It was the end of December. I had overslept and was rushing to brush my teeth, shave, and cotton swab my ears after a shower. Unfortunately, my son chose that moment to bang the door open right into my elbow, which was bent to hold the swab in place. First I felt the clap of pain, then I realized I couldn’t hear from my right ear.
Two hours later I was in the ENT office, on my back and under a microscope. The doctor removed the blood from my ear canal with a tiny vacuum. She said there was a small tear of the skin that would heal quickly and that the eardrum was OK. I made two New Year’s resolutions: get a louder alarm clock and lose the cotton swabs.
Ear Wax Impaction
Approximately 12 million people in the United States experience buildup of ear wax each year that leads to some sort of blockage (impaction). Why does the ear create wax (cerumen)? What factors contribute to impactions? And how best can you prevent and treat cerumen impactions?
The ear canal is about 1 inch long (24 mm). The outer one-third of the canal is made up of cartilage, whereas the inner two-thirds is made of bone. The ear canal is lined with skin, much like the skin that covers the rest of the body, but there are some important differences.
The external ear has a unique self-cleaning mechanism. Like all skin of the body, outer layers of skin cells are lost every day. In the ear, these cells migrate outwards (from eardrum to ear canal opening) carrying debris with them. They become part of cerumen (ear wax) and extrude on their own from the ear opening. The wax is key to protecting the ear canal skin.
Figure 13.1
The skin of the outer third of the ear canal contains glands that make cerumen (ear wax). Like the skin of your face or hands, layers of ear canal skin shed every day. These layers of skin join glandular secretions to make wax. Like a slow conveyor belt, the wax carries out dirt that may have entered the canal.
Cerumen glands are similar to both mammary glands and sweat glands. The cerumen itself has several functions. It helps prevent outer ear infection because it:
• protects the skin from water (picture your toes after a long bath; all white, crinkly and easy to bruise, which can set the stage for an infection),
• is slightly acidic, making bacterial growth difficult, and
• contains antimicrobial proteins that attack bacteria.
Together these factors contribute to an antibacterial and antifungal effect of cerumen.
The normal migration of cerumen through the ear canal usually prevents the development of impaction. Use of cotton swabs to assist this natural process has a tendency to push the wax back into the ear canal. Think of a muzzle-loading rifle, where the powder is packed deeply into the barrel by a plunger. You may think you’re removing wax because the tip of the swab is stained yellow, but the main effect of most swabbing is to force cerumen deeper in the ear canal. Cotton swabs (or worse, bobby pins or other sharp objects) also cause lacerations of the delicate canal skin, resulting in infection, and occasionally they perforate the eardrum.
Other factors may also lead to cerumen impaction. Some people have narrowing of the ear canal that is present from birth or a result of trauma or infection. A narrow ear canal (smaller than 3 or 4 mm in diameter) may obstruct the exit of wax, causing a buildup. In a similar way, some types of hearing aids may block the opening and lead to cerumen impactions. Finally, patients with dermatologic conditions of the ear such as seborrhea (akin to dandruff) or psoriasis (an autoimmune disease where, among other problems, the skin layers flake off very rapidly), may find that accumulation of dead skin at the opening of the ear canal leads to a blockage.
Symptoms
Cerumen impactions cause a range of symptoms. Most commonly patients experience a feeling of fullness or a clogged sensation in their ear. Itching may also be present. Hearing loss and the sense of hearing your own voice echo in the blocked ear occurs if the ear canal is completely blocked. These complete-blockage symptoms may seem worse after showering, as water in the ear canal causes the wax to swell or fill in a small air gap to form an airtight blockage.
Prevention
People with a tendency to get wax impactions may require special preventative management. Softening agents may help wax come out of the ear canal more easily. Baby oil, mineral oil, and olive oil have all been used effectively. On the other hand, using hydrogen peroxide–based cleaners and detergents to loosen or remove wax can damage the ear canal skin and lead to infection when used repeatedly. In rare cases, regular removal of ear hair or cerumen by a physician is necessary. Even rarer, people with a narrow ear canal may benefit from surgical enlargement.
Treatment
The safest and most effective means for removing impacted cerumen is by an ear doctor with micro-instruments under a microscope. Gentle irrigation, in either a physician’s office or using home ear wax removal kits, is appropriate to soften and dislodge wax. Sometimes called “syringing,” this process involves directing water toward the back wall or roof of the ear canal in an attempt to wash out the wax plug. The effectiveness of either of these techniques may be enhanced by softening the wax, typically with olive or baby oil for two to three days prior to removal.
Ear candling has been promoted as an alternative medicine technique for removing impacted cerumen, but we do not recommend it. In this technique a hollow candle is placed in the ear and lit. Proponents claim that the heat creates a vacuum in the hollow candle that draws wax out of the ear. As proof, they demonstrate the wax accumulation at the base of the candle. That wax, however, has been shown to be from the melted candle combined with soot from the wick. Candling does not create a vacuum or remove wax. Furthermore it may cause superficial burns when hot candle wax drips down into the ear canal.
Foreign Bodies in the Ear Canal
Any outside material that becomes lodged in the ear canal is a foreign body. It is relatively common, and, not surprisingly, children and adults tend to get different types of objects stuck in their ear canals.
Once children gain manual dexterity (around the toddler stage) they are able to place small objects, such as beads or other small toys, into their ears, where the foreign bodies become lodged.
Adults, on the other hand, may experience insects gaining entry into the ear during sleep. It is also common to find the tips of cotton swabs or components of a hearing aid in the ear (often a tip or “dome” can be left behind when the rest of the aid is removed).
Treatment
Once lodged in the ear canal, foreign bodies should be removed within a day or two with one notable exception (disk batteries). If foreign bodies are left in the ear canal they cause swelling of the skin, obstruction, wax buildup, and infection. Removal of disk batteries requires immediate action because these tiny batteries can destroy the ear canal skin, underlying bone, and the eardrum if not removed quickly.
If living insect(s) are present within the ear canal, they may voluntarily crawl out toward a flashlight in a darkened room. If removal is necessary, sometimes irrigating the ear with tap water will flush the insect out without killing it. Nonetheless, it is usually necessary to euthanize the insect before attempting removal. This can be done by filling the ear canal with alcohol or mineral oil.
Figure 13.2
Round or hard foreign bodies that are deep in the ear canal usually require using a microscope and micro-instruments for removal.
The best way for a doctor to remove a foreign body depends on its size, shape, and texture. Irregularly shaped items and soft compressible objects can commonly be removed in the emergency room by an ER physician. A smooth, hard object, such as a bead or popcorn kernel, is more likely to require an ENT who will remove it using a microscope and micro-instruments.
One recent study demonstrated a success rate of only 34 percent for removal of smooth rounded objects by non-ear surgeons. If a foreign body is deep in the ear canal, or one attempt is unsuccessful, the patient should be referred to an ear specialist. If the ear canal has been cut or bruised, or if a child has been traumatized in the ER, it may be necessary to remove the foreign body under general anesthesia in an operating room.