Overview of Ear Irrigation
Ear wax, also known as cerumen, is a natural substance produced in the external part of the ear canal. This area is home to certain types of glands and hair follicles. The sweat produced by the ceruminous glands, a type of gland in the ear, has the ability to kill bacteria and fungi. This sweat also helps to moisturise and clean the ear canal. Ear wax forms when dead skin cells mix with the oily secretions of sebaceous glands and the modified sweat from the ceruminous glands. Ear wax is mainly composed of dead skin cells, and it helps protect the ear by trapping foreign particles.
Sometimes, certain conditions may affect the ear canal, including cysts, boils, and even gland-related tumors, but the most common issue is the buildup and hardening, or impaction, of ear wax.
The American Academy of Otolaryngology describes ear wax impaction as a build-up of ear wax that causes symptoms or makes it harder for doctors to examine the ear. Normally, ear wax is expelled from the ear canal automatically when we move our jaws. However, this mechanism can fail in some people, leading to impaction. Impaction can also happen when the normal removal of ear wax is hindered, for example, by the use of hearing aids, regular use of earplugs or earbuds, or by cleaning the ears with Q-tips or cotton swabs. Common symptoms include a feeling of fullness in the ear, ear pain, itchiness, a feeling of being off-balance, cough, and hearing loss. Around 5% of healthy adults, 10% of kids, 57% of older people, and 33% of patients with intellectual disability may experience ear wax impaction.
One way to treat ear wax impaction is by irrigating, or washing out, the external part of the ear canal. This method can be carried out by general doctors and in emergency rooms, and can also be done by non-doctors. The irrigation may be done on its own or combined with a substance that softens ear wax, like acetic acid, mineral oil, or hydrogen peroxide. However, before any attempts to irrigate the ear, it is essential that a thorough health and physical examination is done to make sure the drum of the ear is intact and there are no abnormal structures in the ear. If it proves difficult to remove the impacted ear wax after various treatment efforts, the patient should be referred to a specialist doctor of the ears, nose and throat, called an otolaryngologist.
Anatomy and Physiology of Ear Irrigation
The External Auditory Canal (EAC), also known as your ear canal, travels from the outer ear to the ear drum. This natural tube-like structure in adults trends from the back upper part to the front lower part of your head. Interestingly, for young children below 3 years of age, the ear canal majorly points towards the back upper part of the head. It’s made up of fibrocartilage at the outer one-third and bone in its inner two-thirds. The bone region is covered tightly with skin without any fatty tissues underneath.
Your ear drum, or the tympanic membrane (TM), is the innermost part of the EAC, and it separates your ear canal from the middle part of your ear. About 6 mm towards the outer ear from the TM, the bone canal portion becomes narrow – this is called the isthmus. It’s a crucial point when doctors try to remove foreign material or ear wax (cerumen) from your ear, as anything beyond this point can be quite tough to dislodge.
Two natural canals are found in your ear canal and they extend to surrounding structures. One is located towards the outer ear and is called the Fissures of Santorini. These are essentially channels that connect your ear canal to your parotid gland (one of your salivary glands), glenoid fossa (part of your jawbone), and infratemporal fossa (area beneath your cheekbone). Towards the inner ear exists another canal or opening named the Foramen of Huschke that connects the inner ear canal to the same surrounding structures. Each of these channels can allow infections or malignant tumors to spread to surrounding structures. Therefore, your doctor keeps this in mind when performing irrigation (basically, ear cleaning).
If the ear cleaning process clears the blockage, your doctor should be able to clearly view the ear drum. A healthy ear drum has a pearly gray color, is translucent and has a light reflecting pattern (cone of light) in its front lower quadrant pointing towards your nose. They should also be able to observe the structure of malleus, an important bone in your ear that is somewhat cone shaped. If any bulging or distortion in the ear drum is observed or if the malleus isn’t easily visible, it could signify an infection or fluid buildup in the middle ear.
Pertaining to ear cleaning, doctors are careful to ensure the temperature of the water used is close to the body’s natural temperature. Water that is too hot or cold may cause you to feel dizzy because of the nearness of a part of your inner ear called the lateral semicircular canal to the ear canal. Your inner ear is innervated by two parts of the vestibulocochlear nerve: the cochlear nerve that is responsible for hearing and the vestibular nerve which helps with balance and spatial orientation.
Why do People Need Ear Irrigation
If you’re experiencing symptoms like a feeling of fullness in your ear, ear pain, itching, a sense of imbalance, coughing, or even reduced hearing, you might be dealing with cerumen impaction. Cerumen, more commonly known as earwax, can sometimes build up and cause these symptoms. Another sign that you may have this issue is if a doctor can’t see your eardrum due to an earwax build-up, especially when they need to inspect it.
If you have earwax impaction, one of the common treatments is ear irrigation, which means flushing out the earwax using water or a saline solution. Sometimes, this method can also be used for something else called “caloric stimulation”, but that’s a separate topic.
When a Person Should Avoid Ear Irrigation
Sometimes, a doctor may not be able to do an ear cleaning procedure (called ear irrigation) for a few reasons. Of course, if a patient doesn’t give their consent, the doctor cannot proceed with the treatment. Other reasons include:
If the patient can’t sit upright, or they can’t or won’t stay still, ear irrigation may not be possible.
