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Vincent’s S.C.A.N.S 
Ear, Nose and Throat (ENT), Head and Neck Surgery
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Last update:  10/5/14 
EDUCATION Ear Wax   10 Important Facts
Medical product used here is for illustration only and does not imply endorsement of any ear drop solution. This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of their decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.
© Vincent Tan ENT
© Vincent Tan ENT
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Ear wax is produced as a useful product to the body to protect the outer ear The ear wax protects the EAC from invasion of bacteria and fungi due to its inherent  bactericidal (action of killing bacteria) or bacteriostatic (action of inhibiting bacterial growth) action of its components. Once secreted, subsequent evaporative process of the ear wax occurs allowing the now sticky substance to entrap dust, bacteria, fungi and epithelial squames before being expelled by the self-cleansing 'epithelial migration' mechanism, a process which is aided by jaw movement. The outward movement of the ear wax also prevent dust, dirt and other substances from entering the ear canal to a certain extent. The skin of the EAC has a pH of 6.5-6.8, i.e a slightly acidic condition to prevent bacterial growth. Earwax also helps maintain the ear canal's acid balance and protect the ears from infection. Ear wax also helps protect the delicate skin of the ear canal from becoming irritated when water is in the canal.
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The ear wax can be dry, flaky or wet - and that depends on your genetics !  A gene known as ATP-binding casette CII is important in controlling the type of ear wax produced. Without the contribution of this gene, one has dry ear wax (Yoshiura). Dry wax is common in Asia, while wet wax is common in western Europe.The composition of wax also varies in different racial groups.
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Ear wax is produced from a modified sweat gland in your body Human beings have two kinds of sweat - the mostly-watery type that we use for cooling ourselves down, and the smelly, oily kind that we have in our armpits and a few other select spots around the body. Apocrine sweat glands (the smelly kind) add protein and fats to the sweat. A modified apocrine sweat gland a.k.a ceruminous in the outer external ear canal of the ear produces cerumen. Cerumen is produced to primarily to trap skin sheddings/dead skin (keratin debris) and lubricate the external ear canal (EAC). The ceruminous glands are only found in the outer 3rd of the EAC where the skin is thicker. However, in the deeper part of the canal, the skin is thin and has no other skin appendages including glands. Ear wax is a normal product of the ear which is a mixture of the following:
sebum from the EAC sebaceous glands
cerumen from the outer EAC modified apocrine (ceruminous) glands 
other components such as dead skin, sweat, and oil in the EAC.  
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The outer canal can cleanse itself ! Cleaning of the ear canal occurs as a result of the "conveyor belt" process of epithelial (=outer skin layer) migration, assisted by our jaw movements. From the middle of the ear drum, the epithelial cells moves outwards (at a rate comparable to that of fingernail growth) to the walls of the ear canal, and move towards the entrance of the EAC. The cerumen in the canal is also carried outwards, taking with it any dirt, dust, and particulate matter that may have gathered in the canal. The wax usually makes its way to the opening of the ear, where it falls out or is removed by washing. I am sure you must have experienced tiny objects falling out from your ears all of a sudden as you are sitting quietly ! .
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Cotton bud usage causes more problems than actually removing the wax ! Usage of cotton bud (sometimes known as Q-tip)  is the major cause of impacted ear wax, the commonest complaint about the ear wax that brings a patient to his/her doctor. Impacted ear wax refers to the condition where the ear wax completely blocks the EAC causing the patient to experience symptoms like pain, hearing loss and/or tinnitus. Earwax is not formed in the deep part of the ear canal near the eardrum, but in the outer one-third of the ear canal. So when a patient has wax blockage against the eardrum, it is often because he has been probing the ear with other things or using cotton buds to attempt ear wax removal. The ear canal is shaped somewhat like an hourglass-narrowing part way down, making impacted ear wax in the deeper EAC difficult to remove. An ear can also get plugged up with earwax when fingers or objects are used to clean the ear canal. The finger or object may push ear wax deeper into the deeper part of the EAC. As a result, not only it is mechanically compressed, the inner portion of the ear canal also lacks the ceruminous glands, so the compacted earwax is no longer coated with oil and hardens. This may cause a sudden loss of hearing or ear pain Not only that, with frequent cotton bud usage,  you risk injury to the EAC causing pain, otitis externa (infection of the EAC) and also perforation of the eardrum.
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Some people have ear wax problems due to faulty self-cleansing mechanism or excessive wax production. Risk factors include: Cotton buds usage: The use of cotton buds may actually push wax deeper into the ear, thus producing a blockage. Physiology : A narrow shaped ear canal may trap excess ear wax, This is especially common in children, as they are naturally born with small EAC. This is even more pronounced in those children with congenital abnormalities of the ear. Hair in the canal : More-than-nomal amount of hair in the ear, seen primarily in men. Environment : Working in dusty or dirty environments, particularly outdoors. In environments such as these, the ear may produce excess wax as a means to block dirt, etc. from entering the ear canal. Skin disorders: Certain conditions of the skin or scalp may contribute to excess ear wax production. This includes keratosis obturans, in which the faulty epithelial migration causes wax buildup in the EAC. Frequent hearing aid/headset users : -the hearing aids acts like a plug to prevent the ear wax from being expelled and may even push the wax deeper in to the EAC !. Placing anything in the ear that keeps it sealed for a period of time may increase the production of wax, which can then lead to discomfort when using hearing aids or headsets. Swimmers : Frequently submerging the ears in water may contribute to increased wax production.
