Earwax

 

Earwax, also known by the medical term cerumen, is a gray, orange, or yellowish waxy substance secreted in the ear canal of humans and other mammals. It protects the skin of the human ear canal, assists in cleaning and lubrication, and also provides some protection against bacteria, fungi, insects, and water.

Earwax consists of shed skin cells, hair, and the secretions of the ceruminous and sebaceous glands of the outside ear canal. Major components of earwax are long chain fatty acids, both saturated and unsaturated, alcohols, squalene, and cholesterol. Excess or compacted cerumen can press against the eardrum or block the outside ear canal or hearing aids, potentially causing hearing loss.

Excess earwax
Excessive earwax may impede the passage of sound in the ear canal, causing conductive hearing loss. Hearing aids may be associated with increased earwax impaction. It is also estimated to be the cause of 60–80% of hearing aid faults.

Treatment
Movement of the jaw helps the ears’ natural cleaning process. The American Academy of Otolaryngology discourages earwax removal, unless the excess earwax is causing problems.

While a number of methods of earwax removal are effective, their comparative merits have not been determined. A number of softeners are effective; however, if this is not sufficient, the most common method of cerumen removal is syringing with warm water. A curette method is more likely to be used by otolaryngologists when the ear canal is partially occluded and the material is not adhering to the skin of the ear canal. Cotton swabs, on the other hand, push most of the earwax farther into the ear canal and remove only a small portion of the top layer of wax that happens to adhere to the fibers of the swab.

Softeners
This process is referred to as cerumenolysis. Topical preparations for the removal of earwax may be better than no treatment, and there may not be much difference between types, including water and olive oil. However, there were not enough studies to draw firm conclusions, and the evidence on irrigation and manual removal is equivocal.

Commercially or commonly available cerumenolytics include:

Any of a number of types of oil
Urea hydrogen peroxide (6.5%) and glycerine
A solution of sodium bicarbonate in water, or sodium bicarbonate B.P.C. (sodium bicarbonate and glycerine)
Cerumol (peanut oil, turpentine and dichlorobenzene)
Cerumenex (triethanolamine, polypeptides and oleate-condensate)
Docusate, an emulsifying agent, an active ingredient found in laxatives
A cerumenolytic should be used 2–3 times daily for 3–5 days prior to the cerumen extraction.

Ear irrigation
Once the cerumen has been softened, it may be removed from the ear canal by irrigation, but the evidence on this practice is equivocal. This may be effectively accomplished with a spray type ear washer, commonly used in the medical setting or at home, with a bulb syringe. Ear syringing techniques are described in great detail by Wilson & Roeser, and Blake et al., who advise pulling the external ear up and back, and aiming the nozzle of the syringe slightly upwards and backwards so that the water flows as a cascade along the roof of the canal. The irrigation solution flows out of the canal along its floor, taking wax and debris with it. The solution used to irrigate the ear canal is usually warm water, normal saline, sodium bicarbonate solution, or a solution of water and vinegar to help prevent secondary infection.

Patients generally prefer the irrigation solution to be warmed to body temperature, as dizziness is a common side effect of ear washing or syringing with fluids that are colder or warmer than body temperature.

Curette and cotton swabs
Earwax can be removed with an ear pick/curette, which physically dislodges the earwax and scoops it out of the ear canal. In the West, use of ear picks is usually only done by health professionals. Curetting earwax using an ear pick was common in ancient Europe and still practised in East Asia. Since the earwax of most Asians is of the dry type, it is extremely easily removed by light scraping with an ear pick, as it simply falls out in large pieces or dry flakes.

It is generally advised not to use cotton swabs (Q-Tips or cotton buds), as doing so will likely push the wax farther down the ear canal, and if used carelessly, perforate the eardrum. Abrasion of the ear canal, particularly after water has entered from swimming or bathing, can lead to ear infection. Also, the cotton head may fall off and become lodged in the ear canal. Therefore, cotton swabs should be used only to clean the external ear.

