APB Lec 19: Wax Management

Introduction

• Presentation starts by notifying students about the material's copyright by the University of Melbourne under the Copyright Act of 1968.

• Emphasizes an engaging and interesting topic: wax management in the ear.

Lecture Overview

• This lecture has been expanded from a condensed version previously given to the second-year students, aiming to prepare students for practical advanced otoscopy and wax removal activities.

Learning Outcomes

• Students should be able to:

  • Identify composition and purpose of cerumen (earwax).

  • Recognize when there is excessive cerumen and understand its management.

  • Know when to refer patients for further treatment.

  • Educate clients about the helpful role of earwax and how to manage it.

Importance of Educating Clients

• Emphasizes the necessity of educating clients regarding earwax, including:

  • Understanding that some wax is healthy and beneficial.

  • Using visual aids (e.g., photographs) to explain ear damage caused by improper cleaning techniques, such as cotton swabs.

Common Misconceptions and Cleansing Tools

• Highlights the common practice of using cotton swabs to clean ears despite warnings against it.

• Introduces a product called WaxVac, claiming to be a safer alternative for ear cleaning with the following features:

  • Gently draws wax and moisture out of the ear instead of pushing it in.

  • Equipped with a safety guard to prevent deep insertion.

  • Promotes the idea of being a safer, effective solution, although research indicates it is ineffective at wax removal.

Ear Canal Anatomy Review

• Restates previous knowledge about ear canal anatomy:

  • Cartilaginous portion is resilient and can withstand manipulation, while the bony part is more fragile.

  • The thin epithelial lining in the bony canal is susceptible to infection and damage if mishandled.

  • No hairs are located in the bony portion of the canal as compared to the cartilaginous region.

Composition and Function of Cerumen

• Cerumen is composed of a mixture of oils and skin flakes, where its production varies significantly between individuals.

• Importance of cerumen includes:

  • Lubricates and protects the ear canal; it is hydrophobic (repels water).

  • Traps dust and foreign particles through its sticky nature.

  • Acts bactericidally, causing a reduction in bacterial populations found in the ear.

  • Epithelial migration pattern allows for self-cleaning of the ear: migration occurs from the umbo (center of eardrum) outward, based on blood supply.

  • Aging may slow this self-cleaning mechanism and result in harder wax buildup.

Expert Role of Audiologists in Wax Management

• Audiologists serve a critical role in ear health, often spending more time with patients than GPs or ENTs.

• Importance of clear ears for effective audiological assessments (e.g., audiograms, ear impressions, probe tube measurements).

• Background on addressing wax issues routinely as part of the audiologist’s skill set.

Assessing Excessive Wax

• Determining how much wax is too much often relies on subjective assessments or patient reports of blockage or discomfort.

• Example shared of a patient with a single hearing ear needing wax removal due to significant buildup affecting hearing.

• Usage of micro suction as a recommended method for safely removing wax when deeper impaction is present.

Types of Cerumen

• Cerumen varies by appearance, with two basic types:

  • Dry and hard wax (associated with certain genetic backgrounds).

  • Soft and oily wax that is more common and easier to manage.

• Genetics and ethnicity play a role in the wax's consistency; variations can occur based on age, individual health changes, and environmental factors.

Removal Techniques and Considerations

• Earwax removal techniques discussed include:

  • Manual removal using specialized tools (i.e., curettes, forceps).

  • The importance of gentle techniques to avoid damaging the ear.

  • Consultation about when wax removal is advised versus when it’s beneficial to leave some wax present for its protective properties.

Patient Education

• Patients are encouraged to avoid using unsafe cleaning methods (e.g., cotton swabs, bobby pins, ear candles) which may inadvertently introduce harm.

• Emphasis on ongoing communication and education regarding ear health to prevent future issues with cerumen occlusion.

Effective Wax Management Techniques

• Several procedures outlined for wax removal:

  • Suction is the preferred method for ear wax management as machinery becomes more cost-effective and accessible.

  • Aerosolized irrigation systems are less favored due to potential risks but might be employed under specific circumstances.

  • Various drops are available (aqueous/oil-based) to assist in wax softening but should always be confirmed safe based on eardrum integrity; alternatives like hydrogen peroxide were emphasized for use only if eardrums are intact.

• Suggested best practices for cerumenolytics involve educating clients on proper techniques and understanding that it is a tool to assist with the management of cerumen rather than a one-stop solution.

Clinical Practices and Safety Measures

• In clinical practice, establishing patient comfort and safety is paramount.

• Continuous assessment of patient welfare and ready communication is essential during procedures that may discomfort clients.

• Communication of risks, emergency procedures, and informed consent are foundational to a successful patient experience.

Conclusion

• The importance of the knowledge accumulated regarding cerumen composition, management tactics, and the ethical considerations in patient treatment is reiterated.

• Patients should be properly educated on earwax’s role and how to manage ear health effectively.

• Closing remarks encourage engagement and participation in the next lecture focused on pediatric management case studies.

🩺 Introduction

• Lecture topic: Wax management — foundation for future advanced otoscopy and wax removal sessions in second year (PRC).

