One of the most frequently performed and frustrating procedures in primary care of children is cleaning wax and debris from their S-shaped ear canals to see the tympanic membrane. To achieve a high degree of precision when evaluating the status of the middle ear by the appearance and mobility of the tympanic membrane, I am convinced that the entire eardrum should be visible, if at all possible. To do this with young children requires careful removal of all obstructing debris and cerumen.
|Richard Schwartz, MD, is from the department of pediatrics at Inova Fairfax Hospital for Children, Vienna, Va.|
It is curious that medical students and pediatric residents, usually at the forefront of technical advances, often use rather primitive and ineffectual equipment for the task. Homemade curettes fashioned from nasopharyngeal swabs or metal paper clips and homemade aural irrigation attachments fashioned from butterfly needles and a 10 ml syringe appear to be the tools of the trade for these trainees. Disposable plastic aural curettes in four styles are now available (Bionix Safe Ear Curettes) and used by some pediatric residents and practicing pediatricians. Few otolaryngologists use them in my area and, to my knowledge, there are no studies to compare their effectiveness with blunt, angled, Buck's or Shapleigh's metal aural curettes the gold standard for the task.
In a previously published study, mechanical removal of the cerumen was necessary to visualize the eardrums of 29% of 279 children with unilateral acute otitis media. In general, the younger the child, the greater the chance of having to remove cerumen and squamous debris in order to properly visualize the ossicular landmarks of the eardrum. Seventy percent of infants 2 to 6 months old and 50% of infants 7 to 12 months old required removal of cerumen to clearly see the ossicular landmarks. One of three children 13-24 months old, and approximately 15% to 20% of older children, also need to have their ear canals cleaned. Only a few children in that study had excessive hard-inspissated earwax which required softening with ceruminolytic agents. Spotting of blood after use of a No. 1 Buck's metal curette was noted in about 10% of children, and 6% of those children had enough bleeding to require insertion of a cotton wick, with or without instillation of coagulant solution such as phenylephrine, 0.5% or Monsel's solution, a ferric subsulfate that coagulates blood at bleeding sites. Ethnic Chinese, Korean, and Vietnamese children with Down syndrome often had dry, flaky, pale earwax which was more difficult to remove.
Earwax can be removed by three methods: water pressure, suction and curettes. I much prefer using a metal aural curette such as Buck's angled (not straight), blunt (not sharp), size 1 German-made curette. Although I have limited experience with the plastic disposable curettes, they seem inferior to a proper-designed metal curette because of their light weight and thickness of the ring. However, in the hand of a novice, compared with a metal curette, the flex-loop design or infant ear scoop may be less likely to scratch the canal wall. One day soon, I plan to start a comparison trial of metal vs. plastic.
If the child/adolescent can remain still and the earwax is not tightly impacted or located more than one centimeter deep in the ear canal, skillful removal of the earwax can be performed in the sitting position. Many infants or struggling older children must have aural cleaning in a supine position with the arms and thighs restrained against the examining table.
After otoscopy shows me where the earwax has accumulated, the angled curette, which has been cleaned with isopropyl alcohol, is slowly introduced into the ear canal adjacent to the canal wall, taking care not to touch the canal wall itself. Although most procedure books demand that the procedure be done under direct vision using an operating head of the otoscope, I prefer to hold the curette in one hand and use the free hand to manipulate the auricle posteriorly and superiorly, to optimally straighten the ear canal.
After I believe that I have passed the earwax with the ring portion of the curette, I engage the circular ring of the curette at the inferior portion of the wax plug and very gently scoop the wax toward the external canal orifice. Care is taken to avoid friction against the tender canal walls. The procedure is repeated until otoscopy reveals an ear canal free of any obstructing wax or desquamated skin.
