Most of the visits any good ENT doctor or clinic is ear wax. Some parents are even scared when they bring children to our ENT hospital, and say that the ear is discharging and that the child has an infection in the ear. I once had the experience of parents coming in a panicked state stating that an ayurvedic physician (an alternate medicine practitioner) had diagnosed some kind of necrosing infection in the 11 year old child’s ear, and that he said that even surgery is required for the condition. It was only ear wax (cerumen).
Ear wax or cerumen is a combination of secretions from the outer ear canal, and dead cells from the canal. The ear canal has a self cleaning property, and cerumen is gradually pushed towards the external meatus. Cerumen impaction is the symptomatic accumulation of cerumen in the external canal or an accumulation that prevents a needed assessment of the ear. In patients who present to our ENT clinic at Trivandrum, the symptoms may include hearing loss, tinnitus, pruritus, fullness, otalgia, cough, odor, and dizziness. Impaction often results from instrumentation with cotton-tipped applicators (ear buds) by patients on their own, which should be discouraged. Elderly patients with changes to external canal epithelium, patients with external canal abnormalities (e.g., osteomas, exostoses, stenosis), and users of hearing aids and earplugs are also at risk for impaction. Excessive cerumen production as a primary problem is a relatively common condition at our ENT hospital.
In most people, cleaning the external meatus with a finger in a washcloth while bathing is sufficient to maintain the ear canals. Treatment of cerumen impaction by the clinician may involve ceruminolytic agents, irrigation, or manual removal. Ceruminolytic agents include water-based; oil-based; and non–water-, non–oil-based solutions. A Cochrane review found that any type of ear drop (including water and saline) is more effective than no treatment, but the study quality was lacking. Office irrigations may be performed using a large syringe with a large angiocatheter tip. The type of irrigant solution used is probably not critical, although a tepid or warm temperature is important to prevent the patient from becoming vertiginous from a labyrinthine caloric response. Instilling a ceruminolytic 15 minutes before irrigation may improve the success rate. Irrigations should not be performed in those with tympanic membrane perforations or previous ear surgery. Of note, irrigation with tap water has been implicated as a causative factor in malignant otitis externa. Therefore, instilling an acidifying ear drop after irrigation in patients with diabetes is recommended. Manual removal requires knowledge of ear anatomy and special care to avoid trauma. A handheld otoscope with a curette and other instruments may be used. Otolaryngologists often use binocular microscopy to aid with visualization. Patients inquiring about ear candling should be informed that it has not been shown to be effective and presents a risk of thermal injury to the ear.
At our ENT clinic at Trivandrum, we use a microscope and suction carefully to aid in painless wax removal.