• Aims:

  • Identify composition and purpose of cerumen.

  • Recognise when there is too much and how to manage or refer.

  • Understand education as a universal role for audiologists.

• Even if you don’t remove wax, you must educate clients:

  • Some wax is healthy and protective.

  • Show otoscopic images (e.g. bruises from cotton buds) to reinforce safe habits.

👂 Ear Canal Anatomy Review

• Cartilaginous portion:

  • Robust, flexible; tolerates movement, sleeping pressure, scratching.

  • Contains hair follicles and glands.

  • First bend occurs just past the concha bowl — wax often hides behind this bend.

• Bony portion (medial ²/₃):

  • Very thin epithelial lining (30-50µm)

  • Lacks hairs and glands.

  • Blood supply drains to internal maxillary artery → possible intracranial infectious route → avoid trauma/infection to prevent meningitis.

• Key difference: hair & glands = cartilaginous only.

🧴 Earwax ( Cerumen )

Composition

• Mix of extruded oils, skin flakes (keratin)

• Naturally occurring and desirable

• Rate of production varies from person to person

• Consistency depends on genetics:

  • Dry type (Asian/Native American) vs Wet/Oily type (European/African).

• Fresh wax is lighter and squishy; Old wax is harder and darker

Normal Location & Function

• Found in lateral ⅓ to ½ of ear canal.

• Over-cleaning removes protection.

• Functions:

  1. Lubricates ear canal – prevents dryness/itching

  2. Hydrophobic – repels water

  3. Cleanse ear canal / sticky — trap dust, insects, debris (then migrates out)

  4. Bactericidal – reduces bacterial counts by 17–99 % (esp. in soft/wet wax)

  5. Unappealing to insects – bitter taste

🔄 Epithelial Migration (Self-Cleaning Mechanism)

• Discovered by Makino & Amasu (1986):

  • Ink dots on TM migrated outward related to orientation of blood vessels in TM and canal

• Requires intact TM and blood flow; Poor blood supply to TM → epithelial migration disturbance

• Slows with age → wax hardens, darkens, becomes impacted.

• Sebaceous gland atrophy with age → reduces lubrication in elderly

👩‍⚕ Audiologists’ Role

• Experts in:

  • Ear anatomy & hearing health.

  • Communicating to hearing-impaired clients.

• More time and skill than GPs or many ENTs for routine wax care.

• Clean ears essential for:

  • REMs, ear impressions, tymps, audiometry etc.

• Historically: lack of wax-removal skills → GP referrals → poor outcomes.

• Now: audiologists should routinely manage wax safely and educate clients.

❓ How Much Wax Is Too Much?

• Judgement call:

  • Depends on symptoms & clinical task

  • Example: client with one functioning ear—small amount of deep wax → significant impact → needs microsuction

• Never irrigate a single-hearing ear; risk > benefit.

• Removal justified when:

  • Symptomatic (blockedness, tinnitus).

  • Obstructs test equipment.

  • Prevents probe-tube or ear-mould seal.

• Always leave some soft, lateral wax for protection.

🧫 Impact on Audiological Tests

🧬 Types of Cerumen

• Produced in outer ⅓–½ of canal.

• Migrates medially → laterally with epithelium → extruded from cartilaginous portion of the meatus

• Genetic variation: ethnicity → dry vs wet wax.

• Wet type: light, shiny, sticky.

• Dry type: dark, flaky, hard.

• Desquamated epithelium may adhere; removing too early = tearing a scab off → bleeding risk.

• Establish how easy it will be to remove

  • Firm enough that holds together in one piece

  • Soft enough that doesn’t traumatise the canal wall when removed

📸 Clinical Examples (Described in Lecture)

• Case 1: Sheets of keratin + wax → recurrent build-up every 3–4 months → feedback in hearing aid → routine suction.

• Case 2: Evaluate ease of removal beforehand:

  • Ideally firm but not hard.

  • Avoid over-softening (e.g., excessive Waxol → slurry).

  • Assess first before advising drops.

🧰 Wax Removal Technique Principles

• Goal: remove enough for clinical purpose (not totally)

• Assess:

  • Location (depth, sides).

  • Consistency (dry/flaky/runny).

  • Visibility of landmarks (2^nd bend, TM, malleus, light reflex).

• Stop when: task achievable and canal remains lubricated.

🔎 Otoscopy Best Practice

• Purpose = diagnosis, not speed.

• Identify: light reflex (anterior), handle of malleus, IS joint, second bend.

• False fundus: appears as a false ending in scarred/short canals — may follow ear surgery/ chronic middle ear issues/ repeated scraping/trauma/ thickened/scarred TM

  • no clearly identifiable landmarks

  • Refer if uncertain

• Always photograph and document.

🚫 Foreign Bodies & Injuries

Common Findings

• Grommet in child ear — may turn sideways in canal; remove with hook.

• Hearing-aid domes — frequent detached foreign bodies.

• Sand on eardrum — post-beach exposure.

• Cotton Bud Abuse (CBA) — canal haematoma, bruising in bony canal.

