Ear Wax
by Timothy C. Hain, MD
Last edited 8/2008
What is Ear Wax?
Ear wax is a normal product of the ear which protects the skin of the ear from water and infection. Ear wax is formed from wax glands in the external ear canal. Different individuals vary considerably in the amount and consistency of their ear wax. There are two types described, wet and dry, which are inherited. Dry wax is common in Asia, while wet wax is common in Western Europe. Dry wax contains by weight about 20% lipid (fat). Wet wax contains by weight about 50% lipid (Burkhart et al, 2000). While ear wax is generally simply felt to be a nuisance, in medieval times, ear wax was used as a component of pigment for illumination of manuscripts (Petrakis, 2000). Too little ear wax increases the risk of infection (Fairey et al, 1985). Too much wax also increases the incidence of infection and hearing loss. Therefore, you want just enough.
While we are not aware of a study of this, some people (and some ears) are "wax producers," and others remain wax free without much maintenance.
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| Fig 1. Artists depiction of ear wax blocking external ear canal. |
What Can Go Wrong With Too Much Ear Wax?
Too much ear wax can cause several problems:
- Wax can plug up the ear, causing hearing to be reduced, and a full feeling in the ear
- Wax can trap bacteria in the ear, leading to infection. This is usually painful or at least itchy.
- Wax can obscure vision when the doctor looks in your ears, possibly hiding a dangerous process.
Direct vision is the easiest way to determine if you have too much ear wax. An otoscope (figure 2) is used to visualize the wax.
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| Fig2. Otoscope (top) and Ophthalmoscope with handle (bottom) |
How is Problematic Ear Wax Treated?
Problematic wax can be removed with drops, with water jets (irrigation), and with instruments by a doctor, audiologist, or trained technician.
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| Fig 3. Wax removal under direct vision. A metal speculum (the trumpet shaped device) is placed in the ear canal. Wax is removed using an instrument called a cerumen spoon, sometimes supplemented with gentle suction and forceps. Ordinarily, this is done using an examining microscope (not shown), which provides magnification and a bright light. |
Removal under direct vision by a doctor or other professional is the best method of getting wax out, but it requires a doctor's visit and the doctor must have access to a microscope. Practically speaking, this generally requires yearly visits to see a specialist called an otologist.
A physician can also remove wax using an endoscope instead of a microscope to visualize the ear canal (Pothier, 2006 [2]). Endoscopes are more commonly available and easier to use and may be more comfortable for the patient.
Over-the-counter drops that help remove wax are all basically oil and peroxide solutions Brand names include Debrox and Murine. Hydrogen peroxide is present for the mechanical effect; it does not dissolve ear wax (Burkhart et al, 2000). These preparations are best for those with small to moderate amounts of wax. These preparations should not be used by persons who have an eardrum perforation. We advise against use of enzyme-based preparations, such as Cerumenex, because of problems with allergy. One study found plain water to be more effective and faster than hydrogen peroxide or olive oil in dissolving ear wax (Chalisazar, 2007). Another found water to be as effective as over-the-counter products Murine and Ceruminex (Roland, 2004).
Irrigation or "syringing" is a standard method of wax removal and approximately 150,000 ears are irrigated each week in the United States (Grossan, 1998). Installation of water into the ear canal for a few minutes prior to syringing may aid in removal by softening the ear wax (Pavlidis, 2005).While this is a conventional and accepted method of ear wax removal, it has many disadvantages compared to removal under direct vision. For example, in the rare instances when there is a perforation, irrigation may force water and wax into the middle ear, causing a nidus for infection.
Water jet devices, such as used for dental care, have also been used for ear wax removal. While generally effective, this method is judged unpleasant by many patients. There is also danger of perforation of the ear drum using these devices. Special tips can be used to reduce or eliminate this risk.
"Candling" is an alternative method of removing wax. This method is not felt to be effective.
