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.
Following treatment of 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 you observe a bulging tympanic membrane, there is usually a distortion of the cone of light, and there is little to no visibility of the umbo and the handle of the malleus. This can indicate an infection or fluid in the middle ear space, a serous or purulent otitis media.
A eustachian tube dysfunction usually causes a retracted tympanic membrane.
Cold water should not be used for ear irrigation; the water temperature should be warm and close to the patient's natural body temperature. Cold water on the tympanic membrane can cause a sensation of dizziness due to cranial nerve VIII, the vestibulocochlear nerve. 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 promoting hearing. 
Cerumen impaction irritates the ear canal with itching, pain, chronic cough, or 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 can also be used for caloric stimulation. This method is discussed in a different 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, foreign body present in the ear canal, 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 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.
Following prolonged irrigation:
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 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 when cerumen if the patient is symptomatic or if the provider needs to evaluate the tympanic membrane.
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.
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