Ear syringing is a simple and common procedure, but it should be performed with caution and by an experienced professional. Cautionary advice: Medical negligence claims related to complications of ear syringing are common.1
Syringing should not be performed in the acute stages of otitis media or when perforation of the tympanic membrane cannot be excluded. In these instances, wax should be cleared with a hook or curette under direct vision (Fig. 13.6a).
Removal of wax: (a) a hook is rotated behind the wax to remove it; (b) syringing technique, in which water is directed around (not at) wax; (c) ear ‘cup’ to collect water; (d) the Higginson syringe with special attachments
In otitis externa, syringing may be performed to remove debris from the canal. Meticulous drying after the procedure is mandatory.
The average wax production is 2.81 mg/week. Most ear wax clears spontaneously without treatment. Proprietary preparations may be used as an alternative to syringing or to assist removal. These include hydrogen peroxide, carbamide peroxide (Ear Clear®) and docusate sodium (Waxsol®), but dioctyl sodium sulphosuccinate should not be used if perforation is suspected. Sodium bicarbonate (available on prescription) or olive oil drops may also be used. Culinary vegetable oil can be used by the patient prior to visiting the office.
A study by Kamien led to the conclusion ‘that the most effective, cheapest and least messy cerumenolytic is a 15% solution of sodium bicarboonate’.2 It can be readily made by dissolving ¼ teaspoon of sodium bicarbonate in 10 mL of water. Apply it with a dropper.
Another simple method is to fill the ear with liquid soap. Request the patient to ‘pump’ their tragus for a couple of minutes then attempt syringing.
The syringe should have a properly fitting nozzle and an airtight plunger. Friction in a metal syringe can be reduced by coating the inner plunger with petroleum jelly; it can also be primed with liquid soap. Water at body temperature (37°C) is a satisfactory solution (vertigo, nausea and vomiting may be precipitated by excessively hot or cold fluid coming in contact with the tympanic membrane).
The nozzle of the syringe should rest just inside the auditory meatus and the syringe should be angled slightly upwards (Fig. 13.6b). Water directed along the roof of the external auditory canal cascades around and behind the plug of wax. Pulling the pinna upward and slightly backward straightens the canal, and may assist partial separation of the wax plug.
While a kidney dish is the traditional collecting vessel for the syringed fluid, an empty plastic ice cream ‘bucket’ is a practical alternative: the pliable sides mould easily into the shape of the neck. Another improvised ear ‘cup’ can be cut out from a used hospital 1 L plastic bottle. A small recess can be made for the ear (Fig. 13.6c).
This is a very effective system that provides a constant flow of water, maximum safety, and a free hand when syringing the ear.
The apparatus consists of:
The washer maintains the rubber syringe in the basin of water during the ear syringing. The metal eustachian catheter provides an ‘accurate’ jet of water, which is aimed superiorly above the wax in the usual, recommended manner (Fig. 13.6b).
If the patient complains of deafness due to water retention, instil acetic acid-alcohol drops (Aquaear® or Ear Clear®). This gives instant hearing. Some doctors routinely use these drops after syringing out the wax.
A simple ear syringe can be improvised from a 20 mL or 50 mL syringe and a plastic ‘butterfly’ intravenous cannula. The apparatus is also useful for instilling ointment to treat otitis externa.
Firmly attach the ‘butterfly’ cannula to the syringe and cut off the tubing, leaving it about 3–4 cm long (Fig. 13.7).
This ‘ear syringe’ is flexible, safe and easy to use, especially for children. The curve at the end of the tubing permits good positioning in the ear canal.
Note: Some doctors testify to the value of adding a small quantity of povidone-iodine solution to the water, especially if otitis externa is present. Others prefer hydrogen peroxide (100 mL bottles of 30 mg/mL are available in supermarkets) for ear toilet, especially with low-grade otitis externa.
People who use hair sprays are prone to developing hard wax if it finds its way into the ear canal. Advise these people to cover their ears when they use the spray.
Keratosis obturans—a pearly white plug of keratin—can develop.