Cerumen Impaction Removal

Removal of cerumen (wax) from the ear forms a significant part of the workload of an otolaryngologist and is, therefore, an essential skill to master. ^{[1, 2]} However, general practitioners, emergency department staff, nurses, audiologists, audiological physicians, and alternative medicine practitioners may all be confronted with the scenario of excess ear wax that causes difficulty in examination, hearing loss, or discomfort. ^[3]

Cerumen impaction is defined as an accumulation of cerumen that causes symptoms, prevents assessment of the ear, or both. ^[4]

In an evaluation of 279 children with acute otitis media with effusion, ear wax needed to be removed to visualize the tympanic membrane in 29% of consultations. ^[5]

Many options are available to attempt to clear ear wax. These include the following:

Conservative approach

Advising the patient to avoid the use of cotton tip applicators for routine cleaning. Normal external ear canal skin will desquamate in such a way  that wax tends to be pushed to the outside. Regular “cleaning” with cotton tip applicators may be pushing wax deeper into the canal.

Wax-softening drops

A multitude of over-the-counter and commercially available products are sold. Opinion varies on which is the most effective. These products can usually be divided into wate- based (such as peroxide ear drops), oil-based  (such as olive oil), and non-water non-oil based (such as carbamide peroxide and glycerol-combination preparations). ^[6]

Wax-softening drops are intended to soften the wax over a period of hours to days. It is often prescribed for 2 weeks for maximal effect. The drops may be enough to clear obstruction as the ear canal skin will assist in pushing out the wax over time. However, these may also worsen the patient symptoms in the short term by converting a partial obstruction to a complete blockage. In these cases, mechanical wax removal under vision (micro-suctioning) or irrigation of the ear may need to be considered to improve symptoms.

Ear irrigation

This procedure involves the use of warm (ideally body temperature) water under pressure directed into the ear canal to mechanically remove the wax. While a seemingly simple procedure it has a significant risk of damaging the tympanic membrane (ear drum) and middle ear structures, which led to it being a common reason for litigation in general practice in the past. Pressure-controlled devices limit the risk but tympanic membranes vary in strength from patient to patient and the risk of damage remains. Ear irrigation should not be undertaken without undergoing specific training, taking a full otological history, otological examination, seeking informed consent from the patient, and with the correct pressure-limited instrumentation.

Mechanical wax removal under vision

This is typically done using an operating microscope with the patient awake. The operating microscope affords depth perception and allows accurate targeting of the wax. The wax may be removed with small suction tips (micro-suction), small forceps (called crocodile forceps), blunt instruments (for example, Jobson Horne Probes), or small cotton tip applicators.

Correct patient and care provider positioning is important and improves visualization of the external canal and tympanic membrane.

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The ear is composed of external, middle (tympanic cavity) (malleus, incus, and stapes), and inner (labyrinth) (semicircular canals, vestibule, cochlea) portions. The auricle and external acoustic meatus (or external auditory canal) compose the external ear. The external ear functions to collect and amplify sound, which then gets transmitted to the middle ear. The skin of the external ear canal is unique in that it exhibits directional desquamation or growth. This allows the normal external ear to be self-cleaning. If a dot of ink is placed on the tympanic membrane and the patient followed up over weeks the ink dot will be seen to move outwards and in a circular pattern.

The tympanic cavity (middle ear) extends from the tympanic membrane to the oval window and contains the bony conduction elements of the malleus, incus, and stapes. The primary functionality of the middle ear is that of bony conduction of sound via transference of sound waves in the air collected by the auricle to the fluid of the inner ear. The inner ear, also called the labyrinthine cavity, is essentially formed by the membranous labyrinth encased in the bony osseous labyrinth. The labyrinthine cavity functions to conduct sound to the central nervous system as well as to assist in balance.

For more information about the relevant anatomy, see Ear Anatomy.

Cerumen in the external ear canal is physiological.

Cerumen, commonly known as ear wax, is a hydrophobic protective covering in the ear canal. It acts to shield the skin of the external ear canal from water damage, infection, trauma, and foreign bodies. ^{[7, 4]}

Cerumen impaction is asymptomatic but in some circumstances it requires removal when causing symptoms or to facilitate ear examination.

Indications to address the cerumen include the following: ^{[8, 9, 6]}

• Difficulty in examining the full tympanic membrane
• Otitis externa
• Wax occlusion of the external ear canal
• As part of the workup for conductive hearing loss
• Prior to taking the impression for hearing aid fitting
• Suspected external ear canal or middle ear cholesteatoma
• Suspected external ear canal pathology such as squamous cell carcinoma or eczema
• As part of the follow-up of canal wall down mastoidectomy
• As part of grommet insertion or middle ear surgery (preoperatively, intraoperatively, or postoperatively)
• Itchy ears
• Reflex cough
• Patient hearing impaired or discomfort in the ear
• Foreign body removal, mainly in children
• Patient request

Specific contraindications exist for each specific procedure. Individual assessment should dictate which technique is the most appropriate ^[6] .

