Ear wax management

External ear – pinna, ear lobe, conchal bowl,
- Blood supply from external carotid
- Innervation – cervical plexus, trigeminal, facial, glossopharyngeal, vagus
To visualize EAC adult – pull pinna upwards and back, child – down and back

Definition:
- Composition: Mixture of secretions from ceruminous and sebaceous glands with exfoliated squamous epithelium.
- Purpose: Forms a protective barrier in the ear canal.
Functions:
- Protection: Shields the ear canal from dust, microorganisms, and other foreign particles.
- Antibacterial Properties: Contains lysozymes and acidic pH that inhibit bacterial growth.
- Lubrication: Prevents dryness and itching in the ear canal.
- Self-Cleaning Mechanism: Traps debris which is naturally expelled from the ear canal through jaw movements and epithelial migration.

Disruption of Self-Cleaning Mechanism:
- Anatomical Variations: Narrow or obstructed ear canals can impede wax expulsion.
- Infectious or Dermatological Diseases: Conditions like otitis externa or eczema can interfere with normal cerumen migration.
Irritation from Foreign Objects:
- Cotton Tips: Push cerumen deeper and cause chronic changes to the ear canal skin.
- Hearing Aids and Ear Plugs: Obstruct the ear canal, preventing natural expulsion of wax.
Age-Related Changes:
- Atrophy of Ceruminous Glands: Leads to the production of drier wax which migrates more slowly.
- Prevalence: Cerumen impaction is found in up to 57% of older adults compared to 5% in younger, healthy individuals.

Symptomatic Wax Impaction:
- Hearing Loss: Conductive hearing loss due to blocked ear canal.
- Ear Discomfort: Pain, itching, or a sensation of fullness in the ear.
- Other Symptoms: Dizziness, tinnitus, reflex cough due to ear canal irritation.
Diagnostic Needs:
- Visual Obstruction: Impacted wax that obscures the view of the tympanic membrane.
- Audiometry: Necessary for accurate hearing assessments.

Cerumenolytics:
- Types: Eardrops like docusate sodium, glycerin, mineral oil.
- Effectiveness: Increases likelihood of cerumen clearance, no significant difference between water-based or oil-based drops.
- Usage: Patients should be discouraged from using cotton buds, only outer ear cleaning is acceptable.
Irrigation or Manual Removal:
- Indications: Hard impaction or disease of the ear canal.
- Process: Often preceded by cerumenolytics to facilitate removal.

Preparation:
- History and Examination: Take a full patient history and examine the ear.
- Informed Consent: Explain potential complications to the patient.
- Equipment: Assemble appropriate syringing equipment.
Irrigation Technique:
- Syringe: Use a large (20 mL) syringe with warm, sterile water or saline.
- Technique: Aim the water jet towards the edge of the cerumen, not directly at the eardrum.
- Depth: The syringe tip should not go beyond the outer one-third of the ear canal (approximately 8 mm).
- Safety: Cease if the patient experiences pain or if bleeding occurs.
Post-Procedure:
- Examination: Check the external canal and tympanic membrane.
- Documentation: Record patient consent, procedure details, and examination findings.

Absolute Contraindications:
- Active Infection: Signs or symptoms of otitis externa or otitis media.
- Tympanic Membrane Issues: Current or past perforations.
- History: Previous ear surgery or unilateral deafness.
Relative Contraindications:
- Recurrent Conditions: History of recurrent otitis externa or tinnitus.
- Immunocompromised Patients: Increased risk of infection.
- Behavioral Factors: Uncooperative patients, such as young children.

Common Issues:
- Skin and Tympanic Membrane Damage: From the mechanical action of syringing.
- Nerve Irritation: Can cause coughing (via CN IX and X), tinnitus, or vertigo.
Infection Risks:
- Otitis Media and Externa: Especially if water is retained behind residual cerumen.
Severe Complications:
- Tympanic Membrane Perforation: May require treatment with ciprofloxacin drops.
- Referral: Persistent issues may need audiology or ENT referral.

Microsuction:
- Procedure: Performed under microscope, often combined with curettage.
- Advantages: Avoids moisture exposure, fewer contraindications, lower infection risk.
- Discomfort: Noise can be bothersome, though it doesn’t affect hearing.

Criteria for Referral:
- Pain or Bleeding: Occurring during syringing.
- Failed Removal: Despite multiple attempts and use of cerumenolytics.
- Persistent Symptoms: After successful cerumen removal.
- Chronic Impaction: Repeated occurrences.
- Contraindications: Including perforated tympanic membrane, prior ear surgery, or only hearing ear involvement.
- Abnormal Tissue: Presence in the ear canal.
- Other Concerns: Any additional clinical concerns requiring specialist assessment.

Self-Cleaning Mechanism: Educate patients about the ear’s natural cleaning process.
Avoid Foreign Objects: Discourage the use of objects like cotton buds in the ear canal.
First-Line Treatment: Use eardrops to soften wax for symptomatic relief.
Professional Syringing: Conducted by trained staff if first-line treatments fail.
Specialist Referral: Indicated for complex cases or if contraindications to syringing exist.