.)

Left ear

• Relevant modifying factors: [suspected non-intact TM / prior tubes or ear surgery / otorrhea / pain with water entry / canal stenosis or exostoses / dermatitis / suspected infection or inflammation / anticoagulation / diabetes or immunocompromise / cooperation concerns] (Omit line entirely if none present.)
• Otoscopic exam: [Cerumen amount: scant / moderate / copious]; [Character: soft / dry / hard]; [Impacted/obstructive: yes / no]. [EAC abnormalities if present: erythema / edema / abrasion]. TM status: [TM visualized—intact / tube present / abnormalities noted / TM partially visualized / TM not visualized due to cerumen obstruction] (Never leave blank; if not visible, state reason.)

(Delete untreated ear subsection.)

Consent

[Verbal / Written] consent obtained after discussion of risks, benefits, and alternatives. Risks discussed included canal abrasion or bleeding, pain, dizziness/vertigo, otitis externa, incomplete removal requiring repeat treatment, and rare tympanic membrane injury. Alternatives discussed included watchful waiting, cerumenolytic drops, and ENT referral.

Technique

(Include only treated ear(s). Document volume/attempts only if prolonged, complicated, or incomplete.)

Right ear

• Positioning/visualization: [Patient position]; [otoscope / microscopy]
• Cerumenolytic: [Agent] with dwell time [duration] (Include only if applied.)
• Irrigation: [water / saline] at body temperature via [syringe / electronic irrigator]; [approach description] (Include only if performed.)
• Instrumentation: [curette / suction / forceps] under direct visualization (Include only if performed.)
• Combined approach: [Sequence, e.g., irrigation to loosen, then curette for residual] (Include only if applicable.)
• Tolerance: [well tolerated / mild discomfort / limited by pain / dizziness / anxiety / movement]

Left ear

• Positioning/visualization: [Patient position]; [otoscope / microscopy]
• Cerumenolytic: [Agent] with dwell time [duration] (Include only if applied.)
• Irrigation: [water / saline] at body temperature via [syringe / electronic irrigator]; [approach description] (Include only if performed.)
• Instrumentation: [curette / suction / forceps] under direct visualization (Include only if performed.)
• Combined approach: [Sequence, e.g., irrigation to loosen, then curette for residual] (Include only if applicable.)
• Tolerance: [well tolerated / mild discomfort / limited by pain / dizziness / anxiety / movement]

(Delete untreated ear subsection.)

Results

(Include only treated ear(s). Post-procedure TM status required.)

Right ear

• Post-procedure otoscopic exam: Removal [complete / partial]. (If partial: due to [patient discomfort / canal edema / hard wax]; plan: [describe].) EAC: [clear / mild erythema / abrasion / retained moisture]. TM status: [TM now visualized—intact, no perforation / tube present / abnormalities noted / TM still not visualized—reason] (Never leave blank.)
• Symptom response: [Improved hearing / improved fullness / unchanged / not assessed]

Left ear

• Post-procedure otoscopic exam: Removal [complete / partial]. (If partial: due to [patient discomfort / canal edema / hard wax]; plan: [describe].) EAC: [clear / mild erythema / abrasion / retained moisture]. TM status: [TM now visualized—intact, no perforation / tube present / abnormalities noted / TM still not visualized—reason] (Never leave blank.)
• Symptom response: [Improved hearing / improved fullness / unchanged / not assessed]

(Delete untreated ear subsection.)

Tolerance / Complications

Overall tolerance: [well tolerated / limited by pain / dizziness / anxiety / movement]
Complications: [No immediate complications] (If present, specify: [canal abrasion or bleeding—hemostasis with (method) / suspected TM injury / vertigo or nausea / vasovagal symptoms / new concern for otitis externa]. Always include explicit statement even if none.)

Aftercare / Plan

• Counseling: Advised to avoid inserting objects (including cotton swabs) into ear canal; avoid ear candling. [Keep ear dry for (timeframe)] (Include if moisture exposure or canal trauma occurred.)
• Return precautions: Instructed to return for worsening pain, bleeding, drainage, fever, persistent hearing loss, or severe dizziness.
• Follow-up: [Return as needed / Scheduled recheck (timeframe) / Cerumenolytic course at home with recheck / ENT referral for (failed removal / anatomic difficulty / suspected perforation / need for sedation or microscopy)]
• Medications prescribed: [Medication name] — [dose] — [frequency] — [duration] (Omit line if none prescribed.)