CERUMEN (Ear Wax) is not dirt but a wonderful matrix

Cerumen, or “Earwax,” is a naturally occurring substance in the external ear canal. Normally, it is expelled by a self-cleaning mechanism. Accumulation of cerumen, caused by failure of the same, is one of the most common reasons that patients seek medical care for ear-related problems. Cerumen is usually asymptomatic, but when it becomes impacted, it can cause various problems such as hearing loss, pain, or dizziness. The removal of cerumen and subsequent improvement of hearing can be one of the most satisfying experiences for patient and doctor alike.

Cerumen (i.e., earwax) is composed of secretions and sloughed epithelial cells and hairs from the external ear canal. Cerumen, with its content of lysosymes, glycoproteins, immunoglobulins, lipids and trace elements, exerts a bactericidal or bacteriostatic action and thus probably plays some role in maintaining local host defences. Genetic factors are believed to influence the consistency and composition of cerumen. Most Caucasians and Negroes have the 'wet' phenotype, where the cerumen is moist, pale, honey-coloured, while mongoloid races tend to have the ‘dry’ phenotype with grey, granular and brittle cerumen.

Cerumen and old skin of the ear canal makes its way out in a “conveyor belt” fashion, taking with it any dirt, dust, and particulate matter that may have gathered in the canal. Normally, Cerumen is expelled by a self-cleaning mechanism, which causes it to migrate out of the ear canal, assisted by jaw movement (talking and chewing).
Risk factors for cerumen impaction include a twisted or narrow ear canal, ears that overproduce cerumen, dense hair growth in the ear canal, trying to remove cerumen with a cotton-tipped swab, Hearing aid use, use of ear-plug type hearing protectors and intellectual disability.

Impacted cerumen may give rise to complaints like pain in the ear (otalgia), itching in the ears, ringing in the ears (tinnitus) and hearing loss. Other complaints include sensation of fullness, dizziness, odour, drainage and cough. The amount of hearing loss depends on the degree of occlusion of the canal with cerumen. Impacted cerumen may lead to social withdrawal and poor work function.

The diagnosis is done by an ENT Specialist after taking a thorough history in relation to the complaints and examination of the external ear canal with an Otoscope. An Otoscope is an instrument used for better visualisation of the inside of the ear canal. It provides illumination as well as magnification. Treatment options include manual removal, use of ceruminolytic agents and irrigation with or without ceruminolytic pretreatment. Manual removal involves the use of a metal loop.

This can be done under a microscope to improve depth perception and enhance safety. Another technique is Suctioning. A machine that sucks objects out of the ear canal is used to remove small, formed cerumen plugs. This procedure uses a small plastic or metal tube that goes in the external ear canal and is connected to the machine. A cooperative patient and clinical skill of the specialist led to the successful manual removal of impacted cerumen. Ceruminolytics are agents that soften cerumen. These are available in the form of ear drops. Ceruminolytics alone may take a longer duration of treatment, and the success rate for effective cerumen removal is not very high. Irrigation (syringing) may be attempted alone or with a ceruminolytic pretreatment. 

Water at body temperature is pushed into the external ear canal with a special syringe, and the water returns, carrying with it the impacted cerumen. Meatoplasty, a surgery to widen the opening of the external ear canal, becomes necessary when wax impaction is a result of canal stenosis(narrowing), which causes recurrent infection or hearing loss and requires frequent visits to an ENT Specialist.

Most people believe that wax is an unnecessary substance in the ear and should be removed. The comparison of wax with dirt is a misconception, and self-cleaning attempts often lead to harm. People commonly use cotton swabs, also called Q-tips, as a household item for cleaning ears. However, the Q-tip is designed for cleaning the external ear and not for cleaning the inner canal. Ear candling is another process seen on social media, where a cone-shaped candle is placed into the ear canal. It’s not only ineffective but also dangerous.

In many parts of the country, roadside ear cleaning service is provided by ear cleaners popularly called kaan saaf wallahs. They have no formal training, use metallic tools and cotton and a head mirror to pull out wax. The entire process is exposed to injury and infection. 

Recently, earwax has been seen as the next frontier for the diagnosis of cancer. Studies have revealed that cancer can be detected by biochemical analysis of the metabolites in earwax. Cancer produces volatile organic metabolites that are present in earwax, allowing detection through an assay called cerumenogram. Compared to other biological fluids like blood, urine, sweat and tears, earwax has a lower turnover rate, making it ideal for analysis. Researchers are investigating earwax to detect Alzheimer’s disease, Parkinson’s disease, Diabetes etc., but larger trials and validation studies are required before cerumenogram becomes a standard and universally accepted medical diagnostic tool. It would be correct to conclude that cerumen is a wonderful biological matrix awaiting further exploration.

There are no proven ways to prevent cerumen impaction. People prone to repeated wax impaction or using hearing aids should consider seeing an ENT Specialist every 6 to 12 months for a check-up and routine preventive cleaning. Ears are our guardian against danger by providing 360 degree 24x7 enviromental awareness (hearing) and spatial orientation (balance). Our Ears are delicate, and they need care.

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