How to pronounce cerumen
Remove cerumen - if so, do it with feeling!
Is cerumen removal always necessary in symptom-free patients? No. As a general practitioner, one should be careful here anyway. Such treatment is often superfluous - and it is also not entirely harmless. It can injure the ear canal, eardrum or ossicular chain. For the general practitioner, inexpensive manual irrigation systems are also available today, with which z. B. the eardrum is no longer hit directly and thus its damage is largely excluded.
Every family doctor knows the situation: Even people with subjectively healthy ears keep expressing the wish that the doctor should inspect their ears for cleanliness. Apparently, our culture regards earwax as a blemish and a sign of poor hygiene (see Box 1). Suddenly, a supposedly unsavory problem can develop from this: A smaller, symptom-free cerumen plug lurks in the patient's ear canal, which does not restrict the ear inspection. The case seems simple and can usually be solved easily with an ear canal irrigation. Contrary to expectations, the action can also be very time-consuming and sometimes have nasty consequences: painful or functionally restricting injuries to the ear canal, eardrum or ossicle , facial nerve lesions, damage to the auditory or equilibrium organ, ear canal infections [1, 2, 3] or even a vagally induced cardiac arrest . Claims for damages are not excluded here. [4, 10]. From the point of view of "primum non nocere, secundum cavere, tertium sanare" ("firstly do not harm, secondly be careful, thirdly cure"), the question arises whether the earwax discovered by chance needs to be removed at all.
What do the guidelines say?
The still valid DEGAM guideline No. 7 (earache) states that "cerumen (...) is initially nothing abnormal", "but if it leads to hearing loss or earache, one will try to remove it."  The current guideline of the American Academy of Otolaryngology-Head and Neck Surgery notes in its latest 15-page update on cerumen removal: Doctors should not routinely treat cerumen from asymptomatic patients whose ears can be adequately examined .
So ear wax does not have to be removed at all costs, but only if it becomes or could become symptomatic ("impacted cerumen") - for example in the case of a diver before a planned dive or if an inspection of the eardrum is absolutely necessary. Keeping the ear clean and thus functional is guaranteed by the self-cleaning mechanism (epithelial migration) of the human body, which is supported by the movement of the temporomandibular joint. Last but not least, ear wax also has a physiologically important protective function (Box 2).
Self-cleaning of the ear canal often only works inadequately in older people. There can be many reasons for this, including local ones: If the diameter of the auditory canal is too large, the massaging movement of the auditory canal wall emanating from the mandibular joint is obviously not effective enough - perhaps also because the patient eats less or speaks less. As a result, the cerumen masses accumulate until the ear canal is completely closed.
Conversely, an ear canal that is much too narrow can act like a bottle neck and impede the migration of cerumen. The anatomical hurdles can be congenital or acquired, such as ear canal stenoses, exostoses, tumors or an exorbitantly increasing hair growth in the ear canal entrance. In addition, ear wax changes throughout life and its composition is subject to age, gender and hormonal influences . As it ages, it undoubtedly gets tougher and loses its youthful creaminess. Age-related sebostasis, but also skin diseases, can also influence this to different degrees. This means that the process of removing the ear wax is differently difficult.
But what can the family doctor do if a wax plug has become symptomatic? It is not always desirable or possible to refer the patient to an audiologist. Sometimes the situation calls for timely action, as in the following case.
The problem case: hard of hearing, immobile, dementia
The 92-year-old Olga S. is demented, virtually unable to move and has binaural hearing aids. As long as they are worn, communication works - despite the cognitive limitations - to the extent that no major nursing problems arise. Despite the hearing aids, communication is no longer possible. The nurses are at a loss. During a home visit, even without an otoscope, the patient's auricle is pulled up slightly to see that both auditory canals are completely obstructed by obturating and impacted wax plugs (Fig. 1).
General practitioner procedure
In the very old, immobile patient, the removal of the wax mass can practically only be carried out as part of a home visit. The only possible family doctor procedure is irrigation, ideally after preparation with a suitable cerumenolytic. It is not easy to answer which active ingredient should be used, because the requirements for "ideal" ear drops are high. They should have lipophilic and hydrophilic qualities, a low surface tension, a neutral to slightly acidic pH, have antiseptic qualities and contain no allergenic ingredients.
The available studies are very heterogeneous, without one or the other preparation having any significant advantages. The ingredients of most cerumenolytics can essentially be reduced to three therapeutic approaches: reduce surface tension, increase lubricity, loosen material. In most cases, however, other substances are also added to optimize the effect (see Table 1). Ultimately, it is up to the experience of the user what he wants to work with. Simply softening before rinsing with sufficient exposure time (15 to 30 minutes) proved to be clearly superior to lacking pretreatment [9, 11]. This is definitely expedient for a successful treatment.
The rinsing itself must be carried out with water at body temperature (37 ° C) in order to avoid caloric irritation of the equilibrium organ. Conventional plastic or metal syringes (Fig. 2) have different lengths, rigid, not harmless - and also hygienically not harmless - attachments and a practically non-controllable pressure generation. There are definitely alternatives to these traditional systems today. The Bionix OtoClear® hand rinsing system (costs around 100 euros for the hand-held dishwashing device and around two euros for the plastic disposable head) based on a conventional spray bottle (see Fig. 3 and 4) has proven itself very successfully during almost two years of practical use. In our own experience, the risks of ear canal irrigation can be significantly reduced for everyone involved. Overall, patient acceptance and success rate are very good [11, 13].
The best effect results - according to our practical experience - especially in geriatric patients from the combination of 20-minute cerumenolysis and the subsequent rinsing with the hand-held irrigation device. The total time required is of course considerable - especially if the treatment also involves a home visit (Fig. 5). For older, handicapped or immobile patients who no longer want or can no longer make the way to the ENT doctor, this represents a real family doctor service, which is rated very positively by those affected and their relatives.
The most important rule at the end
Decisions from arbitration boards on cerumen removal  show: It is advisable for the doctor to personally irrigate the ear canal. If he delegates this service to assistants, they must be specially trained and monitored in their work. This also means that the relevant contraindications must not only be queried and excluded before the irrigation, but also the treated ear canal and the eardrum must be examined afterwards. In addition, tuning fork tests should be carried out and documented.
Conflicts of Interest: The authors have not declared any.
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