Everybody makes and develops ear wax. However, in some people the ear wax has a tendency to build-up and become impacted. There are many factors that can cause ear wax to build-up and become impacted. Some people are simply just genetically more predisposed at secreting ear wax at a quicker rate than it can naturally migrate out of the ear. Other reasons are:

• • • • • the ear wax doesn’t naturally migrate outwards due to an abnormal layer of skin lining the ear canal that doesn’t move sideways as it grows and sheds;
        • the ear canal is very narrow causing the ear wax to become impacted;
        • the ear canal has bony protrusions (exostosis) blocking the ear wax inside;
        • the ear wax is pushed deep into the ear canal through the use of cotton buds;
        • excessive hair (cilia) is present in the ear canal that traps the ear wax and prevents it from escaping out;
        • the ear wax is dry and hard (more common with age) which makes it more difficult for it to migrate outwards;
        • a worn hearing aid or earplug obstructs the natural migration path of ear wax.

The most common symptom caused by impacted ear wax is a ‘blocked ear’. The sensation of a blocked ear is due to the ear wax creating a “plug” inside the ear canal. Other than a blocked ear, a plug of ear wax can lead to the following symptoms:

• • • • • feeling of fullness and dullness;
        • temporary hearing loss;
        • internal sounds (e.g. chewing, breathing, own voice) being louder (occlusion);
        • earache (otalgia) and discomfort;
        • ringing in the ear (tinnitus);
        • mild vertigo (sensation of the room spinning) – exact link not yet established;
        • cough – due to excessive pressure created by the ear wax stimulating the facial nerve inside the middle-ear;
        • whistling (acoustic feedback) of hearing aid;
        • itchiness/irritation of the ear canal.

When a person develops a blocked ear and/or other symptoms associated with impacted ear wax there are many ear wax removal treatment options available. Some methods of ear wax removal and treatment are safer and more effective than others.

Ear wax drops & sprays

There are many over-the-counter ear wax drops & sprays that are available at your local pharmacy to help soften, loosen and sometimes even dissolve the ear wax. Typically, these are either oil-based (e.g. Cl-ear Olive Oil Ear Drops or Cl-ear Olive Oil Ear Spray) or water-based (e.g. urea hydrogen peroxide drops such as Cl-ear Express Ear Drops or sodium-bicarbonate ear wax drops such as Care). It is thought that water-based ear wax drops and sprays are more effective at breaking up ear wax than oil-based ear wax drops. However, water-based ear wax drops and sprays are more prone to causing irritation and can sometimes lead to an infection. In addition, compared to oil-based ear wax drops and sprays, they can cause ear wax to swell and expand more therefore leading to a complete ear wax plug and exacerbation of the blocked ear sensation.

When using ear wax drops and sprays they need to be at room temperature. Using ear wax drops and sprays that are either slightly cooler or warmer than room temperature can cause short-term vertigo due to the ‘caloric’ effect. The caloric effect is when the balance (vestibular) organ in one ear is out of sync with the balance organ in the opposite ear due to an inhibition in its function (cooler air or water) or excitation in its function (warmer air or water). The mismatch in signals sent to the brain via the two balance organs then confuse the brain into thinking you’re moving when you are still and stationary, leading to vertigo.

After applying the ear wax drops and sprays the affected ear needs to be facing upwards for around 5 to 10 minutes to allow the ear wax drops and sprays to enter the ear canal and penetrate the ear wax to soften and loosen it. This can be achieved by either tilting your head or lying on your side. Repositioning your head back to the centre or sitting back up after the allocated time will allow the ear wax drops and sprays to drain out of the ear canal, hopefully removing some of the ear wax at the same time. This process generally needs to be repeated 2 or 3 times a day for anything between to 10-14 days. Even so, if there is excessive or impacted ear wax then ear wax drops alone may not successfully remove the ear wax.

Ear Syringing (irrigation)

Up until recently, ear syringing (or irrigation) was the standard and conventional method used to remove ear wax (if using ear wax drops was not successful) and clear blocked ears. Ear syringing is usually performed in GP surgery’s by a practice nurse and involves gently pumping water (either via a bulb-type syringe or electronic ear irrigator nozzle) into the ear canal at different angles to flush, dissolve, and rinse the ear wax out of the ear canal. Prior to ear syringing, it is recommended that ear wax drops or sprays are applied 2 or 3 times a day for atleast 10-14 days in advance to help soften the ear wax and aid its removal.

There is a growing reluctance amongst GPs and practice nurses, however, to perform ear syringing due to the obvious clinical risks involved. Although old-fashioned, high-pressured ear syringes have since been replaced by modern directional jet pressure-controlled ear syringes and electronic irrigation machines, whereby the water flow pressure can be regulated and controlled using a foot pump, the procedure is still performed ‘blind’ with no direct vision. There is also still the risk of perforating the eardrum by applying excessive pressure, especially if the eardrum has been previously operated on or is fragile due to a healed perforation in the last 12 months. In addition, where an unknown and undetected perforation is present behind the ear wax plug, ear syringing can inadvertently force both ear wax and water through the perforation in the middle-ear cavity and trigger an infection. This could also be said to be true if a grommet (ventilation tube) has been surgically inserted through the eardrum. Furthermore, ear syringing is not appropriate for anybody who has had a middle-ear infection (otitis media) in the last 6 weeks since it can increase the chance of it returning. Similarly, ear syringing should be avoided in anybody who is currently suffering from an outer-ear infection (otitis externa) since it can increase its severity whilst also being extremely painful for the individual. Even in normal ears, there is always the chance of infection post-ear syringing, albeit small, especially if the water being used has not been adequately sterilised. Additionally, as like with ear wax drops, the temperature of the water needs to be carefully controlled at body temperature (37ºC) to avoid short-term vertigo due to the ‘caloric’ effect which has been described earlier.

