“In Medicine one must pay attention not to plausible theorizing but to experience and reason together. . . . 1 agree that theorizing is to be approved, provided that it is based on facts, and
systematically makes its deductions from what is observed. . . . But conclusions drawn from
unaided reason can hardly be serviceable; only those drawn from observed fact.” Hippocrates:
Precepts
. . .
(This heading and text seem appropriate for a section to be composed of brief factual articles.
Longer papers require coras*lerable time for review and, often, for revLsion. Opinion and criticfsm
can appear more promptly in Letters to the Editor, for which Pwrmcs disclaims resporibiZity.
Although contributions for this new section will require editorial review, their brevity should
shorten that process.)
113
PEDIATRICS, January 1964
EXPERIENCE
AND
REASON-Briefly
Recorded
A
Simple
Device
and
Technique
for
Removing
Ear Wax
All of us who have occasion to examine the
ear drum find ourselves frequently annoyed
by the presence of obstructing cerumen.
At-tempts at removal of this substance may be
so time-consuming and unpleasant that they
are often abandoned, thus leaving the true condition of the ear drum and the diagnosis
ill doubt.
Devices and methods currently used for
the removal of cerumen are generally
unsatis-factory for one reason or another. These
meth-ods consist of: (1) the removal of wax by
irnigatioll or by the use of a cerumenolytici 2
followed by irrigation; (2) the removal of wax
by use of an ear spoon or a cotton-tipped
applicator without the benefit of direct vision;
(3) the
removal of wax under direct vision byuse of an ear curette or ear spoon. Method No. 3 is the most efficient and frequenfly used of the three but has the disadvantage of
me-(uiriIlg skilled assistance ill small,
unco-opema-tive children and of being very difficult and
traumatic when the patient is struggling.
Method No. 1 is very time-consuming and
is often annoying to the patient. Its use is
al-most impossible in infants and small children because of their lack of co-operation. Method No. 2 is quite inefficient, often painful, and
may result in injury to the ear canal on ear
drum.
Years of thoroughly annoying encounters with ear wax have led the writer to develop
a device which has been found to avoid most
of
the difficulties encountered with the meth-ods listed above. This device consists of asomewhat elongated speculum with a spoon-like projection molded smoothly into its distal
eIld. In looking through the speculum, one can
see the tip of this projection as well as a field
sufficiently large to enable manipulation of the
projecting tip under direct vision. When the
device is attached to an otoscope, manipula-tions are performed by movement of the en-tire instrument, thus requiring the use of only
one hand, the other being free to hold the ear
and head.
The autilor, who confines his practice to pediatrics, has used this device in his practice
for more than two ‘ears. He has used it in all
cases where obstructing cerumen has
pre-vented a clear view of the ear drum. In the
vast majority of cases, he has been successful in removing enough of the wax to allow a
satisfactory view of the ear drum. In the
re-mainder, he has resorted to irrigation or to the
use of a cerumenolyticl 2 followed by
irriga-tion. In most cases, sufficient wax was removed
with one application of the instrument to al-low a satisfactory view of the ear drum (a view at least of the light reflex, the malleus, and the short process). In the remainder, two or three applications were necessary, wax being wiped from the tip of the instrument be-tween applications. As a matter of course, all
infants and small children voiced their
objec-tions to the procedure, but, in olden,
. .
114 EAR WAX
FIG. 1. The dewaxing speculum,
like tip.
TECHNIQUE
I;
.F#:
showing 5P00
In using this device, one must first study the obstructing wax. In the few cases where there is a solid plug of wax, the possibility of
its removal depends upon its nature. In many
cases, it will be stick and one can merely imbed the tip of the device firmly illtO one
side of the mass with a hooking motion and
remove it by gentle, slow traction. If,
how-ever, the solid plug of wax be hard, a ceru-menolyti& should be used without wasting
time. Fortunately, ill most cases a partial rather
than a solid plug of wax is present and a small
portion of the ear drum is visible. It is in these
cases that the device finds its greatest use.
Here, the wax may be removed by hooking
the tip tinder it or into its side and exerting
slow, firm tractiOll or by using a skimming motion. Because of the operator’s
concentra-tion Oil engaging the wax with the tip of the
spoon, he may lose his awareness of the
proximity of the back of the 500fl to the wall
of the ear caIlal. This relationship should be
kept ill mind LS 1)resSure on the canal vall
may be (Itlite 1)ainful. In mans- cases it may be difficult to remove the entire plug but easy
to remove enough of it to allow a satisfactory
view of the ear drum.
Good visibility is of great and crucial im-portance to the successful operation of this
device. It will be materially increased by ar-ranging the relative poSitiOlls of the attached
dewaxing speculum and the magnifying viewer of the otoscope so that the operator can look somewhat obliquely through the speculum, his line of vision running away from the tip (the
less the operating tip projects into the field of vision, the better the view).
