Consider one or more of the following methods for cleaning the ear canal to facilitate application and effectiveness of topical treatments:

• Gentle syringing or irrigation — to remove debris, provided that the tympanic membrane is intact — regarded as controversial by some experts.
• Dry swabbing — to gently mop out thin secretions from the external auditory canal.
• Microsuction — if irrigation and swabbing are ineffective or inappropriate. Microsuction will usually require referral to secondary care.

• Clearing the auditory canal of debris and discharge is thought to improve drug penetration and reduce the risk of future infections [American Academy of Otolaryngology et al, 2006]. However, CKS found no clinical trials of different cleaning methods in people with acute localized otitis externa.
• Irrigation, dry swabbing, and microsuction under direct vision, are commonly used methods of aural cleansing, and are recommended in a number of guidelines [Block, 2005; NHS Scotland, 2005; American Academy of Otolaryngology et al, 2006].
• Some experts recommend that irrigation is not attempted in people with otitis externa unless the tympanic membrane can be seen to be intact [Sander, 2001]. However, if cleaning is thought to be beneficial, the tympanic membrane is likely to be obscured. CKS therefore recommends that the integrity of the tympanic membrane be clinically assessed rather than referring all such cases to secondary care.
• Irrigation is thought by some experts to be unsafe in the elderly, in people with diabetes, and in people who are immunocompromised [American Academy of Otolaryngology et al, 2006].
• It has been suggested on the basis of a small case-control study (13 cases, 26 controls), [Rubin et al, 1990], and a case series [Zikk et al, 1991], that aural irrigation for impacted earwax might precipitate malignant otitis externa in elderly people with cutaneous hypoperfusion secondary to diabetic microangiopathy.
• The majority of people who get malignant otitis externa are immunocompromised, usually by diabetes mellitus [Grandis et al, 2004].
• CKS found only one case series that documented the circumstances under which malignant otitis externa developed. All six cases presented after weeks to months of treatments at primary care level with oral and local antibiotics [Sardesai and Krishnakumar, 2002].
• CKS found no reports of malignant otitis externa being associated with aural irrigation in people being treated for otitis externa. Aural irrigation for otitis externa is likely to be less traumatic than irrigation for impacted earwax because in otitis externa the purpose of irrigation is to remove soft debris from a tender ear canal, rather than impacted earwax.
• CKS therefore recommends that, if it seems to be the most practical method, aural irrigation be performed gently, and with extra caution in people at risk for malignant otitis externa, who should in any case be followed up closely.