It is important to note that ear syringing should under no circumstances be performed in individuals with a known perforation, cleft palate, foreign object in the ear canal, and mastoid cavity following a mastoidectomy. Also, it is sometimes reported that ear syringing can lead to tinnitus, or exacerbate it in people who already experience it.

Microsuction of Ear Wax Removal

The use of microsuction to remove ear wax and clear a blocked ear is generally performed in hospital outpatient’s clinics by ENT doctors and ENT nurses if all other ear wax removal treatments have either proven to be unsuccessful or unsuitable. Its major advantage over all other ear wax removal treatments highlighted above is that ear wax is removed safely under direct vision at all times. The procedure is undertaken through an ENT binocular operating microscope (to provide magnification, depth perception and light source) and a sterile suction probe that is connected to a gentle suction machine. Other instruments, such as cerumen spoons, Jobson-Horne and miniature crocodile forceps can also be used in conjunction with the suction probe to safely remove ear wax. Furthermore, microsuction is generally a ‘dry’ technique and does not involve the use of water, significantly reducing the risk infection and damaging/perforating the eardrum as a result.

Microsuction can at times be noisy both due to the suction machine and ‘clarenetting’. This when dry and flaky skin ‘flaps’ within the ear canal due to the suction probe. Subsequently, like ear syringing, sometimes people report tinnitus or increased tinnitus if they already experience it pre-microsuction. There is also the small chance of slight bleeding due to grazing and scratching of the layer of skin lining the car canal with the suction probe. Secondary trauma of the eardrum caused through the suction probe and other ENT instruments is also possible, albeit rare. In addition, when using the suction probe cool air currents are generated within in the ear canal, and similarly to the ear wax drops and ear syringing ear wax treatments there is a risk of short-lasting vertigo due to ‘caloric’ effect. Nonetheless, the use of microsuction compared to the other ear wax removal treatments is quicker and safer and doesn’t require weeks of instilling ear wax drops or sprays (although applying Cl-ear Olive Oil Ear Drops or Cl-ear Olive Oil Ear Spray, for example, the day before to slightly soften the wax is sometimes advisable).

As mentioned earlier, microsuction is generally performed by ENT doctors and ENT nurses using expensive and large ENT binocular operating microscopes in hospital outpatient’s department. Subsequently, many people have to wait weeks or months for an appointment if being referred by their GP for microsuction ear wax removal. As a result, many Audiologists/Hearing Aid Audiologists are now getting trained to perform microsuction using microscope ‘loupes’ since they are more readily available and affordable. However, these are not as effective or safe to use when compared to ENT microscopes.

Endoscopic Ear Wax Removal

An alternative to microsuction is endoscopic ear wax removal. In fact, endoscopic ear wax removal has been clinically found to be less painful, more comfortable, quicker and easier to perform than microsuction, even when using an ENT microscope (Pothier et al. 2006). To perform endoscopic ear wax removal an oto-endoscope is used. An oto-endoscope is a more advanced medical ‘ear torch’ than the conventional oto-scope used by Audiologists and ENT doctors to inspect the ear. It can either be rigid or flexible and uses a small diameter fibreoptic telescope to provide an incomparable ‘wide’ high resolution view of the ear canal. Subsequently, it can be comfortable and safely rested into the ear canal opening using one hand to visualise the whole ear canal and eardrum, with minimal manipulation of the patient’s head or ear as would be the case with either a microscope or an oto-scope. This allows the other hand to gently remove the ear wax by using the sterile suction probe in conjunction with other ENT instruments, if required.

Similarly to microsuction, endoscopic ear wax removal can be noisy and there is a very small risk, as with all other ear wax removal treatments, that some people may report tinnitus or increased tinnitus if they already experienced it pre- ear wax removal. There is also the small chance of slight bleeding due to grazing and scratching of the layer of skin lining the car canal with the suction probe, although compared to microsuction this risk is somewhat reduced given there is a far greater degree of operating space available. Secondary trauma of the eardrum caused through the oto-endoscope, suction probe and other ENT instruments is also possible, albeit rare. In addition, when using the suction probe cool air currents are generated within in the ear canal, and similarly to the ear wax drops, ear syringing and microsuction methods of ear wax removal there is a risk of short-lasting vertigo due to ‘caloric’ effect, as described previously. Endoscopic ear wax removal may sometimes be difficult to perform on people with small ear canal entrances, but there are some oto-endoscope with very small diameters available (e.g. 2.7mm) compared to the conventional 4mm diameter used for ear wax removal.