8th July 2013

Ear Wax (Cerumen)

From Introduction to Treatment

Dpt. Aamir Memon

Earwax
Earwax is a mixture of skin and cerumen. It is protective coating over the skin lining the inner ear. Earwax comprises of an oily substance known as cerumen, mixed with dirt and sloughed skin cells from the ear canal. Skin of the ear canal around eardrum grows fastest and migrates outward bringing the wax with it toward the ear canal. The location of wax glands is the ear canal (outer portion). The wax serves to lubricate the ears and prevents the skin dryness, chapping, itching, or infections. Wax can accumulate under a variety of circumstances. Insufficient cerumen secretion makes the earwax hard and brittle. This occurrence is natural with aging. Excess secretion of the cerumen makes the earwax sticky. This wax doesnt migrate outward sometimes as expected. Ears and noses of the older people have more hair in them that can thicken earwax. There may be faster turnover of the cells in the skin of the ear canal due to any sort of irritation of the external ear canal. There would be production of a larger volume of earwax due to excess skin. Cerumen is a natural, sticky, waxy substance secreted by in the outer portion of the ear canal. Cerumen glands are located in hair follicles (at the bottom). Cerumen waterproofs ear canal and protects the delicate skin of the canal from infection and dirt. It combines with keratin from sweat, sebum (skin oil) and dead skin cells resulting in the formation of earwax. Cerumen has acidic pH (slightly) which helps in preventing the ear infections by inhibiting the bacterial and fungal growth. The earwax may be categorized as dry or wet, yellow, brown, or black. This protects skin of the ear canal from getting boggy and wet, just like the wax of a paper cup protects the paper from becoming saturated. Therefore, water which enters the ear canal will bead up rather than soaking into the skin and will roll back out of the ear canal. The ear wax gets washed out because of frequent showering, swimming, or excessive use of wax-removing drops resulting into the excessive moisture of the skin of ear canal, and the bacteria present in the ear canal may flourish that may cause an infection. This condition is known as painful swimmers ear which is commonly called otitis externa. Two basic types of earwax exist; namely wet and dry. Your type of earwax is inherited. The wet wax containing about 50% fat is commonly found in people of Western Europe, Dry wax that contains about 20% wax is common in Asia. As you chew or talk; the jaw joint which forms one third of the ear canal moves the skin of the canal, slowly pushes the wax out and takes with it the trapped debris. This wax randomly falls out. Earwax has a number of functions including: It traps dirt It prevents the ear from getting too dry It pushes away water and germs.

Ear Wax Build Up

Earwax is good & necessary but it can build up resulting into blockade of the ear canal and causing infection, hearing loss, or pain. There are many reasons for earwax build up such as: Idiopathic excessive production of earwax (some people make too much). Second, some people have crooked or narrow ear canals (the wax can not get out). Third and most commonly encountered cause is using the Q-tips where cotton tipped swabs are used to exclude wax out of ear which were neither intended nor designed to be used in ear canal. Instead of the wax removal, the swab can push it deeper into the canal. This tight wax dries out and gets jumbled into the ear canal. Furthermore, these swabs can scratch the delicate skin in the canal & lead to infection and it is a very common cause of "swimmer's ear" in those who dont swim. Fourth, some people have excessively hairy ear canals due to which the wax cant go out and gets accumulated in. Fifth, if you work in a dusty environment then there is a possibility for wax build up because dust will also lead to wax accumulation inside the canals. Sixth, if you have a skin condition such as psoriasis or eczema. The outer ear canal is a 3 cm long tunnel running from the ear hole to eardrum. It is lined with hairs, skin, and small wax producing glands. The wax protects the skin of the ear canal and gives it a waterproof coating. There is natural removal of the ear wax through a self-cleaning action of the ear canal. Ear wax build-up can occur at any age but is more common with aging process. Symptoms of earwax build up Earwax is only a problem if it causes earache, hearing loss, or ringing in ears (tinnitus). The classic presentation of earwax impaction is sudden loss of hearing after swimming, bathing, showering, or diving. The reason for this is, the wax builds up slowly but until there is a tiny air hole leading to the eardrum, there will be normal hearing. When water enters the ear canal, it will shift the wax & close the air hole resulting into sudden hearing loss. Prevention of earwax build up Q-tips and bobbie pins are the culprits which will pack the wax in or may worsen the blockade and can perforate your ear drum! It may be helpful to wear ear plugs if your work environment is particularly dusty though the plugs themselves can also push wax further in. If there is a problem of repeatedly blockade of ears with wax, it may be dealt with putting a few drops of olive oil into each ear once or twice a week. Ear wax is not a bad thing but the blockade is, and if there is no problem with your wax; dont worry about it. Lubrication and softening of the wax with ear drops helps & sometimes this is the ultimate need & the solution which may be followed by irrigation.