Bleeding can be expected about 10% of the time, so warn parents about this before the procedure. In most cases it is scant spotting. When bleeding is heavy (an infrequent event), I tell the parent that I am going to irrigate the ear canal with warm water because the cleaning caused some bleeding. The bleeding is kind of scary, but it does not mean that there is any damage to the eardrum, which lies about 1 inch away from the entrance. After gentle irrigation of the blood, I sometimes instill phenylephrine drops (0.5%) or Monsel's solution to control the bleeding, and pack the canal with a wick of cotton or with a methylcellulose expandable otowick. Should the curette method fail to remove the earwax, I turn to the disposable plastic syringe for aural irrigation.
For aural lavage, warm water is introduced into the ear with the aid of metal ear syringes, plastic irrigation syringes, or with the aid of a Water Pik irrigation system. Aural lavage is not advisable when there is a patent tympanostomy tube in place or when there is a perforation of the ear drum. Although a plastic emesis basin can be used to catch the effluent of water, it is preferable to purchase an inexpensive plastic aural basin, which is made for that purpose. Metal syringes with flanged cuffs can be purchased in the smaller 10-cc size or the larger 50-cc size. The latter can be very messy to use and can frighten young children. The 10-cc size German-manufactured syringe (Bausch & Lomb) refills itself automatically by spring recoil, after the content of the syringe is squirted into the child's ear canal. Irrigation instruments can be assembled from a 20-cc syringe and 18-gauge angiocath or 21-gauge butterfly needle with the needle and butterfly removed.
A simple-to-use commercially available squirt bottle can be purchased instead of using homemade devices (Elephant Ear Washer). Some primary care physicians use a Water Pik irrigation device at the lowest possible setting to irrigate the aural canals. I found that this is a very messy method that requires a plastic protective apron draped around the patient. When aural lavage is necessary, I prefer to use an inexpensive, portable 10-cc Monoject #412 plastic syringe with a scimitar-shaped plastic tip (Sherwood Medical Company). These dental syringes are designed for dry sockets after removal of impacted wisdom teeth. I use plain warm water (37° C), unless the impacted wax is especially difficult to remove. The curved tip is inserted into the ear canal and the stream of water is directed toward the posterior superior canal wall.
After four or five syringfuls of water have been squirted into the ear canal, the impacted earwax has usually been softened and relocated closer to the auditory orifice. A quick peak through the otoscope will verify this. A few more ranking motions with the blunt aural curette effectively removes the obstructing earwax.
Occasionally, I add about 25% by volume of 3% hydrogen peroxide to the warm water. Infrequently, I need to emulsify the wax for 15 to 20 minutes with docusate disodium drops (Colace, Waxsol), carbamide peroxide drops (Debrox, GlaxoSmithKline) or triethanolamine polypeptide (10%) in propylene glycol drops for the irrigation procedure to succeed. Triethanolamine (Cerumenex, Purdue Frederick) must be used only in the office. Home use can lead to severe contact dermatitis of the canal and auricle. Ten percent sodium bicarbonate solution is said to effectively soften hard earwax, but I have no experience with it. After the ceruminolytic agent has softened the hard, impacted wax, gentle aural lavage usually is successful.
On occasion, I have used a suction method machine with a neurosurgical suction tip (#7) to suction out the earwax, but this requires time-consuming assembly of the components. In addition, the noise off the suction in the ear canal can be frightening to children. Should all the above efforts fail to dislodge and remove impacted earwax, the child's parent is advised to install several drops of olive or vegetable oil into the ear canal(s) each night for several days, followed by insertion of an absorbent cotton wick to prevent the oil from dripping out of the ear.
It is said that meticulous removal of obstructing earwax is the mark of a good otoscopist. I know it is a miserable chore. I also know how much it is overlooked or overdiagnosed by failure to perform the task.
For more information:
- Schwartz, RH, Rodriguez, WH, McAveney W, Grundfast KM; Cerumen Removal: How necessary is it to diagnose acute otitis media. Am J Dis Child 983; 137:1064-5.
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