COMMENT
This device has several outstanding
ad-vantages over the preSelltlv available methods
of wax removal: (1) All manipulations are performed with one hand, the other being free to hold the ear and head. Hence, in the case of the small, unco-operative child, the only assistance needed is that of the parent (when using the ordinary ear curette under direct vision, the operator uses both hands and must
have two unskilled assistants or one very skilled and agile assistant). (2) Manipulations are
per-formed under good direct ViSiOn. This makes
for efficiency in wax removal and reduces the
likelihood of trauma. (3) A smaller speculum
can be used with this device than when a
curette is used, thus making it possible to
work on smaller patients. Indeed, one can use
this device successfully on small infants. (4) In all patients, large or small, the spoon which comprises the operating portion of this device
is larger, and therefore more efficient, than
one which can be thrust through an ordinary
speculum of the same size.
Because 110 more than one unskilled
as-sistailt (usually the parent) is needed when
this device is used and because of its efficiency, much time can be saved in the busy office
where the necessity for removal of ear wax
is a frequent thing. The operation of wax
re-moval becomes a casual thing ratiler than a
EXPERIENCE AND REASON-BRIEFLY RECORDED 115
even Ill one’s own office), wax may still be
re-moved with relative ease.
As can be deduced from the foregoing, the
device is niost useful in infants and small
children but it is convenient and effective in
older age groups as well.
SUMMARY
A simple device and technique for the rapid
removal of ear vax are described. The device0
COI1SiStS of a modification of the ordinary ear
speculum in which a spoonlike projection is
molded smoothly into the distal end. B’ its
use, the removal of wax is accomplished
quickly tinder direct vision. Since all necessary
manipulations are easily performed with one
ilalld, the other hand is free to hold the
pa-tient’s ear and head. Thus, no more than one unskilled assistant is required even with the
most unco-operative patients. The device is
most useful ill the many cases in which soft
or sticky wax partially occludes the ear canal. It has particular merit in infants and small,
unco-operative children.
Asheville, N. C.
B. H. HARTMAN, M.D.
REFERENCES
1. Dubow, E. : A new cerumenolytic for use in
pediatric ear examinations, Amer. J. Dis.
Child., 97:863, 1959.
2. Gant, Jas. Q., Jr. : An evaluation of a new
cerumenolytic agent, AMA Arch. Derm., 79:651, 1959.
0 If not available locally, write Dewaxing
Specu-lum, Suite G, 675 Biltmore Avenue, Asheville,
NC.
Albumin
in the
Meconium
of Infants
with
Cystic
Fibrosis:
A
Preliminary
Report*
Several investigators have described an
Un-usual protein in the meconium of patients with
meconium ileus.1 2, 3 This protein could be
de-tected by emulsification of meconium in water and extraction with ether,1 chemical
precipita-tlOil,2 electrophoresis, or immunologic analy-sjs. Green, Clarke, and Shwachman presented
evidence that most of the unusual protein
isolated assumed the position of albumin by
aThese studies were supported in part from
USPIIS Grant 2A-5:321.
paper electrophoresis, although small amounts of alpha-2, beta, and gamma globulins were also detected. Precipitin tests showed that the
albumin content of extracts of normal
me-conium was only 1-2% of that of the abnormal
extract. It was postulated that the unusual protein conteiit of meconium might lead to the
formation of the meconium plugs responsible for meconium ileus.
The purpose of this investigation was to
determine whether or not samples of
me-conium from infants with cystic fibrosis of the pancreas who do not present witll meconium
ileus also demonstrates an unusual protein
content and to prove the identity of this
pro-tein by immunoelectrophoresis. It also seemed
of interest to determine wilether the finding of
unusual protein colitent in meconium could be
used in a predictive manner to identify cases of cystic fibrosis ill the newborn period.
METHODS AND CASE MATERIAL
Meconium was collected from infants born
in Salt Lake City during a two-year period
(1961-1962) to parents who already had one or more children with a previously proved diagnosis of cystic fibrosis. Five such infants came to our attention during tile period of study. Meconium samples from eleven normal
newborn infants selected randomly from our
newborn nursery were used as controls.
Extracts of meconium were prepared for
electrophoresis by the method of Green, Clarke, and Shwachman. Paper electrophoretic
pat-terns were performed by the method described
by the same authors, using a Beckman Model R Paper Electrophoresis System. Amido-schwartz dye was substituted for
bromo-phenol blue.
Immunoelectrophoresis was performed ac-cording to the method of Scheidegger, using
an Agafor (National Instrument Co.) Electro-phoresis apparatus. A veronal buffer at pH 8.6
was used, and the slides were stained with
thiazine red after elution of the nonprecipi-tated proteiiis. Purified crystalline albumin ob-tamed from the California Biochemical Co.
was used in a 1 : 100 (by weight) dilution iii
the top and bottom holes of the agar patterns,
as shown ill Figures 2 and 3. A 5f suspension
of meconium was used in the center hole. Rab-bit antihuman albumin serum, obtained by
immunizing healthy adult New Zealand
rab-bits with 1% human albumin in Freunci’s
