Describe wax and foreign bodies in the ear with their management.

Cerumen and its Removal

• Cerumen (wax) is the normal secretion of the ceruminous and sebaceous glands of the cartilaginous canal, mixed with desquamated epithelium.
• It is protective, not dirt, being acidic, water-repellent and rich in lysozyme and immunoglobulins.
• Two genetically determined types — wet (sticky, brown), dominant and usual in Europeans, Africans and most Indians; and dry (flaky, grey), recessive and usual in East Asians. The difference lies in a single gene affecting apocrine secretion

Foreign Bodies in the Ear

• Foreign bodies are commonest in children, and are self-inserted and asymptomatic, discovered incidentally or after a clumsy removal attempt. In adults, cotton wool, insects and broken cotton buds predominate
• The classification governs the management:
• Non-living, non-vegetable (inorganic) — beads, pebbles, plastic toys, buttons. They are inert, may be left safely until proper facilities are available, and syringing is permissible
• Non-living, vegetable (organic) — peas, beans, seeds, grain. These swell with water and become impacted, so syringing IS absolutely contraindicated and they must be removed instrumentally
• Living (insects) — which cause intense distress, noise and pain from movement against the drum. The insect must be killed first, by instilling oil, spirit or lignocaine, before any attempt at removal
• Button (disc) batteries are a special emergency — they leak alkali and cause liquefactive necrosis within hours, destroying the canal skin, drum and ossicles. They require immediate removal without irrigation
• Principles OF removal, and they are mostly about restraint:
• The first attempt IS the best attempt. Repeated blind attempts push the object past the isthmus, cause bleeding and oedema, and turn a simple problem into a general anaesthetic
• Remove under direct vision, with adequate light, magnification and appropriate instruments — never blindly with forceps
• Do not grasp a smooth, round object with forceps.
• Syringing is suitable for small inert objects but not for vegetable matter, batteries or a suspected perforation
• General anaesthesia is indicated for an uncooperative child, a deeply impacted object, a failed first attempt, or where the object is against the drum — and choosing it early is a sign of good judgement, not of failure
• Examine the other ear and the nose, since children frequently insert more than one
• Always examine the drum after removal and document its state
• Wax is protective, not dirt, and explaining this is what prevents the patient returning with the same problem
• Impaction means the self-cleaning mechanism has failed, and cotton buds pushing wax inward are much the commonest reason
• Soften for several days before removal; it eases every method and converts a difficult procedure into a simple one
• Syringe at body temperature; water too hot or too cold causes caloric vertigo that is unpleasant and entirely avoidable
• Direct the stream posterosuperiorly so that it passes behind the wax and floats it outward rather than compacting it
• Never syringe a perforated or previously operated ear, nor an only hearing ear, nor where vegetable matter is present
• Microsuction is safer and is now preferred, being done under direct vision and without wetting the ear
• Syringing generates disproportionate medicolegal claims, so consent and documentation of the drum afterwards both matter
• Sudden deafness after bathing is the classic history of wax swelling and occluding a canal that was already narrowed
• Wax rarely causes more than thirty to forty decibels of loss, so a greater loss needs explaining after the wax is removed
• Kill an insect before attempting removal with oil, spirit or lignocaine; a moving insect against the drum is intolerable
• A button battery is an emergency, leaking alkali and causing liquefactive necrosis within hours
• Never irrigate a button battery; it accelerates the leak and spreads the alkali along the canal
• Pass a hook beyond a round object rather than grasping it with forceps.