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Impacted ear wax can have serious consequences. Something as trivial as ear wax can cause potential complications. If the ear causes no problem, it is best to leave it alone. If the ear wax is impacted, it can lead to Sensation of blockage or fullness Pain Itching, odour and discharge Tinnitus (ringing sound in the ear) Hearing loss Otitis externa (external ear/EAC infection) Hearing aid malfunction- Ear wax is the commonest cause of hearing aid malfunction .
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Do not have your ear wax syringed if you know you have or unsure about eardrum perforation. Generally, treatment for impacted ear wax include: A) Softening the ear wax prior to removal if it is hardened This is known as cerumolytics, which functions to soften the wax and facilitate subsequent removal. There are many solutions available in the market eg: Waxsol, Soluwax (active ingredient: docusate sodium) Sodium bicarbonate solution Sea water Other preparations described in the medical literature (effectiveness may not be clinically proven) include: Glycerin Baby oil Hydrogen peroxide Carbamide peroxide For instructions to instill ear drops, see here. B) Removal can later be performed via: Syringing: Syringing involves your doctor directing a jet of water or normal saline from a syringe or specialised ENT instruments directed into you EAC to flush out the ear wax. However, this is strictly ill-advised if you have a known ear drum perforation. In the event you have an undiagnosed perforation, there is a risk of the wax being flushed into you middle ear (the space behind the ear drum) risking a serious ear infection. The water used must be at a room temperature as well as water too warm or cold can trigger an acute vertigo (sensation of spinning) episode. Too strong a jet may injure the ear drum, EAC or cause an acoustic trauma. Suction under direct vision using a microscope or endoscope. This is usually done by the ENT doctors who will remove the wax under magnified view using a microscope or endoscope. This approach also allows the EAC and TM to be closely examined for any sign of infection and structural deformity.
Animation showing epithelial migration -as illustrated by how a blue dye can travel from the ear drum to the outer EAC
NEVER use a cotton bud to remove ear wax
Hearing aid usage predispose to wax impaction problem. At the same time, wax impaction can cause malfunction of the hearing aid.
© Vincent Tan ENT
Ear wax impaction in the EAC, blocking the view of the ear drum
© Vincent Tan ENT
© Vincent Tan ENT
A large nugget of hard ear wax !
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Provided the removal of wax is complete, the chances for recovery of symptoms like pain and hearing loss is very good. Hearing usually returns completely after the blockage is removed. However, it may happen again in the future if the old habits of using cotton bud or other risk factors persist. Some swimmers put baby oil or olive oil into the ear on a regular basis prior to their daily swim. Put in the drops and allow it to remain in the ear for a few minutes, then let it drip out again. Otherwise, there are no proven ways to prevent cerumen impaction.  If you are prone to repeated wax impaction or are currently use hearing aids, consider seeing your doctor about every 6 to 12 months for a routine examination. Should the wax builds up, it can be removed before it gets impacted again.
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The take-home message : Just leave the ear alone, do not attempt to remove the ear wax as nature has its way of dealing with it. Cotton buds are not made to remove ear wax, so please don't use it anymore to remove ear wax.
References Yoshiura K, Kinoshita A, Ishida T et al. "A SNP in the ABCC11 gene is the determinant of human ear wax type." Nat Genet. 2006; 38 (3): 324-30.
© Vincent Tan ENT
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NEVER use a cotton bud or metal scoop to remove ear wax
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ear drum perforation
middle ear space
A view of the right ear drum under microscope showing a non-healing perforation or hole in the ear drum
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external ear canal
Acute otitis externa (infection of the EAC): pus collection (red arrow) with inflammed external ear canal (blue arrow)
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
ear drum perforation
A view of the right ear drum under microscope showing acute traumatic perforation or hole in the ear drum
Acute fungal infection of the EAC. Notice the black dots indicating a type of fungus.
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A view of the right ear drum under microscope showing hamatoma (blood clot) underneath the skin
hamatoma (blood clot) underneath the skin
A view of the right ear drum under microscope showing very swollen canal skin (blue arrows) and pus in the canal (yellow arrow)
After suction cleaning, guess what was seen in the ear canal? A retained piece of cotton bud -much to the patient’s surprise !
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© Vincent Tan ENT
© Vincent Tan ENT
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© Vincent Tan ENT
Abrasion of the outer EAC predisposing to subsequent acute otitis externa.
© Vincent Tan ENT
© Vincent Tan ENT
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NEVER use fingers to remove ear wax
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Talks about HEARING LOSS on 28/2/14
ENT
D R. V INCENT T AN Consultant Ear, Nose and Throat, Head and Neck Surgeon, MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Cert.in Allergy (UK), A.M. (Mal), Fellowship in Rhinology (Singapore) Fellowship in Head and Neck Oncology & Surgery (Amsterdam)
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