Ear wax, or cerumen is a naturally occurring lubricant, is somewhat water repellent, and has antimicrobial activity; therefore it is a protectant of the external auditory canal. Cerumen is produced by ceruminous glands in the lateral two-thirds of the external auditory canal and pilosebaceous glands at the roots of hairs, and is mixed with sloughed squamous epithelial cells.
There are two common forms of ear wax. The predominant form is a wet, sticky, honey-colored wax that can darken. A dry, scaly form also occurs in some patients. Normally cerumen is carried from inside the canal to outside by tiny cilia, an activity that is enhanced by chewing movements. At Dr Joel’s ENT clinic, one of the best ENT clinics in Trivandrum, we commonly see patients presenting with symptoms like decreased hearing, tinnitus, vertigo, infection, or a sensation of increased pressure. The hearing loss is usually quite sudden when the cerumen seals off the canal; it is often described by the patient as a “blocked ear.” Asymptomatic cerumen buildup does not require removal; in fact, most people do not need a regular schedule for prevention of ear wax.
Accumulation is common in elderly patients, and in patients working in dusty environments. At our ENT clinic, we often see patients who often do a poor job of removing cerumen with cotton-tipped swabs, other instruments, or over-the-counter preparations, leaving the clinician to complete the procedure. In fact, overzealous use of these applicators frequently disrupts the natural ciliary cleaning process. At our ENT clinic, ENT specialists have had to treat patients who even presented with otitis externa (or infection of the ears of the outer ear), following failed attempts at wax removal themselves.
For removal by the clinician, topical anesthesia may be desired; foreign bodies may also need to be removed. The overall goal of this procedure is to remove cerumen under direct visualization or by irrigation without causing injury. The risk of injury is not to be taken lightly because ear irrigation is one of the more common causes of iatrogenic injuries treated by otolaryngologists. There is some data that mere use of a ceruminolytic on a regular basis may also prevent cerumen impaction.
While using ceruminolytic drops appears better than no treatment (drops prior to irrigation may improve success rate by as much as 97%), there is a lack of evidence regarding which ceruminolytic is superior. Hydrogen peroxide is commonly used, but has not been studied extensively. The liquid stool softener docusate sodium in some studies was more effective than commercially available ceruminolytics. A 5% or 10% solution of sodium bicarbonate was also found to be more effective than commercially prepared ceruminolytics. (The sodium bicarbonate solution can be made at home by dissolving ¼ teaspoon sodium bicarbonate [baking soda] in 10 mL of water.) Triethanolamine is one available commercial preparation. Olive oil has also been used to some effect. If nothing else is available, even water or saline are effective at cerumen softening and disintegration.
Indications for wax removal:
- Tympanic membrane or ear canal obscured by cerumen with otologic complaint
- Patient complaint of decreased hearing (“blocked ear”), fullness, itching, odor, discharge, otalgia, tinnitus, vertigo, reflex cough, unsteady gait associated with cerumen, or problems with hearing aid (cerumen can damage hearing aids or cause feedback sound)
- External otitis associated with cerumen (the ear should be dried meticulously after the procedure)
- Tympanic membrane or ear canal obscured by cerumen and clinician needs to examine or patient needs hearing tested
- Patient with cerumen buildup who may not be able to complain about symptoms such as young children or cognitively impaired individuals
- Uncooperative patient or infant who cannot be adequately restrained.
- Clinician unfamiliar with or unable to define anatomy of the external auditory canal.
- Patient with distorted anatomy (e.g., prior or current injury obscuring normal anatomy, neoplasm of ear canal), although this is a relative contraindication.
- Previous ear surgery with resultant scarring, tympanoplasty/myringoplasty, or radiation therapy to the head and neck, both resulting in increased risk of perforation (relative contraindication).
- Known or suspected cholesteatoma.
- The affected ear is the only hearing ear (relative contraindication, but referral should be considered).
- Consideration should be made to refer patients with diabetes, an immunocompromised state, or on anticoagulation therapy or with a coagulopathy who also have any of the other contraindications listed above.
- For irrigation, acute otitis media, known/suspected perforation of the tympanic membrane, or presence of tympanostomy tube is a contraindication. In these situations, the curette or suction catheter should be used under direct visualization.
Curette or Suction Technique
A curette is usually the fastest way to remove cerumen and may be preferred for small amounts of easily visible and reachable wax. It is also usually the easiest method for children, who may find it difficult to remain still for suction or irrigation. In adults, suction can be used for deeper or slightly more adherent impactions. Suction works best for multiple tiny fragments or for soft cerumen; it often fails when there is a single, hard, irregular, and impacted cerumen plug. Young children are often frightened by the noise suction makes. For children and adults, irrigation will be necessary for dense, adherent, or circumferential impactions.
The irrigation technique takes longer than the curette or suction technique. However, irrigation rarely fails; it is also the safest technique. While irrigation is the technique used most often by nonotolaryngologists, it is often used when other techniques have failed or caused pain.
• Tympanic membrane perforation and damage to ossicles with possible hearing loss
• Otitis externa
• Vertigo or nausea and vomiting
• Minor canal wall abrasions—as mentioned earlier, some bleeding may occur if hard wax is adherent to the epithelium and causes desquamation with removal (if noted, antibiotic otic drops should be used for a few days)
Postprocedure Patient Education
Instruct the patient to contact the clinician’s office for fever or vertigo or for decreased hearing, purulent drainage, or pain in the affected ear. Slight bleeding from the affected ear may be expected if the skin was disrupted. Diabetic and other immunocompromised patients should be especially observant for signs of infection because they are prone to development of malignant otitis externa (often due to Pseudomonas ), with its resultant high morbidity and mortality rates.
Inform patients with recurring cerumen impactions, unless contraindicated, to perform monthly or bimonthly ear cleansing using hydrogen peroxide, docusate sodium, 5% to 10% sodium bicarbonate (mixed as previously described in Equipment section), a commercial ceruminolytic, or distilled water as an irrigant from a squeeze bulb ear syringe (similar to nasal bulb syringe used in newborns; both are available at local pharmacies). Advise the patient to avoid self-instrumentation of the ear canal with cotton-tipped applicators or any other instrument. It may be helpful to explain that cotton-tipped applicators or other instruments often disrupt the cilia and other natural ear cleansing mechanisms, even causing an accumulation of cerumen. Cotton-tipped applicators should be used only on the external ear and never inserted into the canal. Another option is the instillation of two to three drops of mineral oil, pure vegetable oil, or liquid docusate sodium every couple of weeks in the ear canal to soften the wax (these are contraindicated with suspected perforation). Again, there is no consistent evidence that one ceruminolytic is better than another. Patients who use hair spray should cover the ears when spraying to avoid hardening the cerumen.
For painless wax removal, book an appointment at Dr Joel’s ENT clinic, the best ENT clinic in Trivandrum