Ear candles and vacuuming
Ear candling, also called ear coning or thermal-auricular therapy, is an alternative medicine practice claimed to improve general health and well-being by lighting one end of a hollow candle and placing the unlit end in the ear canal. It, however, is not recommended as it is both dangerous and ineffective. Advocates say that the dark residue that shows after the procedure consists of extracted earwax, proving the efficacy of the procedure. Studies have shown that the same dark residue is left, whether or not the candle (which is made of cotton fabric and beeswax and leaves a residue after burning) is inserted into an ear. This demonstrates that the waxy residue is derived from the candle itself and not the ear. The color of the candle wax matches the light brown-colored wax of the human ear, making the distinction between the two waxes more difficult for a layperson. Because the candle itself is a hollow tube, some of the hot burnt wax could drop down inside the candle, into the ear canal, potentially injuring the eardrum. The American Academy of Otolaryngology states that ear candles are not a safe option for removing ear wax, and that no controlled studies or scientific evidence support their use for ear wax removal. The Food and Drug Administration has successfully taken several regulatory actions against the sale and distribution of ear candles since 1996, including seizing ear candle products and ordering injunctions.

Home “ear vacs” were ineffective at removing ear-wax, especially when compared to a Jobson-Horne probe.

Potential complications
A postal survey of British general practitioners found that only 19% always performed cerumen removal themselves. It is problematic as the removal of cerumen is not without risk, and physicians and nurses often have inadequate training for removal. Irrigation can be performed at home with proper equipment as long as the person is careful not to irrigate too hard. All other methods should be carried out only by individuals who have been sufficiently trained in the procedure.

The author Bull advised physicians: “After removal of wax, inspect thoroughly to make sure none remains. This advice might seem superfluous, but is frequently ignored.” This was confirmed by Sharp et al., who, in a survey of 320 general practitioners, found that only 68% of doctors inspected the ear canal after syringing to check that the wax was removed. As a result, failure to remove the wax from the canal made up approximately 30% of the complications associated with the procedure. Other complications included otitis externa (swimmer’s ear), which involves inflammation or bacterial infection of the external acoustic meatus, as well as pain, vertigo, tinnitus, and perforation of the ear drum. Based on this study, a rate of major complications in 1/1000 ears syringed was suggested.

Claims arising from ear syringing mishaps account for about 25% of the total claims received by New Zealand’s Accident Compensation Corporation ENT Medical Misadventure Committee. While high, this is not surprising, as ear syringing is an extremely common procedure. Grossan suggested that approximately 150,000 ears are irrigated each week in the United States, and about 40,000 per week in the United Kingdom. Extrapolating from data obtained in Edinburgh, Sharp et al. place this figure much higher, estimating that approximately 7000 ears are syringed per 100,000 population per annum. In the New Zealand claims mentioned above, perforation of the tympanic membrane was by far the most common injury resulting in significant disability.

History
The treatment of ear wax was described by Aulus Cornelius Celsus in De Medicina in the 1st century:

When a man is becoming dull of hearing, which happens most often after prolonged headaches, in the first place, the ear itself should be inspected: for there will be found either a crust such as comes upon the surface of ulcerations, or concretions of wax. If a crust, hot oil is poured in, or verdigris mixed with honey or leek juice or a little soda in honey wine. And when the crust has been separated from the ulceration, the ear is irrigated with tepid water, to make it easier for the crusts now disengaged to be withdrawn by the ear scoop. If it is wax, and if it is soft, it can be extracted in the same way by the ear scoop; but if hard, vinegar containing a little soda is introduced; and when the wax has softened, the ear is washed out and cleared as above. … Further, the ear should be syringed with castoreum mixed with vinegar and laurel oil and the juice of young radish rind, or with cucumber juice, mixed with crushed rose leaves. The dropping in of the juice of unripe grapes mixed with rose oil is also fairly efficacious against deafness.

Uses
In medieval times, earwax and other substances such as urine were used to prepare pigments used by scribes to illustrate illuminated manuscripts.
The first lip balm may have been based on earwax. The 1832 edition of the American Frugal Housewife said that “nothing was better than earwax to prevent the painful effects resulting from a wound by a nail skewer”; and also recommended earwax as a remedy for cracked lips.
Before waxed thread was commonly available, a seamstress would use her own earwax to stop the cut ends of threads from fraying.

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