Indications for referral to a specialist:
(1) persistent severe pain during conservative attempts at cerumen removal (see below)
(2) vertigo during irrigation with water kept at body temperature (may indicate a perforation of the oval window or a perilymphatic fistula)
(3) swollen or edematous ear canal
(4) unusual anatomy for the external ear canal
(5) history of tympanic membrane perforation
(6) history of radiation therapy to the region
(7) history of ear surgery
(8) hearing deficit after cerumen has been removed
If severe pain is encountered during the first attempt at cerumen removal:
(1) Discontinue the removal attempt.
(2) Lubricate the canal with olive oil for a few days.
(3) Attempt the cerumen removal again.
(4) If severe pain occurs, then discontinue the removal attempt and refer the patient to a specialist.
Additional reasons for referral:
(1) presence of pus
(2) presence of unexplained bleeding
