Cerumen should be removed when it causes symptoms or obscures the tympanic membrane — not routinely. The wax has a protective function, and the commonest complication of ear syringing is that someone syringes an ear that did not need syringing. The second commonest is that the syringing is performed on a tympanic membrane that was already perforated.

Indications

Otoscopy: earache, hearing loss, ear discharge, dizziness, tinnitus, fever in a child without an obvious focus, and before every ear syringing.

Removal of cerumen:

Hearing loss, a blocked sensation, itching, earache or dizziness attributable to a wax plug.
The tympanic membrane cannot be inspected and the examination is needed for the diagnosis.
Before audiometry or the fitting of a hearing aid.
Recurrent otitis externa in which the wax retains moisture.

Contraindications

Absolute contraindications to irrigation:

A known or suspected perforation of the tympanic membrane — including a history of grommets, ear discharge or pain on contact with water.
A history of ear surgery in which the middle ear may be open (a mastoid cavity, mastoidectomy).
An only hearing ear.

Relative (choose a manual technique or refer to ENT):

Condition	Reason
Diabetes, immunosuppression	A risk of necrotising otitis externa
Anticoagulant treatment	Bleeding into the ear canal
Previous radiotherapy to the head and neck	Fragile skin, poor healing
Ear canal stenosis or exostoses	Narrow and hard to reach
Ongoing otitis externa	Pain, spread of infection
A small or uncooperative child	Movement causes injury

Preparation and equipment

Otoscopy: an otoscope with a charged battery and clean disposable specula in several sizes. Use the largest speculum that will fit — it gives the most light and the best view.

Irrigation: a 30–60 mL syringe with a soft irrigation catheter, or an electric ear irrigator with pressure limitation, body-temperature water or saline (36–37 °C), a kidney dish, a towel, suction.

Manual technique: an operating otoscope or a head lamp with a loupe, a cerumen curette or loop, an angled hook, alligator forceps, a suction catheter (Frazier or Baron, 5 Fr).

Cerumenolytics (docusate sodium, sodium bicarbonate drops, olive oil, carbamide peroxide) are instilled 15–30 minutes before the procedure, or over a few days at home for a hard plug. Have the patient lie with the ear uppermost for 5 minutes after instillation.

Procedure

Otoscopy

Inspect the outer ear, the tragus and the area behind the pinna before the otoscope is inserted — mastoid erythema and a protruding ear are not part of the tympanic membrane, but they are the most important finding when they are present.
Straighten the ear canal: pull the pinna upwards and backwards in adults, downwards and backwards in small children.
Rest your hand against the patient's cheek so that the otoscope moves with the head if it moves.
Insert the speculum under vision, to a maximum of about 8 mm.
Follow a systematic order: the skin of the ear canal → the colour and translucency of the tympanic membrane → the light reflex → the handle and short process of the malleus → the pars flaccida → signs of fluid (a level, bubbles, retraction or bulging).
Where needed, pneumatic otoscopy: a slight change of pressure with the bulb shows whether the tympanic membrane is mobile — an immobile membrane suggests fluid in the middle ear.

Two panels: in the adult the pinna is pulled upwards and backwards, in the small child downwards and backwards, and in both cases the straightened ear canal is shown in section — Figure 1. The ear canal is S-shaped at rest and must be straightened for the tympanic membrane to become visible. On the left the adult: the upper posterior edge of the pinna is grasped between the thumb and index finger and pulled upwards and backwards. On the right the small child, whose ear canal is shorter and directed more downwards and forwards: here the pinna is pulled downwards and backwards instead. The section beneath the skin shows how the canal is straightened from the meatus in to the tympanic membrane.

An examiner holds the otoscope like a pen with the little and ring fingers resting against the patient's cheek, while the other hand pulls the pinna upwards and backwards — Figure 2. The otoscope grip. The otoscope is held like a pen, with the grip close to the instrument head, and the little and ring fingers resting against the patient's cheek or cheekbone. The hand and the instrument then move with the head if it moves suddenly, instead of the speculum being driven towards the tympanic membrane. The other hand simultaneously pulls the pinna upwards and backwards. The grip is particularly important in children.

Irrigation

Confirm that the tympanic membrane is intact if it can be seen at all, and ask specifically about a previous perforation or grommets.
Instil a cerumenolytic and wait 15–30 minutes.
The patient sits upright with a towel over the shoulder and holds the kidney dish against the neck below the ear.
Insert the catheter tip no more than 0.5 cm into the ear canal, not beyond the hair-bearing skin.
Direct the jet upwards and backwards along the superior wall of the ear canal, past the plug — not straight at it. The water should get behind the wax and push it out.
Use moderate pressure. Repeat in several rounds and inspect between each.
Dry the ear canal and check the tympanic membrane. With an intact membrane, a few drops of isopropyl alcohol can speed the drying.

