This document discusses earwax, also known as cerumen, and methods for removing impacted earwax. It describes the structure and composition of earwax, noting that it helps clean and lubricate the ear canal while also playing an antibacterial and antifungal role. When earwax becomes impacted, it can cause symptoms like a blocked ear sensation, discomfort, pain, tinnitus, and hearing impairment. The document outlines common techniques for removing impacted earwax, including using cerumenolytic drops to soften the wax, syringing the ear canal with water, and instrumental removal with tools like a cerumen hook. Complications from improper removal are also discussed.

1. EAR WAX ANDEAR WAX AND
SYRINGINGSYRINGING
Dr. Avinash Malekar

2. Histology of EAC
• External canal is lined entirely by keratinising stratified
squamous epithelium. This epithelium is in continuity
with the lateral surface of the tympanic membrane
Bony part (Inner 2/3rd) Cartilageous part (Outer 1/3rd)
The skin lining the bony canal is very
thin, measuring about 30 - 50 microns
in thickness
Skin here is loosely adherent to the
underlying bone, facilitating easy
elevation during surgery
Skin over the cartilagenous canal is
much thicker and more adherent
than the skin of the bony canal
Rete ridges are absent in the skin
lining the bony portion of the
external canal. The skin here lacks
hair and other appendages
It has numerous hairs as well as
sebaceous and ceruminous glands

3. Histology of EAC

4. EAR WAXEAR WAX
• Wax is composed of secretion of sebaceous
glands, ceruminous glands, hair, desquamated
epithelial debries , keratin, dirt
• Sebaceous and ceruminous glands open into
space of hair follicle
• Sebaceous glands provide fluid rich in fatty
acids while secretion of ceruminous gland is
rich in lipid and pigment granules

5. • The primary components of earwax are the final
products in the HMG-CoA reductase pathway,
namely, squalene, lanosterol, and cholesterol

6. Wax
WET WAX
• Light or dark brown and
sticky
• High concentration of lipid
(around 50%) and pigment
granules
• Found in Caucasians and
Africans
DRY WAX
• Grey or tan
and brittle
• Contains around 20% lipid
• Found in Asians
and Native Americans

8. Functions of ear wax
• 1. Cleaning
• Cleaning of the ear canal occurs as a result of the "conveyor belt"
process of epithelial migration, aided by jaw movement.
• Cells formed in the centre of the tympanic membrane migrate
outwards from the umbo (at a rate equivalent to that of fingernail
growth) to the walls of the ear canal, and accelerate towards the
entrance of the ear canal.

9. • The cerumen in the canal is also carried outwards, taking
with it any dirt, dust, and particulate matter that may have
gathered in the canal. Jaw movement assists this process
by dislodging debris attached to the walls of the ear canal,
increasing the likelihood of its extrusion.
2. Lubrication
• Lubrication prevents desiccation and itching of the skin
within the ear canal (known as asteatosis).
• The lubricative properties arise from the high lipid content
of the sebum produced by the sebaceous glands
• Lubrication of EAC helps to entrap foreign material

10. • 3. Antibacterial and antifungal roles
• Recent studies have found that cerumen has a bactericidal
effect on some strains of bacteria.
• Cerumen has been found to be effective in reducing the
viability of a wide range of bacteria (sometimes by up to
99%), including Haemophilus influenzae, Staphylococcus
aureus, and many variants of Escherichia coli.
• The growth of two fungi commonly present in otomycosis
was also significantly inhibited by human cerumen. These
antimicrobial properties are due principally to the presence
of saturated fatty acids, lysozyme and, especially, to the
relatively low pH of cerumen (typically around 6.1 in
normal individuals).

11. Symptoms caused by impacted wax
1. Sense of blocked ear
2. Discomfort or pain in ear
-Patient seldom complains pain unless the wax is
pressing on the drum
3. Tinnitus
- Results from impaction of wax
against tympanic membrane

12. 4. Impairment
of hearing
5. Reflex cough
- Occurs sometimes due to stimulation of auricular
branch of vagus

13. Treatment of impacted wax
• CERUMENOLYSIS
• SYRINGING
• INSTRUMENTAL MANUPULATION

14. CERUMENOLYSIS
•It is usually necessary to soften wax before its removal. This
process is referred to as cerumenolysis, and is achieved using
a solution known as a cerumenolytic agent which is
introduced into the ear canal
•Patient should lie with the affected ear uppermost for 5-10
minutes after the drops have been introduced into the ear
canal. Repeated digital pressure on the tragus encourages
movement of the drops and wax dispersal
•The most common home-remedy for this purpose is olive
oil. Other commercially available and common
cerumenolytics include:

15. CeruminolyticsCeruminolytics

16. Ceruminolytics
Oil based Water based Non-water non-oil
based
Olive oil Sodium bicarbonate
(5-10%)
Carbamide peroxide
Almond oil Hydrogen peroxide
(3%)
Glycerol combination
preparations
Peanut oil Acetic acid (1-3%) 2%
paradichlorobenzene
Docusate sodium

17. SYRINGING
• Irrigation or "syringing" is a standard method of wax
removal
• Indications for syringing:
1. Removal of wax
2. Dried fungal debris
3. Epithelial debris
4. Blunt foreign bodies

18. • Contraindications for syringing
1. Acute inflammatory conditions of the external or middle
ear
2. Discharge from the ear
3. Perforation of the tympanic membrane
4. Previous ear surgeries
5. Impacted hygroscopic foreign bodies
6. Sharp foreign bodies

19. Technique of ear syringing

20. How ear syringing done?
Patient is seated with the ear to be syringed towards the
examiner
A kidney tray placed over the shoulder of the patient
The syringe is held in the right hand. Normal saline,
distilled water or normal water can be used after boiling
and cooling at 37º which is the normal body temperature.
Water has to be cooled to body temperature to prevent
labyrinthine stimulation (Caloric effect)

21. Pinna is pulled upward and backward in adults and
downwards and backwards in younger children to
straighten external ear canal
Stream of water is directed towards the posterio-superior
wall of the meatus. The pressure of the water builds up
deeper to the wax and expels the wax out
The ear is made dry with a cotton swab after the
procedure. At the end of this procedure, the ear canal, and
tympanic membrane must be inspected and dried up with a
cotton pledget.

22. • Complications of syringing can be:
1. Trauma to external canal or tympanic membrane
2. Giddiness usually temporary
3. In the rare instances when there is a perforation, irrigation
may force water and wax into the middle ear, causing a
nidus for infection
4. Vaso-vagal shock

23. INSTRUMENTAL MANUPULATION
• Should be done by skilled hands
• Cerumen hook, Jobson-Horne probe or crocodile forcep
• The instrument is passed alongside and deep to the wax
and drawn carefully outwards, removing the wax deposit

24. Crocodile forcep Jobson Horne’s forbe

25. Otomicroscopic wax removal

26. ReferencesReferences
1. J.F. Guest, M.J. Greener, A.C. Robinson, A.F. Smith.
Impacted cerumen: composition, production, epidemiology
and management. (2004).
qjmed.oxfordjournals.org/content/97/8/477
2. Mark A. Lutterbie, Daniel F. McCarter. Cerumen impaction
(2008). Geriatrics 342-346
3. Specialist-ent.com/procedures-surgeries/syringing-ears
4. Diseases of Ear, Nose and Throat: P.L. Dhingra
5. Diseases of Ear, Nose and throat: Mohan Bansal
6. Anatomy of external auditory canal: www.drtbalu.com
7. Impacted cerumen: composition, production, epidemiology
and management | QJM: An International Journal of
Medicine

27. THANK YOU