Excessive Ear wax

Ear wax is a mixture of skin and cerumen and it is a protective coating over the skin lining the inner ear. Earwax comprises of an oily substance known as cerumen, mixed with dirt and sloughed skin cells from the ear canal. Ear wax production is normal and it is good and necessary for hearing but due to some conditions and reasons there is excessive production of earwax commonly known as excessive ear wax or ear wax impaction. In UK, approximately 2.3 million people suffer from earwax problems every year and which needs to be removed from ear. There is an extra amount of earwax in some people and there are more chances of ear blockade problems; which occurs when earwax gets stuck inside the ear. Using a hearing aid or cotton buds can cause ear blockade & can push earwax back inside rather than taking extra earwax out of ear. Earwax rarely causes pain or ear discharge. You may not be aware of the fullness of ear with wax until there is a waxy discharge or you find it harder to hear. There may be a feeling of sore and itchy ears if there is an infection developing in the skin. Sometimes, too much earwax can cause ear to get blocked which can be very painful and can also make it hard to hear properly. You may also have: Earache Tinnitus (ringing or buzzing sounds in ear) Itchiness Vertigo (a feeling of spinning) Cough Labrynthitis Problems with earwax are quite common for people with learning disabilities and there is no cause for it known yet. A tool called an Auriscope is used to look inside the ear which helps visualize if there is extra wax. Vestibulocochlear system plays a vital role in hearing so it is mandatory to be tested so as to exclude the possible causes of the problem. Hearing can be tested using tools called tuning forks. Rinne test The Rinne test involves a vibrating tuning fork put at the mastoid process near your ear. Hearing is checked unilaterally in this procedure. Weber test In the Weber test, the vibrating tuning fork is put on the vertex (middle of your forehead). Patient is asked if there is difference in bilateral hearing. Complications due to Earwax Blockade include: Infection vertigo (an uncomfortable feeling of moving) Complications after Ear Irrigation include: Swelling or pain inside the ear Perforation or hole in the eardrum Pain Vertigo Feeling Feeling sick or being sick Light bleeding which usually stops on its own

Impacted Ear Wax

Ear wax is a mixture of skin and cerumen and it is a protective coating over the skin lining the inner ear. Earwax comprises of an oily substance known as cerumen, mixed with dirt and sloughed skin cells from the ear canal. Ear wax production is normal and it is good and necessary for hearing but due to some conditions and reasons there is excessive production of earwax commonly known as impacted ear wax or ear wax impaction. Cerumen production occurs in the outer one third of the ear canal and naturally moves to the outer ear as new tissue grows from the area around the tympanic membrane.. Less frequently, cerumen accumulates and hardens in the canal causing the ear canal occlusion. In the most severe cases cerumen can become impacted in the deep (bony) canal causing pain and temporary loss of hearing. Causes of Earwax Impaction include: Production of a lot of wax Having narrow ear canals Having excessively hairy ear canals Using Q-tips on ears i.e. cotton buds and fingertips which push wax further down the canal Having in a dusty work environment Having a skin condition including eczema or psoriasis. The symptoms of a wax impaction in the ear canal include: Mild deafness Ear ache Felling of ear fullness Tinnitus (Ringing in the ear) Vertigo or dizziness Types of Cerumen Cerumen-the natural by-product of the ear canal; lubricates the ear canal skin lining, entraps hair follicles, dust, and foreign bodies, and acts as a water repellent. Cerumen can have many different forms that affect the time and process to remove it. There are two different types of cerumen generally found in the ear canal namely dry and wet. The following are subtypes of cerumen that are commonly encountered and lets see how they may affect the process of irrigation. 1. White or Flaky Cerumen In the irrigation water, this form of cerumen gets easily dissolved. There is relatively short irrigation procedure, and a cerumenolytic agent isnt always needed. Often you will not see solids trapped in the ear tip with this form of cerumen; rather, there will be some of the dissolved cerumen trapped in the ear tip screen. The rest of the dissolved cerumen will exit through the chamber (exit port). 2. Light Brown orJelly-Like Cerumen This cerumen mimics the petroleum jelly consistency and does not completely dissolve in the irrigation water. Some solids may be present in the ear tip, and the procedure time is slightly longer than for the white/ flaky type. To shorten the time of irrigation a cerumenolytic agent is recommended. 3. Dark or Hard Cerumen This cerumen is often found lining the ear canal walls and forms a wax plug in the patient which can produce significant hearing loss. Large solids of cerumen are seen trapped in the ear tip and the procedure time is often longer than the wet/jelly-like cerumen. A cerumenolytic agent is often necessary to shorten the time of irrigation.