If the patient currently has a small tube in their eardrum (a patent tympanostomy tube), or if they have a foreign object lodged in their ear, it’s not safe to do ear irrigation
Ear Irrigation should also be avoided if there’s a hole in the eardrum (a perforated tympanic membrane), an exposed area in the bone behind the ear (an opening into the mastoid), or a severe external ear infection (severe swimmer’s ear or otitis externa).
A history of middle ear diseases, ear operations, problems with the inner ear (especially vertigo, a condition that causes dizziness), or exposure to radiation might require the doctor to choose another way to help clear earwax instead of ear irrigation.
Equipment used for Ear Irrigation
For clearing out earwax safely through a method called ear irrigation, it’s suggested to use certain types of equipment, which include:
A face shield for protecting oneself from any splashes or debris.
An otoscope, which is a tool that has a light on it, used for looking into the ear.
A cerumenolytic, which is a liquid used for softening the ear wax.
Water, which should be made warm before use.
A syringe of around 30 to 60 millimeters in size, attached to a catheter coming from a drip bag (where the needle is taken off).
A pulsating water device like a WaterPik which is used for squirting the softened earwax out of the ear.
An ear irrigation or emesis basin, essentially a small bowl or dish used for catching the water and the pieces of ear wax as they come out of the ear.
A cerumen spoon or alligator forceps, tools which are used for removing any pieces of ear wax that may still be left in the ear after the procedure.
The method of using a syringe and drip bag catheter is usually more common, since these items are more readily available than pulsating water devices.
Who is needed to perform Ear Irrigation?
Someone, like a nurse, can help by gently pulling the outer part of your ear. This action straightens the ear canal, making it easier and more effective to remove earwax.
Preparing for Ear Irrigation
Some medical practitioners might opt to soften the earwax before flushing it out. They can use various substances for this, such as mineral oil, a 1% sodium docusate solution, or a carbamyl peroxide solution. During the irrigation, or the process of washing out the ear, the fluids used, including water, should be warmed up close to the temperature of the human body. Using cold or hot fluids could cause discomfort to the patient, possibly causing dizziness or nausea. If the doctor uses an IV catharine and syringe (a common tool for administering medication), the needle has to be taken off the IV catharine.
How is Ear Irrigation performed
Ear irrigation is a process used to clean out your ears. Here’s how it’s done:
1. First, you’d sit upright and a substance (cerumenolytic) that helps to soften earwax is poured into your outer ear canal. It’s left in your ear for about 15 to 30 minutes.
2. Then, warm water is pulled into a syringe and attached to an IV catheter – a small, flexible tube. This tube is inserted into your outer ear canal, but only goes in as far as the area where the flexible part of your ear (cartilage) meets the harder bone part. This is usually the outer third of your ear canal.
3. A basin is held just under your ear to collect the water that comes out during the irrigation procedure. This helps to keep you dry.
The IV catheter is positioned to aim water towards the upper and rear part of your ear canal. This helps to loosen the earwax from your eardrum. It’s important that the water does not directly hit the eardrum as it might tear it. The water flow is kept gentle to avoid hurting you, causing bleeding or trauma. Once the earwax is loosened, remaining pieces can be gently scooped out with special instruments, taking care not to scratch your ear canal or eardrum. Lastly, several drops of isopropanol, a type of alcohol, are put in your ear to dry up any leftover moisture. This is not done if your eardrum is ruptured or torn.
After a thorough ear irrigation, additional steps can be taken:
1. Drops that contain a topical steroid, like ciprofloxacin or dexamethasone, might be used to soothe your outer ear canal. Some doctors prescribe these to be used for a few days following the ear irrigation.
2. Doctors may also prescribe antibiotic drops to those with a high risk of infection, like people with diabetes. These drops are usually used for several days after the procedure to avoid developing an outer ear infection.
If numerous tries to clear out impacted earwax fail, even with combined treatments, doctors may refer the patient to an ear, nose, and throat specialist (otolaryngologist) for further help.
Possible Complications of Ear Irrigation
When water gets poured into the ear to clean it, it can sometimes lead to problems. These might include an outer ear infection, dizziness, a torn eardrum, or damage to the middle ear if the eardrum is torn. These problems are less likely to occur when a syringe and tube called an IV catheter are used to clean the ear, rather than a device that uses pulsating water.
If a small tool called a cerumen spoon is used to remove any leftover wax, it can sometimes cause damage to the skin inside the ear canal.
Signs of these problems might include sudden ear pain, ringing in the ears, difficulty hearing, feeling nauseous, or feeling dizzy. If any of these occur, the ear cleaning procedure should be stopped immediately. The doctor will then need to look at the ear canal and eardrum using a tool called an otoscope.
If the eardrum is torn, the person should take oral antibiotics to prevent a middle ear infection, and should get referred to an ear, nose and throat specialist for a more detailed look at the ear.
What Else Should I Know About Ear Irrigation?
If your ear feels blocked due to a build-up of earwax (also known as cerumen), doctors may need to water-clean it. This is called ear irrigation. This build-up can make your ear feel full, lead to earache, itchiness, a feeling of imbalance, coughing, and even decrease your hearing. These symptoms may be eased immediately once the wax is removed, unless there is an underlying problem such as infection, cancer, or another disease.
