Ear wax impaction is a ubiquitous problem. An estimated 2.3 million people in the United Kingdom (UK) each year suffer impaction significant enough to warrant intervention.1 In the United States, approximately 150,000 wax removals are performed each week2, and in 2012 the Centers for Medicare and Medicaid services spent $46.8 million in reimbursements for this procedure, predominantly to otolaryngologists in secondary care.
Despite UK recommendation for wax removal to take place in primary care4, variable funding for such practice has led to ever-increasing referrals and waiting lists for removal in secondary care.5 This review summarizes the physiology and anatomy of ear wax, and reviews historical and current treatment options for managing wax impaction.
What is EAR WAX?
Ear wax is a composite material produced in the lateral one-third of the external auditory canal (EAC), comprising a mixture of desquamated keratin from skin cells sloughed off from the walls of the EAC, sebum from sebaceous glands and cerumen from ceruminous glands. It contains long-chain fatty acids, alcohols, squalene and cholesterol, and is usually unproblematic.6,7 There are species difference in wax production, for example the ratio of sebaceous and ceruminous glands increases from medial to lateral in the dog, and aggregates of glands are found near the tympanic membrane in rodents.8 The reasons for such species differences are not understood.
Despite being much maligned, the main function of ear wax is a protective one. It lubricates the walls of the EAC, trapping foreign particles and repelling water, and its acidic nature provides bactericidal and fungicidal properties.
The physical properties of ear wax are genetically determined, particularly by polymorphism in the ABCC11 gene. Those of Asian descent typically have ‘dry’ earwax that is brittle and lighter in colour. Those of African and White descent typically have darker and stickier ‘wet’ ear wax. Whether such variations alter risk of impaction is yet to be determined.
EAR WAX impAction
Ear wax naturally clears through migration of the epithelial cell lining of the EAC, aided by normal jaw movements. Where this process becomes disrupted or inadequate, wax may be retained 10 and is defined as impacted when accumulation in the ear canal becomes symptomatic or prevents assessment via otoscopy.
Causes of impaction are not well researched, but clinical experience suggests several reasons, which may occur in isolation or combination. These include age-related changes, altered anatomy of the ear canal or meatus, altered skin physiology, foreign bodies, or instrumentation of the ear (Table 1). There may also be idiopathic overproduction of wax. One particular cause of wax impaction is following the operation “canal wall down mastoidectomy,” where the posterior and superior bony ear canal is removed such that the mastoid bone of the middle ear becomes part of the outer ear, forming a mastoid cavity. The movement of wax within a mastoid cavity is often haphazard and incomplete 12,13, and many cavities need clearing of wax at variable intervals.14,15 Another common cause of wax impaction is the use of hearing aids (and excessive use of earphones) obstructing normal migration and possibly causing overstimulation of ceruminous and sebaceous glands in the EAC leading to increased wax production. Further, wax can cause hearing aid damage.
Symptoms of ear wax impaction include a sense of aural fullness or blockage, itching or mild irritation, and in some cases tinnitus and hearing loss. 10 It is important to consider other diagnoses in the presence of severe pain, significant hearing loss, or copious ear discharge.
History
Manual methods of ear wax clearance have been in practice since the early ages. The “ear syringe” was mentioned in the 1st Century AD by Celsus for rinsing suppuration and clearing foreign bodies from the EAC, and gained popularity again in Europe in the 19th Century with development of bespoke syringes documented in Germany and Italy, and a kidney bowl to collect rinsing water from the ear. 18 Ear irrigation is now one of the most popular methods of wax clearance, with an estimated 4 million procedures performed annually in the UK alone.
Instruments such as spoons and picks have been used for wax removal for at least two centuries both in Europe and Asia (Figure 1). 20-22 In Japan, the practice of “mimikaki” to remove wax using picks and hooks is still popular in contemporary culture, starting in early life where children sit in their mother’s lap for regular cleaning of the ears23 and with parlours specializing in this practice for adult clients.20 Paid services for wax removal are found in other cultures, too, for example on the streets of Delhi, India.
Summary of Ear Wax impaction causes
| Risk Factor | Presumed aetiology |
|---|---|
| Age > 50 | Cerumen gland atrophy with age contributes to wax that is drier and harder to clear. |
| Hirsute ear canal or meatus | Excessive or coarse hair in the ear canal increases risk of obstruction, particularly if it becomes matted. This is more common in older men. |
| Ear canal anatomy | Narrow or tortuous ear canals impede wax clearance. This may occur in isolation, or as part of wider craniofacial malformation (e.g., narrow canals in Down syndrome). Ear canal pathology such as exostoses, osteomas, external canal cholesteatoma, or surgery such as canal wall-down mastoidectomy, can also impede wax clearance. |
| Ear meatus anatomy | A congenitally narrow meatus (entrance to the ear canal) may occur in isolation or in combination with a narrow ear canal. Acquired narrowing is particularly seen in elderly patients, where reduced tissue elasticity can lead to anterior prolapse of the conchal cartilage of the pinna. |
| Abnormal skin physiology | Dermatological conditions such as keratosis obturans, eczema, or psoriasis may alter wax physiology and clearance. |
| Foreign bodies in the ear canal or meatus | Regular use of earplugs, earphones, or hearing aids in the meatus may impede wax clearance. Foreign bodies in the ear canal, such as beads, or surgically placed grommets (that have extruded from the tympanic membrane) can also create a nidus for wax accumulation. |
| Instrumentation of the ear | Instrumentation, for example with cotton buds, picks, or sticks, may push wax into the deep ear canal where it can become impacted. |
In modern times, objects such as cotton buds and hair pins, and trends such as ear-candling have gained popularity for the removal of earwax, although these remain cautioned by medical professionals and literature.8,17,24 There has also been an explosion of cameras and instruments on sale to the public, to enable people to remove their own wax under visualization.
Current Practices
There is agreement among professional organizations, including NICE, Cochrane and the American Academy of Otolaryngology, that clinicians should only diagnose and treat ear wax impaction in patients where buildup is symptomatic and/or preventing adequate examination of the ear canal or drum.11,25,26 However, clinical experience suggests some patients attend for wax removal frequently, and in some cases, due to habit or misconception (either on the part of the patient or the provider), rather than true clinical need.
Within the National Health System in the United Kingdom, it is a service offered at few primary care practices, due to a combination of lack of funding and training. In secondary care, ear wax removal may sometimes only be offered as part of a wider assessment, facilitating diagnosis, or as part of ongoing management of chronic pathology such as patients with mastoid cavities. In the United States, it is not a procedure covered by medical insurance unless necessary to enable full examination.27 Consequently, there exists a wide range of paid-for ear wax removal services within the community, including high street providers and mobile services.