Manual removal

The work is more stable if the patient lies down with the head supported. Under direct vision: soft wax is removed with suction or a spoon-shaped curette, hard wax with a loop or an angled hook passed beyond the plug to draw it outwards. Never work with an instrument whose tip you cannot see.

Consistency of the wax	Best technique
Soft, liquid	Suction
Firm but yielding	Curette or spoon
Hard, impacted	A cerumenolytic for a few days, then a loop or hook
Wax around a foreign body	No irrigation — see the separate guide

Interpreting the tympanic membrane

Always assess four things: colour, translucency, position (retracted, normal or bulging) and mobility. It is the combination that gives the diagnosis — redness alone is not sufficient, since a crying or febrile patient can have a red tympanic membrane without a middle ear infection.

Otoscopic view of a normal tympanic membrane: pearly grey and semi-translucent with the handle of the malleus as a pale streak and a triangular light reflex below the centre — Figure 4. A normal tympanic membrane seen through the otoscope. The membrane is pearly grey, semi-translucent and slightly concave. The handle of the malleus runs as a narrow pale streak obliquely upwards and forwards from the umbo in the centre and ends above at the short process, which bulges out as a small knob. From the umbo the triangular light reflex extends forwards and downwards into the anterior inferior quadrant. Around the edge runs the annulus fibrosus as a pale ring; above the malleolar folds lies the less taut pars flaccida, and the remainder is the pars tensa. Through the membrane the long process of the incus can be glimpsed.

Otoscopic view in acute otitis media: a markedly red, opaque tympanic membrane bulging outwards, with the light reflex obliterated and the handle of the malleus obscured — Figure 5. Acute otitis media. The tympanic membrane is opaque, markedly red and bulging outwards towards the observer so that the normal concavity is obliterated — the bulging is the finding that carries the most weight, since redness alone can be caused by crying or fever. The handle of the malleus is partly obscured by the swelling and the short process cannot be made out. The light reflex is absent or broken up into scattered glistening patches. Radial vascular markings run along the handle of the malleus and along the annulus, and purulent content can be glimpsed behind the membrane.

Finding	Typical appearance	Interpretation
Normal	Pearly grey, translucent, light reflex forwards and downwards, mobile	No middle ear pathology
Acute otitis media	Opaque, red, bulging, immobile	The question of antibiotics according to the national recommendation
Otitis media with effusion	Dull, yellowish or amber, retracted, a fluid level or bubbles, reduced mobility	Fluid without acute infection — hearing check and follow-up
Perforation	A dark defect with a sharp edge, often in the pars tensa	Irrigation contraindicated
Grommets	A small plastic tube in the membrane, usually in the anterior inferior quadrant	Irrigation contraindicated
Myringitis	Blisters on the surface of the membrane	Painful, often viral
Cholesteatoma	A white flaking mass or a retraction pocket in the pars flaccida	Refer to ENT

The tympanic membrane cannot be assessed at all if the wax obscures it. Describing a tympanic membrane you have not seen is a record entry that can become dangerous — write instead that it could not be inspected, and why.

Complications

Perforation of the tympanic membrane — usually from too high an irrigation pressure or from instrumenting too deeply.
A vestibular reaction with dizziness, nausea and bradycardia if the irrigation fluid is not at body temperature (caloric stimulation).
Otitis externa, particularly if water remains behind residual wax.
Necrotising otitis externa in patients with diabetes or immunosuppression — uncommon but serious.
Bleeding and laceration of the ear canal, tinnitus, hearing loss.

Stop immediately in the event of severe pain, dizziness, tinnitus, sudden hearing loss or bleeding.

Aftercare and follow-up

Check the hearing after the procedure — preferably with the same method as before. Explain that cotton buds push the wax deeper and should be avoided. For recurrent wax plugs, olive oil 2–3 drops a week can be used prophylactically.

With a suspected perforation after irrigation: keep the ear dry, avoid drops containing neomycin, and review after 3–4 weeks. A persisting perforation or hearing loss is referred to ENT.

Common pitfalls

Irrigating on an incomplete history. Ask explicitly about grommets, a previous perforation and ear surgery — otherwise you will find out afterwards.
Cold or hot irrigation fluid provokes dizziness and nausea. Body temperature, every time.
Instrumenting too deeply. Stay within 8 mm unless you have a full view.
Neomycin-containing drops cause contact dermatitis in up to 13 % — choose another preparation.
A water jet device or an oral irrigator as an irrigation tool — the pressure is sufficient to rupture the tympanic membrane.
Continuing indefinitely. Decide in advance how many attempts are reasonable; a hard plug is better resolved by a few days of softening than by ten irrigations.
Removing asymptomatic wax — without an indication there is only risk.

Otoscopy and ear syringing