Continuing Education Activity
The American Academy of Otolaryngology defines cerumen impaction as "an accumulation of cerumen that is associated with symptoms, prevents the necessary assessment of the ear, or both." Irrigation of the ear is one method providers can use to treat cerumen impaction when appropriate. This activity reviews the indications, contraindications and potential complications of ear irrigation.
- Identify the the indications for ear irrigation.
- Describe the technique of ear irrigation.
- Review the complications of ear irrigation.
- Explain the role of the interprofessional team in undertaking steps to safely irrigate the ear and improve patient outcomes.
Cerumen, or ear wax, is a naturally occurring substance that is produced at the lateral one-third of the external auditory canal (EAC). Anatomically, this region houses a collection of pilosebaceous glands that includes ceruminous glands, hair follicles, and sebaceous glands. The modified sweat produced by the ceruminous glands has bacteriocidal and fungicidal properties, functioning to lubricate and clean the EAC. As dead skin cells slough off and move out of the ear canal, they combine with the oily secretions of sebaceous glands as well as the modified sweat of the ceruminous glands. The combination of these substances is what makes up cerumen, consisting primarily of dead keratin cells . Cerumen serves as a protective barrier to trap foreign particles. There are a number of pathologies that may present in the EAC including sebaceous cysts, furuncles, and even glandular tumors, but what most commonly plagues patients is the buildup and impaction of cerumen.
The American Academy of Otolaryngology defines cerumen impaction as "an accumulation of cerumen that is associated with symptoms, prevents the necessary assessment of the ear, or both" . While cerumen is typically expelled from the EAC spontaneously with the aid of jaw movement, this mechanism may fail some patients and lead to impaction. Impaction is more likely to occur when this normal extrusion of cerumen is prevented in some way; whether that be with the use of hearing aids, persistent use of earplugs/earbuds for noise reduction or music, or by the simply attempting to clean the ears with Q-tips or cotton swabs . Common symptoms include a feeling of fullness in the ear, ear pain or otalgia, itchy ear, the sensation of imbalance, cough, and of course decreased hearing . Roughly 5% of healthy adults, 10% of children, 57% of older persons, and 33% of patients with mental retardation suffer from impaction of cerumen .
Irrigation of the external auditory canal is one of the many options in treating cerumen impaction and a method that is readily available to the likes of general practitioners and emergency rooms. Irrigation may be performed by non-clinicians; resulting in its own advantages/disadvantages and can be attempted alone or with the pre-treatment of a cerumenolytic agent, such as acetic acid, mineral oil, or hydrogen peroxide. It is important to note, however, that a thorough history and physical exam through the use of otoscopy should be obtained to ensure the tympanic membrane (TM) is intact, without perforation or tympanostomy tubes, and to assess for any anatomic abnormalities prior to any irrigation attempts. If multiple attempts to remove impacted cerumen—including a combination of treatments—are ineffective, clinicians should refer the patient to an otolaryngologist.
Anatomy and Physiology
The EAC in most adults tends to follow a posterosuperior to an anteroinferior trajectory, laterally to medially. In children less than 3 years of age, the EAC is largely directed posterosuperiorly. The lateral one-third of the EAC is made up of fibrocartilage whereas the medial two-thirds is the osseous or bony portion of the canal that contains skin which is tightly adherent to the periosteum without any subcutaneous tissue. The TM is the most medial portion of the EAC, separating it from the middle ear. Approximately 6mm lateral to the TM there is a narrowing of the bony canal known as the isthmus. This may play an important role in a foreign body and cerumen removal alike, as material medial to this point proves to be quite difficult to remove.
Two tracts or canals exist in the external auditory canal which extend to surrounding structures. More laterally, there are the Fissures of Santorini. These fissures are lymphatic channels that traverse between the incomplete cartilaginous coverings of the lateral one-third of the canal and connect this portion of the canal to the parotid gland, the glenoid fossa, and the infratemporal fossa. More medially, there may be an embryologic defect at the inferior tympanic ring known as the Foramen of Huschke that will connect the medial EAC to the parotid gland and glenoid fossa region. Both of these channels may permit extension of infection or malignant tumors to these surrounding structures, thus special consideration of these possibilities should be kept in mind while performing irrigation of cerumen.
If irrigation was successful in removing the cerumen impaction, one should be able to evaluate the tympanic membrane anatomy. The normal coloring of a tympanic membrane is pearly gray and translucent. There is a cone of light in the anterior, inferior quadrant of the tympanic membrane, and it points towards the nose. One should also be able to observe the umbo and the handle of the malleus. The tympanic membrane is somewhat conical in shape, with a concavity noted at the umbo. A normal tympanic membrane has no perforation. If the provider observes a bulging tympanic membrane, with a distortion of the cone of light, and little to no visibility of the umbo and the handle of the malleus, this may be indicative of an infection or fluid in the middle ear space -- a serous or purulent otitis media. The presence of a eustachian tube dysfunction may result in a retraction of the TM or a serous otitis media.
The provider should be mindful of the temperature of the water while irrigating the EAC, attempting to keep the water temperature close to the patient's natural body temperature. Water that is too cold or hot may cause a sensation of dizziness due to the proximity of the lateral semicircular canal to the EAC. The vestibulocochlear nerve has two parts: the vestibular nerve and the cochlear nerve. The semicircular canals of the inner ear are innervated by the vestibular nerve, which is responsible for orientation in space, balance, and coordination. The cochlear nerve is responsible for hearing.
