THE REAL RISKS BEHIND SYRINGING

An article was published last year by the the RACGP (Royal Australian College of General Practitioners) to inform GPs in Australia about how to best manage patients with impacted ear wax. Below is a summary of some of the key points made. Here is a link to the article for your own perusal - RACGP ARTICLE.

KEY POINTS

• Complications  arising from syringing are an increasingly common reason for people needing to be referred to an ear, nose and throat (ENT) specialist and medico-legal complaints against GPs. 
• 1 in every 1000 patients experience major complications following syringing (1).
• 1 in 5 medico-legal cases involving GPs are related to ear syringing (1)

Why does ear wax accumulate?
​The ear canal has a natural self-cleaning mechanism that pushes wax out laterally. If this mechanism is disturbed, wax can accumulate and become impacted. Things like narrowing or obstruction of the ear canal due to anatomical changes (e.g. exostoses or swimmer's ear), ear infections or dermatological diseases can all alter this natural  migrational ability of the ear canal. Irritation arising from placing objects into ones ears (e.g. hearing aids, cotton buds and ear buds) can disturb the very sensitive layer of skin in the ear canal that can in turn alter the normal skin migration. Hearing aids and cotton buds also tend to push wax back in further down the ear canal never allowing or severely compromising the ability of the ear to self-clean. Lastly, as we get older, the glands responsible for wax production tend to produce drier wax which migrates much slower.

• 57% of older patients experience wax impaction compared with just 5% of younger healthy adults (2).

Symptoms of Impacted Wax (Impacted wax occurs when it obscures visualisation of the ear drum)

• Conductive hearing loss (attenuation of sound before it even gets to the cochlear)
• Ear pain
• Aural Fullness or blocked feeling
• Itchiness
• Dizziness
• Tinnitus
• Cough reflex

Most GPs agree that symptomatic wax should be removed although on average, 1/3 of patients who present with impacted wax will have their wax come out naturally within in 5 days without any intervention (3). Of course, wax should be removed for optimal hearing  with or without hearing aids as well as in helping audiologists administer accurate audiometric hearing tests.

The article then goes on to talk about the safety precautions GPs need to adhere to when using the syringing method to remove wax. Interestingly, the authors do not think that direct visualisation of the ear canal is necessary to perform safe and effective syringing. The view of Comfort Clean Ear is that the ear canal has very delicate skin and anatomy all in close proximity to each other. If you cannot see where you are firing pressurised water, complications may invariably occur. This is probably why 1 in 5 medico-legal cases against GPs is due to complications arising from water syringing.

Contra-indications to the syringing method (anyone who has experienced anything in the list below should avoid having the syringing method used on them)

• Any signs or symptoms of otitis externa (ear canal infection) or otitis media (middle ear infection)
• Past or present ear drum perforation
• History of ear surgery
• Meniere's Disease  (own addition)
• Complete hearing loss in one ear (unilateral hearing loss) (4)
• Never syringe the better hearing ear if the other ear has any sort of hearing loss
• History of tinnitus
•  History of recurrent otitis externa
• Immunocompromised patients (e.g. diabetes)
• Delicate and fragile skin in the ear canal (own addition)
• Patients who have had a bad experience with the syringing method in the past (own addition)

Side Effects and Complications of the Syringing Method

• Syringing can damage the delicate skin of the ear canal 
• Syringing can perforate the ear drum
• Syringing predisposes patients to infections (otitis externa and otitis media) and the retention of water behind dislodged wax does not help.
• Syringing can aggravate tinnitus and balance issues (own addition)

The last part of the article looks at micro-suction as an alternative method for the removal of impacted wax under microscopic observation. It points out that  the micro-suction procedure (as is offered at Comfort Clean Ear) 'has the advantage of not exposing the ear to moisture and thus has fewer contraindications and is associated with a lower frequency of infections'(5).

From this, it would be safe to say that ear wax removal using the micro-suction method under microscopic observation is the safest and most effective method available to remove impacted wax and is why it is the preferred option by ENTs around Australia.

References
(1) Bird S. The potential pitfalls of ear syringing: Minimising the risks. Aust Fam Physician 2003;32:150–51.
(2) ​McCarter DF, Courtney AU, Pollart SM. Cerumen impaction. Am Fam Physician 2007;75:1523–28.
(3) Keane EM, Wilson H, McGrane D, Coakley D, Walsh JB. Use of solvents to disperse ear wax. Br J Clin Pract 1995;49:71–72.
(4) ​Bird S. Ear syringing: Minimising the risks. Aust Fam Physician 2008;37:359–60.
(5) ​Roland PS, Smith TL, Schwartz SR, et al. Clinical practice guideline: Cerumen impaction. Otolaryngol Head Neck Surg 2008;139:1–20.