Do not place in ear canal.

Sounds like simple advice though the simple request that sits on the “Q-tip” box usually goes unheeded.  It always surprises me how many patients react very surprised when I give them this simple advice.  An old 2006 article titled “Don’t put anything small than your elbow in your ear” talks about the genetics of ear wax (AKA Cerumen).

So what can you do about that feeling of an unclean ear?  I came across this conversation today with a patient and went through all of these options and the evidence behind them.  It did make me happy to know that I would have something to blog about today!

Option 1: DO NOTHING!  There is nothing harmful about having wax in your ears.  Very commonly, patients only present regarding this when it affects their hearing, they have a sense of fullness in the ears or some sort of discomfort (not usually described as pain).  Usually this is secondary to the fact that they have compressed the wax with…. some form of cotton tipped applicator, the name eludes me at this point.

2. Something must be done doctor…  How about “Candling”?  This is where a lit “candle” drips hot wax into the ear which then is said to produce a negative suction which draws the wax out of the ear canal.  The FDA (Food and Drug Administration) warns consumers to stay away from products sold as “ear candles”.  While it is not quite a candle, it is actually a hollow cone about 10 inches long and made from a fabric tube that is soaked in some combination of beeswax and/or paraffin.  Due to the high levels of negative press from reputable sources, marketing companies haven’t been as successful in selling these in mainstream stores as much, but they will usually be found in some thrift shops and other smaller retail markets.

The injuries (even when sticking to the manufacturers’ directions can lead to severe injuries, such as burns, bleeding or tympanic membrane perforation (breaking of the ear drum).  The more worrisome problem is both temporary and permanent hearing loss, as well as the possiblity of starting a fire.  As such, the FDA has worked with Health Canada to act against manufacturers of ear candles and commonly stops entry of these products into the country.

With a prevalence of approximately 35% of elder patients having the disease process and the worry of “bothering” a doctor with a minor issue, commonly patients turn to alternative medicine.  Let me be one of the many to say, it’s not a problem to bring in easy problems to fix!

The one study most people will quote is a 1996 study in the journal “Laryngoscope” which noted 21 ear injuries on a subjective survey of 122 otolaryngologists.  End comment was “Ear candles have no benefit in the management of cerumen and may result in serious injury.

Before I continue, I’d like to create a framework for future blogs as commonly I will refer to SORT (Strength of Recommendation Taxonomy) which comes as A, B, or C.

A- Recommendation based on consistent and good-quality patient oriented evidence.

B- Recommendation based on inconsistent or limited-quality patient-oriented evidence

C- Recommendation based on consensus, usual practice, opinion, disease-oriented evidence or case series for studies of diagnosis, treatment, prevention or screening.

An ounce of oil as prevention is better than a pound of wax.

There is level B recommendation of weekly instillation of emollient oil which may decrease the recurrence of cerumen impaction.

It should also be noted that there is a level B recommendation that saline placebo is just as effective as use of ceruminolytic products on the market.   There was an interesting comment that docusate sodium may be the best of the worst, which might be the only good use for the medication, but that’s a story for another day.

Most physicians are very quick to use irrigation of water in the office, as it has been shown to be very easy and safe to do.  Most commercially available syringes do not produce the pressure needed to cause a true tympanic membrane perforation (break in the ear drum).

The biggest side effect to irrigation is that it may not work.  Leaving the patient wet and still not hearing well.  Most patients that get some sort of wetting of the wax for a few days prior to the irrigation do better than those that come in directly with their symptoms. It can be discussed with patients to use a  bulb suction to self irrigate when they feel symptoms of cerumen impaction (SORT B).

One in three patients will improve their hearing by a mean of 5 dB (SORT B) with removal of cerumen impaction.

In the end, it’s more important not to put any cotton tipped applicators, keys or safety pins into the ears at any point than anything else.  ‘First do no harm!’

• Cerumen
• Hearing
• Impaction
• Outer ear infection
• Qtip
• Wax