1. Irrigating an ear with a missing or diseased ear drum puts the middle ear and hearing at serious risk. In these situations, an ENT physician will suction the wax under binocular microscopic vision. The PCP should never put a diseased ear at risk, by irrigating or picking blindly.
   
   
2. Following oto irrigation, the ear canal is at risk for Pseudomonas proliferation and resultant otitis externa. This is easily prevented by placing 1 or 2 drops of Domeboro, Vosol or Cortisporin otic in the irrigated canal. For individuals who reaccumulate wax frequently, Domeboro otic, 2 qtts A.U. twice weekly after showering is excellent treatment. Ear wax accumulates because of excess production or poor migration out of the external auditory canal. Ear canal skin is generated on the tympanic membrane and then migrates laterally out the ear canal. The Domeboro otic increases the migration rate, thereby improving cerumen removal.
   
   
3. Cerumen softeners:
   1. Mineral oil/baby oil
   2. Cerumenex
   3. Rubbing Alcohol and White Vinegar (50/50)

Overview of Cerumen Extraction

Cerumen production and impaction is a common problem, more frequent amongst some ethnic groups. The only real means available to the primary care physician to remove the wax is to irrigate. This is an effective technique; most of the time. In some cases because the wax is too hard it will not irrigate and the addition of cerumen softeners (either those commercially produced or plain mineral oil) will facilitate irrigation.

A number of different irrigation setups are available. The simplest is a 20cc syringe with a 14 gauge angiocath. Commercial irrigators are available. Some use a dental Waterpik. If compressed air is available, conventional ENT otic irrigation systems are used.

The base irrigant is water. Some add alcohol, some add hydrogen peroxide, some add vinegar and some add a small amount of Burrow's solution. The additives, as long as they are not harmful, are irrelevant. It is important that the water be body temperature. If the water is too hot or too cold, vestibular caloric stimulation occurs and patients will be dizzy. Those who are extremely dizzy, may even vomit.

Following irrigation, it is wise to protect against otitis externa with a single application of any commercially available ear drop.

Irrigation with or without cerumen softeners will work most of the time. When irrigation fails to work, persistence rarely brings success, and often brings pain. Propitious ENT referral is then wise. An otolaryngologist will remove the wax under direct vision either with a loop and small cup forceps often with a binocular microscope with 6x or 10x magnification.

There are some ears which should not be irrigated. These include those with chronic otitis media. If the ear drum is missing, irrigation will force the wax into the middle ear and will cause an otitis media. It potentially could cause ossicular or round window damage and subsequent hearing loss.

Contraindications, therefore, are chronic ear disease or tympanic membrane perforation by history. If the patient has only a single hearing ear and this is the one filled with wax, then that patient should be taken care of only by an otolaryngologist.

How to prevent recurrent cerumen accumulation is not a well studied topic. If a patient requires cerumen disimpaction every two or more years, most are better off simply to come to their physician to have this done. If the accumulation is more frequent, or if they wish for definative treatment two paradigms are offered.

Option 1: Self-administered two or three drops of mineral oil into each ear canal once weekly. Some patients will use a small bulb syringe to flush their ear with warm water. If indeed they can keep the wax soft and successfully irrigate their ear, remove the wax, not hurt themselves and not induce vertigo, this is a reasonable plan.

Option 2: Prescribe a 60cc bottle of Domeboro otic with instructions to place two drops in each ear once weekly after showering. Cerumen is produced by eccrine glands in the lateral portion of the external auditory canal. The accumulation is a balance between the wax production and the outward migration rate of the external auditory canal epithelium. The external auditory canal epithelium is generated on the tympanic membrane and then migrates laterally, out the external auditory canal. The Domeboro stimulates the epithelial migration and therefore facilitates natural removal. This is an effective technique, but requires an individual who is both compulsive and compliant.

A word about Q-tips. The standard ENT recommendation is "nothing smaller than your elbow in your ear canal". This obviously excludes Q-tips. However, many individuals use Q-tips on some regular basis without having difficulty. The official recommendation is to not use them. The unofficial recommendation is to not use them, but if you do, to only use them once or twice a week, and to use them gently to swab the lateral half of the external auditory canal. At no time are they to be used on a once or twice daily basis and at no time are they to be used vigorously to scrub every last bit of wax and oil from the external auditory canal.