  • Recent frustrations with hearing aid → too forceful with insertion of aids (power domes)

  • Educate patient with otoscopic images.

🦴 Bony Growths

Exostoses (“Surfer’s Ear”)

• Bony outgrowth from repeated cold water/air exposure.

• Multiple, broad-based, often bilateral.

• May cause ≥ 80 % occlusion → ENT referral.

• Avoid syringing/sprays — fluid can be trapped behind lesions.

Osteoma

• Pedunculated (narrow-based) bony protrusion.

• Benign, asymptomatic, histologically same as exostosis.

• Can collect debris behind

• Document and monitor growth with otoscopic photos.

• If uncertain → refer ENT to rule out cholesteatoma.

🦠 Fungal Infections (Otomycosis)

• Appearance: fluffy white/black spores, smelly (purulent)

• Symptoms: pain, itch, odour.

• Treatment:

  • Aural Toilet

  • Clean with 3 % hydrogen peroxide (only solution that is safe if eardrum integrity unknown).

  • Suction

  • Frequent re-checks.

  • Avoid introducing new infection vectors (cotton buds, keys, nails).

• Possible outcome: perforation → often heals over months with scarring.

💧 Irrigation (Syringing)

• Last resort, desperate practice

• Risks:

  • Drum rupture (high pressure).

  • Vertigo (if temperature ≠ body temp).

  • Blind procedure → trauma.

• Never syringe:

  1. Better hearing ear.

  2. Mastoid cavity.

  3. Non-intact TM.

• Safer spray systems now use radial jets and temperature gauges.

🧴 Wax-Softening Drops (Cerumenolytics)

Oil-based

Aqueous-based

• Do not use any drops unless TM is intact.

• 3 % Hydrogen peroxide = only safe option if TM status uncertain.

📊 Research — Effectiveness of Ceruminolytics

• Saxby, Williams & Hickey (2012) in-vitro study:

  • Compared distilled water, olive oil, NaHCO₃, Sulfradex, urea + H₂O₂, betamethasone.

  • Result: Distilled water was better than any commercially available agents

  • Limitation: wax homogenised mixture → not realistic.

• Conclusion: tailor method to individual wax type.

🧫 Ceruminolytic Mechanisms

Cerumenolytics: appropriate for assisting in keeping wax soft for more effective migration.

Procedure Example

• Head tilted ear-up; 2 drops H₂O₂ via speculum.

• Observe oxidation bubbling = active effervescence loosening wax.

⚙ Mechanical Removal Techniques

Tools

• Forceps (alligator / round-nose).

• Currettes (flat, angled, hook, spoon types).

• Tweezers (fine hairs or small debris).

• Suction (microsuction unit ≤ 500 mmHg).

Suction Notes

• Most effective and controlled method.

• Modern machines ≈ $700–800; older > $4000.

• Always clean canisters — stagnant wax smells.

• Clarinetting = squeaky noise from sheet-like keratin over suction tip.

• Beware of cooling effect → possible caloric vertigo.

Key Rule

🧠 Decision Making During Removal

Usually mix methods (dissection → suction → rinse).

🔍 Essential Equipment

• Magnification + illumination (otoscope / O-scope / microscope / WaxScope).

• Depth perception (not binocular)

  • Binocular viewing

• Patience

• Steady hands

• Specula – multiple sizes, stainless steel / autoclavable plastic

• Ergonomic setup – stable anchoring points.

• Cost guide:

  • O-scope ≈ $3.5 k.

  • Microscope ≈ $15 k.

  • WaxScope ≈ $5–6 k (+ training $3–4 k).

🪞 Patient Interaction & Consent

• Explain procedure in plain language (with hearing aids in if help communication)

• Obtain explicit consent — ask for permission to proceed / if it’s ok to touch their ear

• Warn about discomfort; MUST let you know if becomes unbearable or painful

• Show images before & after → education + medicolegal proof.

• Check for anticoagulant use → bleeding management (tissue spears, vasoconstrictor spray).

• Maintain dialogue throughout; observe body language.

🚫 When Not to Proceed

• No consent.

• Wax beyond your skill level.

• Canal anatomy prohibits safe access.

• Client cannot sit still (Parkinson’s, children).

• Lacking proper equipment.

• Self feeling uncomfortable performing procedure.

🪑 Patient Setup & Clinician Positioning

• Client:

  • Seated comfortably, neck supported.

  • Head slightly tilted away to straighten canal.

• Clinician:

  • Feet flat, arms anchored (e.g., chair arm or shoulder rest).

  • Speculum held with hand nearest nose (left ear = left hand).

  • Use opposite hand for instrument if possible (ambidextrous practice).

  • Plan approach → identify “handle” (area to start lifting).

  • Avoid deep blind curettage.

  • Assess gaps behind wax before using suction or curette.

🧩 Example Analysis

• Deep, shiny dark wax → likely dry, hard → poor suction grip → start posteriorly, loosen edges.

• If visible gap at top → hook behind and peel; if not → attempt gentle suction only.

🧷 Foreign Body Extraction

• Prefer forceps for domes, beads, or grommets.

• Drops contraindicated.

• Always reassess TM after removal.