• Contraindications to irrigation include the presence or history of a perforated tympanic membrane, previous pain on irrigation, or previous surgery to the middle ear and in the presence of a discharge. In the case of a pediatric patient you will also need a cooperative patient and supportive parent.
• A relative contraindication to probing is the inability to visualize the ear canal.
• Relative contraindications to the use of visually directed micro-suction include severe previous exacerbation of tinnitus, very hard cerumen, and an uncooperative patient.
• Exceptional caution has to be used when clearing cerumen in patients who have undergone a mastoidectomy in the past, during which sensitive anatomical structures like the facial nerve and semicircular canals may have been exposed. 

Topical anesthetic drops have no documented benefits in ear wax removal.

Local anesthetic injections into the ear, although effective, are particularly painful and are therefore not used.

General anesthesia may be needed in some cases. For instance, special needs patients that are unable to comply may need to have a general anesthetic to allow cleaning of the ears.

The techniques used in cerumen removal include microsuction, mechanical removal, and irrigation. Instruments are shown in the image below.

Instruments for cerumen removal.

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Instrumentation needed for mechanical wax removal under vision including micro-suction includes the following:

• Operating microscope with focal distance of approximately 200 mm and magnification of 4-25 times. In certain situations (for instance a young child) a headlight or rigid endoscope may be more appropriate.
• Suction device capable of 300 mm Hg suction pressure, with a reservoir and built-in filter
• Suction tips, various sizes, including 16 and 18 gauge (ga)
• Aural specula, various sizes
• Crocodile forceps, various sizes
• Wax hooks/loops
• Jobson Horne probes, various sizes

Equipment needed for irrigation of the ear includes the following:

• Handheld otoscope to evaluate the ear before and after irrigation
• Lukewarm water (ideally 37 degrees Celsius). Water that is either too hot or cold may induce vertigo (dizziness) due to the stimulation of the semicircular canals.
• Kidney dishes
• Absorbent sheeting
• A pressure-controlled ear irrigation device with various sized attachments. Using a device that does not limit the water pressure greatly increases the risk of causing harm and the old metal syringe-type devices should not be used.

Patient positioning may vary according to individual clinician preference or may be dictated by anatomical limitations.

• Usually, the patient is semi-reclined. Although having the patient sitting upright saves positioning time, the attic region is difficult to access with the patient in this position.

• Positioning the patient supine with the head on a pillow simulates the operative view and allows good access to the external ear canal and tympanic membrane, including the attic. The supine position also aids patient stability. This is particularly beneficial if the patient experiences vertigo during the microsuction, as is often the case after mastoidectomy.

Patient positioning and room setup are shown in the images below.

Correct patient and care provider positioning is important and improves visualization of the external canal and tympanic membrane.

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Room setup for cerumen removal.

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Preparation and visual assessment

See the list below:

• Assemble and prepare all necessary equipment.

• Take time to explain the procedure to the patient and obtain consent.

• Connect suction tip and turn on the suction machine and microscope light.

• Position the patient’s head facing away from the operator, the neck flexed laterally and the shoulder pulled down.

• Examine the pinna, outer portions of the external canal, and the adjacent scalp for any evidence of previous surgery incision scars, signs of infection, or discharge.

• Inspect the outer ear canal opening, using the appropriate aural speculum, as shown below:

View through an aural speculum.

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See the list below:

• The speculum should be the largest size that fits. It should be placed deep enough to clear the hair-bearing skin but not deeper, as unnecessary pain may result.
• The speculum should be held with the first and second fingers. Use the other fingers to retract the pinna up and backward in an adult (retract the pinna up and downward in a child).

• Assess the cerumen. Gently probe with a blunt instrument such as Jobson Horne curette to determine whether the cerumen is soft, hard, or bony hard.

• Assess whether tympanic membrane is visible. Look for any air spaces around the cerumen.

• Before beginning the cerumen removal, ensure that the microscope and operator are optimally positioned. The microscope should be positioned to provide the optimal view of the ear canal, and the operator should be sitting comfortably and with a straight back.

Technique for mechanical wax removal

See the list below:

• If space permits, use an instrument to remove the wax. A ring probe (Jobson Horne curette) may be used to scoop the wax out; experienced practitioners may prefer to use a wax hook. If the cerumen is of a harder consistency, attempt to push the wax away from the ear canal walls toward the middle and then pull it out with a crocodile forceps.

