Ear Irrigation

Cerumen, or ear wax, is a naturally occurring substance produced at the lateral one-third of the external auditory canal (EAC). Anatomically, this region houses a collection of pilosebaceous glands, including 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 and the modified sweat of the ceruminous glands. The combination of these substances makes up cerumen, consisting primarily of dead keratin cells. Cerumen serves as a protective barrier to trap foreign particles. Several pathologies may present in the EAC, including sebaceous cysts, furuncles, and even glandular tumors, but most commonly plague patients with the buildup and impaction of cerumen. The American Academy of Otolaryngology defines cerumen impaction as "an accumulation of cerumen associated with symptoms, prevents the necessary assessment of the ear, or both." Although cerumen is typically expelled from the EAC spontaneously with jaw movement, this mechanism may fail in 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 or earbuds for noise reduction or music, or by 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 decreased hearing. Roughly 5% of healthy adults, 10% of children, 57% of older persons, and 33% of patients with intellectual disability suffer from impaction of cerumen.  Irrigation of the external auditory canal is one of the many options for treating cerumen impaction and a readily available method to general practitioners and emergency rooms. Non-clinicians may perform irrigation, resulting in its advantages and disadvantages. They can be attempted alone or with the pretreatment 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 before 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.