Washing Out Earwax with an Irrigation System
While there is not enough evidence to support the superiority of certain earwax removal procedures over the other, some methods such as the use of curettes take time, require a lot of experience and detailed precision in order to treat earwax. Hlololego and Dr Dirk from eMoyo unpacked and evaluated a few irrigation systems available on the market.
Cerumen, or earwax, is brown, yellowish, orange or gray is a waxy substance that is naturally produced inside the ear canal. Cerumen protects the ear canal from foreign objects such as flies, assists in the lubrication and cleaning of the ear canal, and provides protection against water and bacteria.
Although cerumen production is normal, the ear canal glands can make more earwax than necessary leading to impacted cerumen (buildup of earwax blocking the ear canal). Impacted earwax in the ear canal may result in hearing loss, pain, tinnitus and itching. The most common cause of impacted earwax, besides overproduction by glands, is the use of cotton buds to clean one’s ears. When attempting to clean your own ears, you may push the earwax further back causing impacted cerumen. In some cases, injury to the eardrum may occur – cause severe pain and hearing loss. Home use of cotton-tipped buds, thin sticks or wires, and ear candling should be avoided as they are ineffective and may result in severe adverse effects which may be permanent.
Cerumen impaction should be treated when it causes itching, pain, tinnitus, and or hearing loss or when it prevents the hearing healthcare professionals from assessing the ear canal or visualizing the eardrum as a result of impacted earwax. It is important that the treatment/ removal or earwax is conducted by a qualified and trained clinician such as an audiologist, a nurse, or a physician.
Ear Irrigation Systems
Ear irrigation systems are much safer and effective as they use a controlled flow of water. Ear irrigation can be undertaken by using either a mechanical or electronic irrigation system – essentially, both are water pumps. The systems have a reservoir of water and builds up pressure to ensure a steady and controlled flow of water into the ear canal. The water used in the irrigation system is warmed to body temperature (not colder or hotter) to ensure comfort to the patient. The water either breaks up the earwax or pushes it out of the ear canal, flushing it out and captured in a special container that is provided by the clinician.
How to use one.
Otoscopy is important to visualize the ear canal and the ear drum before irrigation. Even during irrigation the clinician may need to visualize the ear canal several times to check if the earwax is moving. The ear canal is pulled back, placing the irrigation system’s nozzle tip by the ear canal opening, then applying water into the ear canal (Figure 1). The nozzle is traditionally moved around at different angles to ensure that the water accesses every corner of the ear canal (particularly with irrigator system 6 in Table 2) – however, some nozzle tips have multiple holes that ensure a 360 degree angle of water flow into the ear canal. Irrigation systems 1 to 5 reviewed in this document used this special ear tip (Indicated in Table 1).
Figure 1: Placement of the irrigation system nozzle ear tip into the opening of the ear canal.
Table 1: The nozzle ear tip with 3 holes surrounding the tip, and an image of it spurting in the 3 directions
The use of irrigation systems is significantly safer, quicker and more effective than manual removal of ear wax such as the use of curettes.
The one disadvantage. The one disadvantage of the irrigation system is that not every patient is a candidate for it. In such cases, other methods should be used : consult your hearing health professional. Patients who are not suitable include: those who have perforated eardrums, have a discharge from the ear, have had recent or current ear infections, and have had recent ear surgery.
The benefits of ear irrigation. (1) It gets all or almost all the earwax out of the ear. It completely washes out the earwax out of the ear canal. (2) It is relatively easy to use compared to other cerumen management techniques. (3) It is much safer as it uses a steady body temperature water flow. (4) It is much quicker than most methods.
Comparison of Ear Irrigation Systems
Below is a comparison of six ear irrigation systems. From this compilation, two are electronic, which are number three (3) and six (6) on the table below. All the below systems will be reviewed using the same nozzle ear tip (image in Table 1), except for the irrigation system 6 which uses a one hole water emission nozzle – see image alongside.
Figure 2: Disposable nozzle for the earigator (System 6)
Table 2: Images of different ear irrigation systems
1: Tridal wave ear cleaning system
2: Bionix OtoClear SprayWash
3: Bionix OtoClear WaterPik Kit
4: Bionix OtoClear Ear Irrigation Kit
5: Bionix OtoClear Ear Wax Removal
6: NuPur Technologies earigator
Irrigation systems 1 and 2 (Table 2) are similar in the way they create pressure and present water into the ear canal. In order to release water from the systems, the clinician has to lever at all times. In inexperienced users this may cause a back and forth jerky movement of the system and the nozzle. This may result in some minor discomfort for the patient. Overall, this system works well and releases sufficient pressure to remove impacted earwax from the ear canal. When bought off the shelf, system 1 costs less than system 2, but fewer ear tips are included and no bucket to catch the water (bucket shown in figure 1). System 2 also comes with a temperature sensitive strip on the bottle that will indicate to you when the water is the correct temperature.
Irrigation system 3 is an electronic system that works on rechargeable battery power. One advantage with this system is that it looks aesthetically pleasing. It has three pressure levels (low, mid, and high) and our opinion is that even the highest level does not emit water with enough pressure to clean out the earwax from the ear canal, especially hard earwax. This electronic system is a modified water pressured dental flosser.
Irrigation system 5 is a small portable system that can fit in one’s pocket. This system works well and releases water with sufficient pressure into the ear. A major disadvantage is the small water reservoir which results in refilling of the system more than once just to irrigate one ear. Nonetheless, this is a system that I would recommend every healthcare practitioner keeps in their office or bag for mobile services. This portable system is sold as a home ear irrigation device.
Irrigation system 4 has a plunger that pulls up and down to build up air pressure in the reservoir. To build up pressure, between five to ten strokes of the plunger is needed. To indicate that there is enough pressure build up, the plunger will be difficult/ resist being pushed down into the irrigation system’s bottle. Upon pressure build up completion, one can use their thumb to press the back of the lid down to release the pressured water into the ear canal. Once there is no more pressure – the water emission will stop and pressure would have to be built up again. Although, one can use about 350 ml of water before the pressure starts decreasing (this is a little more than 50% of the reservoir). Advantages of this system are: steady when being used in the ear, its mechanic and doesn’t require an external power source, sufficient pressure to remove ear wax, quick and easy to use. We wish that the temperature strip, like for system 2 could also be on the bottle. One can however buy forehead temperature strips from your local pharmacy and stick one onto the outside of the bottle to assist with determining when the temperature is about 37°C (99°F)
Irrigation system 6 is an electronic system that needs to be plugged into a power socket in order to function. This irrigation system can only be used when the temperature is optimal: 37 ± 2° C. Should the water temperature be cold or too hot the nozzle would not emit water. This is one of the advantages of this system as it ensures comfort and safety regarding use of appropriate water temperature. The system also has a magnifying glass that allows the practitioner to view the opening of the canal when practicing cerumen management. In addition to this, the magnifying glass prevents water from the ears from splashing back on the practitioner. This is a well-rounded system with a good pressure control system. The noted disadvantages are that the system is bulky thus making it hard to move around especially if one is in a mobile practice. Furthermore, the price of this system is extremely higher than the comparative systems shown in Table 2. Our testimonial opinion is that the 360 flow of water works better than a single one hole flow of water which one gets with the earigator. We found that the earigator would need slightly more knowledge and experience about the morphology of the ear canal and where the earwax is positioned in order to clean it out. However, the 360 flow of the water ear tip allows the water to be emitted in multiple directions to push the earwax out of the ear canal.
Overall, we found irrigation system 4 to work efficiently and effectively, to be easy to use, and more robust than the other irrigation systems.