Dr. Michael Clifford Fabian, FRCPC FRCSC FACS (biography and disclosures)
What I did before
Cerumen build-up is a common problem for patients and doctors alike. According to McCarter et al cerumen impaction is present in approximately 10 percent of children, 5 percent of normal healthy adults and up to 57 percent of older patients in nursing homes (1). If not managed well, this can result in persistent wax build-up (or impaction) for patients and added time to a busy physician’s office – sometimes without effective resolution in the short term. For patients this can sometimes result in sensation of blocked ears, pain and even hearing loss. I previously spent more time cleaning wax in the office, but less so as time went by. This has been an evolution in my practice for over a decade or more, where previously curetting and vacuuming was a regular occurrence in my clinical office. In the case of Family Physicians, syringing is often utilized, which is time-consuming and cumbersome, and sometimes without the desired response. Counseling patients on preventative measures for wax build-up was something I did not routinely do in the past, spending more time on the management of the problem.
What changed my practice
Wax build-up is a bothersome problem for patients and this is, for the large part, preventable. The more time I spent on explaining to patients how to care for their ears and related wax build-up, the less wax problems I encountered in the office. I also took for granted that patients knew that cotton buds are not for use in the external canals – a major factor contributing to wax impactions as well as potentially having more serious morbidity. I, not infrequently, saw patients in the office with a piece of cotton bud broken off in the ear, and occasionally a perforation that resulted from cotton bud trauma. The more I regularly spoke with patients about this basic subject, I more I realized that many patients did not appreciate the improper use of cotton buds. I also began to understand the misperception that water is not good to get in the ears (it is only contraindicated in a small population of people for specific reasons).
What I do now
The literature is not clear as to whether using cerumenolytic drops are beneficial to water alone (2,3) . For all patients presenting with wax related problems, I take the time to talk about aural hygiene. Providing there are no contraindications (eg. perforation or infection), I talk about the value of self-irrigation of the external ear canals with water and to refrain from using cotton buds. I show them how to aim their ear up towards the shower head to let water in the ear, and then tilt the head down to enable water run out. This can be followed by gentle use of facial tissue externally in the ear. For those individuals that bath instead, particularly in the case of children, I explain how to flush the ears with the help of a small cup or bulb syringe. Rinsing the ears, as mentioned above, can be performed with each shower/bath, or as frequently as patients desire. I usually recommend self-rinsing two to three times per week – keep in mind that this is not an exact science so these are my personal suggestions. For those patients who present in my office with unrelated ENT problems and I see that wax build up is, or can be, an issue, I always try to remember or make the time to provide them with this basic information on aural hygiene. I also, at whatever opportunity I can, speak with learners and practitioners about this common clinical scenario.
References (Note: Article requests require a login ID with CPSBC or UBC)
- McCarter DF, Courtney AU, and SUSAN M. Pollart SM, Am Fam Physician. 2007 May 15;75(10):1523-1528. http://www.aafp.org/afp/2007/0515/p1523.pdf
- Burton MJ, Doree C. Ear drops for the removal of ear wax. Cochrane Database Syst Rev. Jan 21 2009;CD004326. (View article with CPSBC or UBC)
- Cerumen Impaction Removal: http://emedicine.medscape.com/article/1413546-overview
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i wonder at the role of oil in the ear as an aid to cerumen disimpaction as well as ongoing? Is this indicated or not?
I will try .
When I see pateints for review of their overall health – physical exams / renewal of meds etc. I often if not always ask about hearing. At that time the topic of wax cleaning comes up. I appreciated this article to review my approach.asuato AHors
I don’t disagree with the water approach but wonder if the idea of oil is more effective and well tolerated, especially in kids?
I will try these recommendations with my patients
In cases where the wax is impacted I often suggest instilling a small amount of warm oil to the affected ear canal. I tell the patient to warm a teaspoon in some hot water,then dry the spoon and place the oil on the warm spoon.Use an eye dropper to draw up the warm oil and then place a few drops in the ear canal with a little cotton batting to prevent it spilling out.
It seems to work well.
Good simple advice.
No cost.
All good advice but it removes the wonderful satisfaction for patient and doctor alike of removing those finger sized wax plugs.
Practical and easy
I HAVE SEEN PATIENTS ON PERIODIC HEALTH EXAM. WITH VERY CLEAN EAR CANALS AND THEY ALWAYS SAY THEY RINSE THEIR EARS IN SHOWER AND CLEAN THEM WITH COTTON BUD AFTER THAT
I’ve had more success with oil but will have patient syringe or syringe in the office if problem becomes intractable.
Ok
Good, simple approach that works for me, too!
This seems simple, not as messy as oil, and patients can do it at home without needing a return visit for syringing. Great idea!
Syringing is so satisfying for patients but not for me. showering to clean ears is new to me.
very helpful, thanks
I do like the warm oil approach for treating presenting hard impactions, often followed by syringing of the shower technique as outlined.
Seems sensible.I will give it a try
I personnaly have chronic wax build up in both ears…..inherited from my father and grandfather.
So I put 3 drops of warm olive oil into one ear close with cotton wool..leave overnight and successfully syringe with slightly warmed water in the morning….alternate ears every 2 weeks…It works.
I suggest warm mineral oil or olive oil at body temperature and cotton plug fro 2 hrs and weekly to monthly oil drop if a recurrent problem.
don’t use a syringe if the ear is painful. be seen by doctor.
good article
This approach may be preferable to patients over oil drops to ears.
Be sure that the syringe or handbulb used is not too long for the canal, especially with children, to avoid trauma. Also, in older patients who are holding their heads at angles in order to allow the water into the canals while they are in a shower, be sure to advise them to hang on to something while washingto avoid vertigo & a subsequent fall. We have all seen shower & bathtub falls result in significant injuries. Vertebrobasilar insufficiency is all too common in the elderly.
I think oil works better for hardend ceruma or impacted wax, when shower water cannot even get in. Also, water may get in and stay in between the tympanic membrane and the impacted wax, which may give the patient a sensation of being under water !
Very common problem, time consuming at best. Have heard the odd patient mention using water in the ear but wasnt sure that it was effective, will spends some time recommending it and see how things turn out.
To those that have needed ear flushing, I have recommended 2-3 drops warm oil HS q2wks as ‘prevention’. I will now suggest water rinsing in the bath/shower and see if it is equally effective. FYI – ‘elephant ear washer’ effective and much less messy than the metal ear syringe.
I always assumed it was more common in frail elderly because they don’t get completely wet. I was unaware other people don’t all or mostly all get water in their ears regularly!