Do-it-yourself ear wax vaccum kits are available over-the-counter. A study comparing these "ear vacs" to syringing found that the ear vacs did not remove any wax at all (Leong, 2005).
Ear Wax Maintenance
First, one should realize that wax isn't all that bad. It keeps your ear dry and helps prevent infection. Thus, you don't want to eliminate wax; you want to keep it from blocking your ears. There are several methods to do this.
One method is to put baby oil or olive oil into each ear on a regular basis. Put in the oil, let it sit in there for a few minutes, then lie down on a towel to let it drip out again. Probably only a few drops every week in each ear is good enough (nobody has done a research study on this). It doesn't hurt to put a few drops of clean olive oil or baby oil into each ear every day. Swimmers often do this prior to their daily swim. However, be sure that the oil is clean, as you don't want to introduce bacteria. This should not be done if you have an eardrum perforation or if you don't know whether or not you have a perforation.
Cerudel Lipolotion is an emollient lotion that has been shown to decrease the rate of wax build-up when applied to the ear canal (Saloranta, 2005).
Another method is to have your ears cleaned out by your doctor on a regular basis. Everyone builds up wax at their own rate, but commonly people need to come back for wax removal at six-month or one-year intervals.
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| Fig 5. When cotton tipped applicators are used to clean out ear wax, there is a risk of breaking the ear drum (perforation). Although we realize that this is commonly done, we recommend against using cotton tipped applicators, hair pins, and similar devices to clean the ear. |
We recommend against using cotton tipped applicators (such as Q-tips), as well as putting other things into your ear, such as hair pins. This can be dangerous because you run the risk of breaking (perforating) your ear drum, as well as jamming wax deeper inside. Cotton-tipped applicators may also increase the risk of bacterial infection of the external canal, commonly called swimmer's ear (Nussinovitch, 2004).
Acknowledgments
Graphics are courtesy of Northwestern University.
References
- Burkhart CN et al. In pursuit of ceruminolytic agents: a study of earwax composition. Am J Otol. 2000 Mar;21(2):157-60.
- Chalishazar U, Williams H. Back to basics: Finding an optimal cerumenolytic (earwax solvent). Br J Nurs. 16(13):806-8, 2007.
- Fairey A, Freer CB, Machin D. Ear wax and otitis media in children. Br Med J (Clin Res Ed) 1985 Aug 10;291(6492):387-8
- Grossan M. Cerumen Removal--Current Challenges. Ear Nose Throat J. 1998 Jul;77(7):541-6, 548. Review
- Leong AC, Aldren C. A non-randomized comparison of earwax removal with a 'do-it-yourself' ear vaccum kit and a Jobson-Horne probe. Clin Otolaryng. 30(4):320-3, 2005.
- Nussinovitch M, Rimon A et al. Cotton-tip applicators as a leading cause of otitis externa. Int J Ped Otorhinolaryng. 68(4): 433-5, 2004.
- Pavlidis C, Pickering JA. Water as a fast acting wax softening agent before ear syringing. Aus Fam Phys. 34(4): 303-4, 2005.
- Petrakis NL. Earmarks of Art History: Cerumen and Medieval Art. AAm J Otol. 2000 Jan;21(1):5-8.
- Pothier DD. How we do it: technical note: endoscopic removal of cerumen. Clin Otolaryng. 31(2):153-5, 2006.
- Pothier DD, Hall C, Gillett S. A comparison of endoscopic and microscopic removal of wax: a randomized clinical trial. Clin Otolaryng. 31(%):375-80, 2006.
- Roland PS, Eaton DA et al. Randomized, placebo-controlled evaluation of Cerumenex and Murine earwax removal products. Arch Otolaryng Head & Neck Surg. 130(10):1175-7, 2004.
- Saloranta K, Westermarck T. Prevention of cerumen impaction by treatment of ear canal skin. A pilot randomized controlled study. Clin Otolaryng. 30(2):112-4, 2005.
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