Earwax Removal
Earwax needs to be removed if there is need of making a mould for a hearing aid. Earwax needs to be removed if earwax makes a hearing aid whistle. Eardrops may be given to soften earwax. They are prescribed for 3-5 days in order to help softening of the wax. They should always be used at room temperature. Lie on side for a couple of minutes with the blocked ear facing the ceiling. It lets the eardrops soak into the wax and soften it. Three basic types of earwax drops are: 1. Debrox and Murine containing oil, water, and a solution of hydrogen peroxide and other ingredients. Hydrogen peroxide doesnt dissolve wax rather it is having a mechanical effect on the wax to help bubble it out. 2. Oil based solutions are containing glycerin, olive oil (sweet oil), propyline glycol, mineral oil, and others. They work better if these solutions are warmed for sometimes. These kind of solutions only lubricate, and soften the wax making it less sticky and easier to be removed. 3. Enzyme based solutions include Cerumenex. These are not usually adviced because these preparations can irritate the ear canal, creating more problems to the ear. By combining vinegar-water-hydrogen peroxide in a 1:1:2 ratio your own earwax drops can be made. Any of these preparations should not be used in your ear if you have a ruptured eardrum. Cerumenolytic Agents These agents are specifically designed to soften or dissolve cerumen. Carbamide peroxide that is the only agent the FDA considers safe for loosening or softening cerumen is an integrant of most softening agents, particularly those products which are used over-the-counter. It is necessary to soften cerumen prior to removal or instead of removal, in some instances. Ear Irrigation It is a process in which earwax is washed out. An irrigator which is an electric tool, pushes water into the ear. Ear may be held at different angles so as to make sure that the water jet reaches all areas. The water jet should not hurt but it will give you a strange feeling in ear. Ear irrigation indications are: There is lot of liquid that is causing hearing difficulties. Previous ear surgery within the one and half year A cleft palate (whether managed or not) An ear infection Ear irrigation contraindications are: Previously had a problem with irrigation Damage to the eardrum A runny liquid coming from your ear A grommet (a small, empty tube) Other Ways of Removing Earwax Micro-suction it is a procedure in which gentle suction is used to remove the earwax out. Aural toilet it is procedure in which the specialist uses a tool for removing the wax.

Ear Candling
Ear Candling or coning is a natural way of cleaning accumulated wax, fungus, yeast, and bacteria from the ears. The accumulations that are withdrawn from ears can be months to even years old. Ear Candles are the custom designed appliances made up of natural fibers that are tapered for precise specifications. It is a simple, time-proven therapy which can be very effective to remove old, troublesome blockages of the ear canal, without the use of probes or solutions. Ear Candling is for problems of the sinuses, ears, and lymphatics. Ear Candling or coning has been employed for centuries. Ancient Egyptians used reeds for candling and the process is known to Tibet, Aztec cultures and India. Native Americans performed it for thousands of years by making use of cornhusks dipped in beeswax in order to make a hollow candle. This process is still being practiced today in many traditional medicine centers, and has been gaining popularity in general. The typical client is one who is searching for a more natural way of alleviating pressure in their upper respiratory area or head or someone wanting pain relief, to smell, hear, see or just to feel better. To a patient or client there wont be any treatment related discomfort. Ear Coning works simply as a catalyst to clear the respiratory system. It helps to clear sinuses & drain lymph glands. It vacuums off ear canal nerve endings and the Eustachian tube. A very wonderful side effect is deep relaxation which in the auditory canal stimulates anti stress acupuncture point; its effect is seen on hyperactive children and adults too. The pretty amazing is deep nerve relaxation and the Chiropractors and body workers have noted better treatment results after the client is coned. Consume lots of water after coning. Candling can be applied on persons of any age. Some conditions which may benefit from Ear Candling are: Headaches, Excessive Wax, Infections, Ringing in the ears, TMJ Dysfunction, Hearing Challenges, Plugged Ears, Inner Ear Pressure, Imbalance, Migraines, Chronic Sinusitis, and Ear Aches. The mechanism through which ear candling works is a process known as convection where toxins and softer waxes will be oxidized, drawn out of the ear, and turned into vapors during the procedure. The bottom contains collected debris. Procedure and Duration of Ear Candling Lie on side with your body aligned straight during a session. A specialized conical shaped candle is inserted into a protective plate & the candle is lit which slowly begins to burn. In ear canal the small tapered end is gently placed. Candling is a painless procedure; you will only feel the candle which is carefully being inserted in ear. As the ear wax is getting pulled from within ears, there may be some crackling and popping sound heard by you. A typical session of candling lasts approximately 45 minutes. Dosage for Ear Candling Initially, most of the people need just 2 to 3 sessions in order to get clean ears. However, there are some people who may need up to 8 sessions for a period of over six months. Personal preference determine how often to have ears candled, once your ears are clean. Every three to four months is recommended.