Cerumen impaction irritates the may result in the feeling of fullness in the ear, ear pain or otalgia, itchy ear, the sensation of imbalance, cough, and of course, decreased hearing . Another indication of impactions is an inability to visualize the tympanic membrane due to cerumen when inspection of the tympanic membrane is needed.
Ear irrigation may also be used for caloric stimulation. This method is discussed as a separate topic.
There are a few contraindications to performing irrigation of the ear including lack of patient consent. These contraindications are a patient's inability to sit upright, a patent tympanostomy tube, a patient who is unwilling or unable to sit still, a foreign body present in the ear canal, a perforated tympanic membrane, an opening into the mastoid, and severe swimmer's ear (otitis externa). Also, a history of middle ear disease, ear surgery, inner ear problems (especially vertigo), or radiation in the area is an additional reason to choose another method for cerumen dis-impaction.
Face Shield (universal precautions)
To safely perform ear irrigation, one should use an otoscope. You will need your cerumenolytic of choice. The water you will use for irrigation must be warmed before use. You can either use a thirty milliliter to a 60-mm syringe with a 16 or 18 gauge intravenous (IV) catheter attached (with the needle removed) or a pulsating water device (such as a WaterPik) to irrigate the impacted cerumen out of the ear. You will also need an ear irrigation basin or emesis basin to catch the water and pieces of cerumen as it leaves the ear.
Due to the availability of syringes and IV catheters when compared to pulsating water devices, the syringe and IV catheter method is more common.
A cerumen spoon or alligator forceps can be used to remove loose cerumen pieces following the ear irrigation procedure.
An assistant can help by holding traction on the pinna. This straightens the ear canal, allowing for more efficient and effective cerumen removal.
Some providers may choose to soften the wax before irrigation. Multiple agents may be used including mineral oil, 1% sodium docusate solutions, and carbamyl peroxide solutions.
Warm the solutions and the water that will be used during the irrigation to near body temperature to prevent dizziness. Cold or hot solutions put in the ear are likely to have an uncomfortable effect on the patient, and it may make them dizzy or nauseous.
If using an IV catheter and syringe, ensure the needle is removed from the IV catheter.
- Ask the patient to sit upright. Place your cerumenolytic of choice in the external auditory canal and leave it in the ear for fifteen to thirty minutes before initiating irrigation.
- Draw up the warm water into the syringe and attach the IV catheter to the end of the syringe. Place the IV catheter into the external ear canal, no further than the cartilage/bone junction. The cartilaginous portion usually makes up the lateral one-third of the external auditory canal.
- Hold the emesis or ear irrigation basin tightly to the skin below the ear, in an attempt to catch the water during irrigation. This will help keep the patient from getting wet.
- Direct the IV catheter superiorly and posteriorly in the ear canal so that the water will separate the cerumen from the tympanic membrane. Do not direct the water stream directly at the tympanic membrane, because this can cause perforation. Do not inject too rapidly as this may result in trauma, bleeding, and pain.
- Following irrigation, you can remove any loose pieces of wax with a cerumen scoop or alligator forceps, being careful not to damage the external auditory canal and the tympanic membrane.
- To dry the remaining moisture in the external auditory canal, apply several drops of isopropanol. This step is especially contraindicated if the tympanic membrane is ruptured.
Following prolonged irrigation:
- Topical steroid containing suspension drops, such as ciprofloxacin/dexamethasone drops, may be soothing to the external auditory canal. Some providers will prescribe these for a few days following the ear irrigation procedure.
- Many providers prescribe antibiotic drops (example: fluoroquinolones) to patients at high risk for severe infections, such as diabetic patients. These drops are usually prescribed for several days following the ear irrigation procedure to prevent the complication of otitis externa.
If multiple attempts to remove impacted cerumen—including a combination of treatments—are ineffective, clinicians should refer the patient to an otolaryngologist.
Irrigation of the ear can lead to otitis externa, vertigo, perforation of the tympanic membrane, and middle ear damage if the tympanic membrane is perforated. These complications are less common with the syringe and IV catheter technique than when compared to the pulsating water device technique.
Using a cerumen spoon to remove the remaining wax can cause damage to the skin covering the external auditory canal.
Symptoms of complications include sudden pain, ringing in the ears, loss of the ability to hear, nausea, and dizziness. If a patient experiences any of these symptoms, the provider should immediately stop and examine the ear canal and tympanic membrane with an otoscope.
If the tympanic membrane is ruptured, prescribe the patient oral antibiotics to treat otitis media prophylactically. Refer the patient to an otolaryngologist for specialty consult.
It is often necessary to perform ear irrigation for cerumen impaction if the patient is symptomatic or if the provider needs to evaluate the tympanic membrane. Cerumen impaction may cause a feeling of fullness in the ear, ear pain or otalgia, itchy ear, the sensation of imbalance, cough, and of course decreased hearing . Removing impacted cerumen often results in immediate relief of some or all of these symptoms should there not be an underlying infection, malignancy, or other pathology.
Enhancing Healthcare Team Outcomes
A nurse or medical assistant is essential to assist with this procedure. His or her assistance will help ensure the procedure runs smoothly, therefore keeping the patient at ease.