Tools for Opening the Ear Canal
For visualizing and accessing the ear canal to remove excessive earwax, clinicians should use a handheld otoscope, binocular microscope, or otoendoscope, with the binocular microscope offering superior stereoscopic magnification for manual removal procedures. 1
Visualization Equipment
The American Academy of Otolaryngology-Head and Neck Surgery recognizes three primary tools for examining and opening visualization of the ear canal 1:
Handheld otoscope or speculum - The most commonly used tool in primary care settings for initial examination and basic manual removal, though success rates are considerably lower than with microscopic visualization 1
Binocular microscope - Provides stereoscopic magnification and achieves approximately 90% success rates for manual removal with no reported canal trauma or perforations in studies of 159 patients 1
Otoendoscope - Specialized equipment available through otolaryngologists that allows direct visualization during removal procedures 1
Instruments for Manual Removal
Once the canal is visualized, the following instruments are used to physically remove cerumen 1:
- Metal or plastic curette loop or spoon - Primary instrument for scooping out impacted wax 1, 2
- Alligator or cup forceps - For grasping and extracting larger pieces 1
- Right-angled hook - Useful for dislodging adherent cerumen 1
- Angulated suction tips (French size 3,5,7) - Connected to negative-pressure pump for aspirating softer wax 1
- Jobson-Horne probe - Specialized otologic instrument for cerumen manipulation 1
- Cotton wool applicator - For wiping out wax with softer consistency 1
Adjunctive Equipment
A compressed cellulose wick should be placed when severe canal edema prevents adequate visualization or drop entry, as it expands when exposed to moisture and facilitates drug delivery 1, 2, 3
Referral Considerations
When primary attempts with handheld otoscopy fail, clinicians should refer to specialists with access to binocular microscopes or otoendoscopes, as manual removal success rates with handheld otoscopes are considerably lower than the 90% achieved with microscopic visualization 1. Specialized equipment becomes essential when repeated attempts are unsuccessful, complications occur, or patient intolerance prevents further treatment 1.
Critical Safety Points
- Never use ear candles - They have never been shown effective and cause serious harm including burns, perforation, and hearing loss 1, 2
- Avoid cotton-tipped swabs - These push wax deeper and can cause injury to the canal 2, 3
- For diabetic or immunocompromised patients, use atraumatic suctioning under microscopic guidance rather than irrigation to prevent necrotizing otitis externa 1, 2
The choice of visualization tool depends on the clinical setting, with primary care typically using handheld otoscopes and otolaryngologists employing binocular microscopes for refractory cases requiring superior visualization and instrumentation 1.