Earwax Treatment Tools

Movement of the jaw helps natural cleaning process of the ear. There are many softeners that are effective in wax treatment but they are not sufficient enough and the most commonly used method of earwax removal is syringing with warm water. An otolaryngologist more likely uses a curette method when there is partial occlusion of ear canal is and the material does not adhere to the ear canal skin. Cotton swabs remove only a portion of the layer of wax situated at the top and drag most of the earwax deeper into the ear canal. 1. Softeners Earwax softening or cerumenolysis is done by using a solution called cerumenolytic agent and it is introduced into the ear canal. This method usually makes the wax come out and it may also facilitate removing the wax by curettage or syringing, if it does not come out. These agents are specifically designed to soften or dissolve cerumen. It is necessary to soften cerumen prior to removal or instead of removal, in some instances. Commonly used cerumenolytics include: Carbamide peroxide that is the only agent the FDA considers safe for loosening or softening cerumen is an integrant of most softening agents, particularly those products which are used over-the-counter. Debrox and Murine containing oil, water, and a solution of hydrogen peroxide and other ingredients. Hydrogen peroxide doesnt dissolve wax rather it is having a mechanical effect on the wax to help bubble it out. Oil based solutions are containing glycerin, olive oil (sweet oil), propyline glycol, mineral oil, and others. They work better if these solutions are warmed for sometimes. These kinds of solutions only lubricate, and soften the wax making it less sticky and easier to be removed. Enzyme based solutions include Cerumenex. These are not usually adviced because these preparations can irritate the ear canal, creating more problems to the ear. 2. Ear irrigation It is done effectively with an ear washer which is a sort of spray type. It is used commonly in the medical settings or at home. Ear syringing techniques are described in great detail by Blake et al. And Wilson & Roeser. Dizziness is a commonly encountered side effect with syringing or ear washing with fluids having temperature warmer or colder than the body. Preferably the irrigation solution must be warmed to body temperature as. Blake et al. recommend using water at 38 C while Sharp et al. recommend 37 C. Any temperature variation may cause vertigo, similarly when performing caloric reflex test. 3. Curette and cotton swabs Earwax can be removed with a curette or ear pick, which physically dislodges the earwax, scooping it out of the ear canal.

Curetting with an ear pick is common practice in East Asia because earwax of most Asians is dry type, and it is easily removed through light scraping with an ear pick causing it to fall out as large dry flakes on its own. It is usually contraindicated to use Q-Tips (cotton swabs or buds) because they will push the wax deeper into the ear canal and can perforate the eardrum if handled carelessly. 4. Ear candles and vacuuming Ear candling or thermal-auricular therapy is performed by lighting one end of a hollow candle while placing in the ear canal, the other end. Ear candling is not a safe option for ear wax removal and its use is not supported by evidence-based studies.

How to clean earwax

Ear wax is a part of the body's normal defence mechanism against germs and dirt. It traps dirt, provides a waterproof lining for inner ear, and slows the bacterial growth. The cause of production of more ear wax or ear blockade in some people is not yet known. Earwax blockade or problems can be initially managed at home. Movement of the jaw helps natural cleaning process of the ear. There are many softeners that are effective in wax treatment but they are not sufficient enough and the most commonly used method of earwax removal is syringing with warm water. An otolaryngologist more likely uses a curette method when there is partial occlusion of ear canal is and the material does not adhere to the ear canal skin. Cotton swabs remove only a portion of the layer of wax situated at the top and drag most of the earwax deeper into the ear canal. 1. Manual Cleaning Earwax which is visible to the eye can be easily wiped out using a washcloth. However, manual cleaning with a cotton swab/cotton bud, a finger or anything else to go deeper inside the ear cab put the delicate skin of inside of the ear canal at risk of damage and potentiate for causing infection. Manual cleaning of any kind should be reserved for exterior of the ear. Curetting with an ear pick is common practice in East Asia because earwax of most Asians is dry type, and it is easily removed through light scraping with an ear pick causing it to fall out as large dry flakes on its own. It is usually contraindicated to use Q-Tips (cotton swabs or buds) because they will push the wax deeper into the ear canal and can perforate the eardrum if handled carelessly.