• If the wax is occlusive, use the large-bore suction (16 or 18 ga) device to remove the wax piecemeal. As soon as the hair-bearing skin is passed, downsize the suction device to 20 ga or larger. As experience grows, one develops a sense of the depth of the tympanic membrane, which allows for safe use of the large-bore sucker closer to the tympanic membrane. But suctioning on the tympanic membrane with a large-bore risks causing a perforation and significant discomfort to the patient and should be avoided.

• Once the cerumen is cleared, reposition the microscope. This may reveal additional cerumen or pathology, especially in the anterior recess or the attic area or if a mastoid cavity is present.

• If the patient reports discomfort during the procedure, postpone the cerumen removal for 2 or more weeks and encourage the patient to instill ear drops such as sodium bicarbonate (5%) ear drops twice daily. Such drops soften the cerumen and make it easier to remove.

Technique for irrigation of the ear

See the list below:

• First explain the procedure to the patient/parent and get informed consent. It is often helpful in calming a child down to let the child touch the instruments prior to using them.
• Position an adult as described above.
• Position a child on the parent’s lap with the parent holding both the child’s arms and the head still.
• Cover the parent and child as best as possible with absorbent towels to avoid them getting too wet.
• Place a kidney dish or other specially designed container under the child’s ear to collect the water exiting the ear when the irrigation is done. An extra pair of hands are needed for this. Note that if the child is pulling up the shoulder there will be no space available for the kidney dish or container. The child pulling up the shoulder may also occlude the external ear canal if the kidney dish is pushed upwards onto the external ear/pinna.
• Use the pressure controlled irrigation device as per the manufacturer’s instructions directing the stream of water in different directions towards the tympanic membrane.
• Collect wax and water in the kidney dish or container.
• Let the patient hold the head with the irrigated ear downwards to let the water out.
• Inspect the ear for further wax. Confirm the tympanic membrane is visible, specifically noting whether or not a perforation is present.

Try to stick to the anterior wall while clearing the canal. At the anterior wall, the angle with the tympanic membrane is more acute, and the transition to the tympanic membrane is less likely to be missed.

Ask the patient to report pain, as this is a safety net. Pain is likely due to trauma to the ear canal skin. However, touching the malleus can cause pain and is to be avoided. A very stoic patient may try to grin and bear the pain when the malleus is accidentally touched; if he or she does so, this warning sign may be missed.

Do not hesitate to postpone the cerumen removal for 2 weeks, as pain and time can be saved by softening the cerumen with drops first. Drops can be selected at the clinician’s individual preference, as reviews have failed to demonstrate significant differences between various drops. ^{[10, 11, 12, 13]} In 2009, a review of completed trials also failed to demonstrate a significant difference between using water or commercially available drops. ^[10]

Take special care with pediatric patients. Carefully explaining the procedure, allowing the child to touch the suction device, and introducing suction into the ear canal slowly may help children as young as 4 years to tolerate a microsuction session. However, most children only tolerate this procedure at age 8 years or older. Using a Jobson Horne probe or a ring curette may be a viable alternative in pediatric patients who do not tolerate microsuction.

Adjust to the individual patient’s needs. Meticulous cleaning is required in patients with otitis externa, but less so if they are having a mold made for a hearing aid. However, for patients who simply present with excessive wax buildup, the clinician only needs to remove most of the cerumen, and the rest can be cleared with weekly olive oil drops.

If visual inspection reveals a foreign body instead of or in addition to cerumen, removal of the foreign body may require different techniques. See Medscape Reference article Ear Foreign Body Removal Procedures for more information.

A 0-degree rigid endoscope may be quicker and easier to access than a microscope when visualizing the cerumen, ear canal, and tympanic membrane. ^[14]

Some cases are better dealt with in theatre under general anesthetic and this option should be discussed as part of informed consent

Most patients tolerate the procedure very well with no analgesia. A minority of patients experience a mild amount of discomfort or even pain.

Some patients experience short-term vertigo.

Because of the noise generated by the suction tip, tinnitus may be worsened in some patients. Suction should be limited or avoided in patients with symptomatic tinnitus.

Hard cerumen, probes, specula, and suction devices may all cause lacerations to the ear canal skin. Minor bleeding and discomfort may result.

Using a large-bore suction device close to the tympanic membrane may cause trauma to the tympanic membrane, including a perforation. Such trauma usually heals spontaneously over the following weeks.

Inadvertent force to the ossicular chain may lead to conductive or sensorineural hearing loss.