2. Softeners Earwax softening or cerumenolysis is done by using a solution called cerumenolytic agent and it is introduced into the ear canal. This method usually makes the wax come out and it may also facilitate removing the wax by curettage or syringing, if it does not come out. These agents are specifically designed to soften or dissolve cerumen. 3. Irrigation It is done effectively with an ear washer which is a sort of spray type. It is used commonly in the medical settings or at home. Ear syringing techniques are described in great detail by Blake et al. And Wilson & Roeser. Irrigation utilizes a rubber bulb syringe which squirts warm water gently into the ear canal, once the earwax has been softened. Temperature of the water warmer or colder than the body is contraindicated because it can lead to vertigo or burns. After irrigation water has been inserted into the ear canal, the head is tilted to the side in order to allow loos wax and water to drain. If a person has had ruptured eardrums in the past or persistent ear infections, this cleaning should be done by an ENT specialist. 4. Candling Ear candling or thermal-auricular therapy is performed by lighting one end of a hollow candle while placing in the ear canal, the other end. The theory is that the flame creates a vacuum action that sucks the earwax. The procedure is very ineffective and hazardous because hot wax can easily burn the internal as well as external canal, causing an infection or even perforating the eardrum.

Home Remedies for Ear Wax Blockade

Ear wax is a part of the body's normal defence mechanism against germs and dirt. It traps dirt, provides a waterproof lining for inner ear, and slows the bacterial growth. The cause of production of more ear wax or ear blockade in some people is not yet known. Earwax blockade or problems can be initially managed at home. If home based management proves unsuccessful, it is better to consult your primary care physician or ENT specialist.

1. Manual Cleaning Earwax which is visible to the eye can be easily wiped out using a washcloth. However, manual cleaning with a cotton swab/cotton bud, a finger or anything else to go deeper inside the ear cab put the delicate skin of inside of the ear canal at risk of damage and potentiate for causing infection. Manual cleaning of any kind should be reserved for exterior of the ear.

Curetting with an ear pick is common practice in East Asia because earwax of most Asians is dry type, and it is easily removed through light scraping with an ear pick causing it to fall out as large dry flakes on its own. It is usually contraindicated to use Q-Tips (cotton swabs or buds) because they will push the wax deeper into the ear canal and can perforate the eardrum if handled carelessly.

2. Soften the Wax with cerumenolytic agents According to evidence based practice and articles on medline database, the first step to remove any earwax blockade at home is to soften the earwax inside the ear canal. The small hair inside the ear canal work as cilia and propel the wax out of the ear. However, the wax can become so hardened sometimes that it cant be propelled down the canal. Cerumenolytic agents such as carbamide peroxide, mineral oil, glycerine, baby oil, or hydrogen peroxide can be used to soften the wax for three to five days duration. Once the wax is softened, either it will be propelled out of the ear canal by ciliary action of small hair or by the use of irrigation. 3. Irrigation It is done effectively with an ear washer which is a sort of spray type. It is used commonly in the medical settings or at home. Ear syringing techniques are described in great detail by Blake et al. And Wilson & Roeser. Irrigation utilizes a rubber bulb syringe which squirts warm water gently into the ear canal, once the earwax has been softened. Temperature of the water warmer or colder than the body is contraindicated because it can lead to vertigo or burns. After irrigation water has been inserted into the ear canal, the head is tilted to the side in order to allow loos wax and water to drain. If a person has had ruptured eardrums in the past or persistent ear infections, this cleaning should be done by an ENT specialist. 4. Candling Ear candling or thermal-auricular therapy is performed by lighting one end of a hollow candle while placing in the ear canal, the other end. The theory is that the flame creates a vacuum action that sucks the earwax. The procedure is very ineffective and hazardous because hot wax can easily burn the internal as well as external canal, causing an infection or even perforating the eardrum.