Moderation in ear hygiene and what to do with sulfur plugs.

Surprisingly, the best way to care for ears is not to clean them. As odd as that might sound, that is what we — otolaryngologists — recommend too. Of course, we should not consider it a norm that "ears are like daisies — white around, yellow in the middle". The main condition in daily ear care is that ear hygiene must consist of cleaning the external cochlea of the ear and not deeper than we can see. Sometimes, that is what ear, throat, nose doctors say — clean the ear as deep as you can reach with your pinky. Unfortunately, very many people feel the need to clean ears without quite understanding the special importance of ear-wax. Most commonly, ears at home are cleaned with a cotton swab, which pushes the ear-wax deeper, thus interfering with normal, physiological process of ear-wax discharge.

The much needed ear-wax

The production of ear-wax is a normal and necessary physiological process of the body. Ear-wax is formed of products of wax-forming glands and fat glands, and is observed in 2 consistency forms: wax type and dry (or flake type). These glands are situated in the front third of the external auditory canal. The human external auditory canal is ellipsoid and it ends at the eardrum. The external auditory canal is narrow, with diameter of about 0.7 cm and 2.3–2.9 cm long, and its volume is 1.0 cm³. The external two thirds of the external auditory canal is formed of skin-covered cartilage, whereas the internal third is skin-covered bone. The wax-producing glands are situated in the skin of the cartilage part of the external auditory canal.

Ear-wax is periodically discharged from the ear canal, and a small amount of ear-wax in the external auditory canal is a norm. As a rule, dry ear-wax does not cause problems, as it does not stay on the ear canal walls for a long time and is easily discharged from the ear canal (this usually is as a result of jaw movements), whereas the soft, waxy type discharge do not detach from the external auditory canal that easily, therefore they tend to accumulate. In terms of colour, too, ear-wax varies: in case of waxy type discharge, the colour can vary from yellow to dark brown (can even look like blood), in case of dry discharge, it can vary from yellow to light yellow.

Protection is the main function of ear-wax. Ear-wax lubricates, cleanses and protects not only the external auditory canal but also the eardrum deep inside the ear canal from bacteria, fungus, insects, dust, various foreign bodies, as well as chemical external environmental pollution. They get stuck in the soft and sticky ear discharge, thus protecting the ear canal and the eardrum deep inside the ear canal.

In most cases, ear-wax clears itself out of the ear owing to physiological ear epithelium movements towards the outside of the external auditory canal in a process called self-cleaning of the ear. It is a pathology if there is no ear-wax in ears or if it is excessively produced causing specific symptoms. If ear-wax is produced excessively or the self-cleaning mechanism is impaired, the next ear-wax layer forms underneath the first one, which has not yet detached. As a result, there is a snow-ball effect, as layers of ear-wax build up on top of each other, and the ear canal can be fully blocked, forming what is colloquially known as the sulfur plug, just like in the saying: "Nothing in excess is good". Excessively intensive formation and build-up of ear-wax in the auditory canal causes a condition called ceruminosis. Worth noting is that we can speak of a sulfur plug also in those cases when the ear-wax does not fully obstruct the external auditory canal, but any amount of it causes the specific symptoms.

What are the most common symptoms caused by excessive ear-wax?

These are, first and foremost, hearing problems. Complete blockage of the external auditory canal reduces sound intensity, thus hearing can be reduced even down to 45 dB, which corresponds to level 1 hearing impairment and means that it might be difficult to hear whispered utterances. Impaired hearing in this case is of conductive type, and it can develop suddenly or gradually. A sudden reduction of hearing abilities usually occurs after self-effectuated ear cleaning with cosmetic cotton swabs, when the ear-wax is pushed as deep as possible into the ear canal. It also often happens after indulging in water procedures — swimming, saunas, washing hair etc., when, in the presence of water, the sulfur plug expands and completely blocks the external auditory canal. What is also important that the manifestation of impaired hearing points to where the sulfur plug has blocked the external auditory canal. Thus, for instance, if the front third of the auditory canal is blocked, what is known as "flat" type hearing impairment develops, which means that the person hears all frequencies — both low and high — equally worse, whereas if the blockage is deep, near the eardrum, then the so-called "high" frequency hearing impairment develops, when hearing is deteriorated in the 2000 to 4000 Herz (Hz) frequency range. Furthermore, excessive amount of ear-wax in the external ear can lead to such symptoms as itching in the auditory canal, pain in the auditory canal, noise in ears, vertigos, inflammation of the external auditory canal, chronic cough attacks, sensation of fullness in the ear, unpleasant odour coming from the ear, as well as discharges from the external auditory canal.

It must be noted that the diagnostic of ear-wax is rather simple and it includes anamnesis and otoscopic examination.

In terms of prevalence, blockage of auditory canal with sulfur plugs is observed in about 10 % of child population, 5 % of healthy adult population, whereas in elderly people in up to 50 % of cases. As regards the steps to take in this situation, it must be reminded that, firstly, you should not engage in self-imposed treatment and try to extract the sulfur plug on your own, because the cotton swabs you can buy in shops are designed for removal of beauty products, however most of us believe that their sole purpose is the cleaning of ears. It is very likely that in the case of sulfur plug the result will be immediate, i.e. one of the aforementioned symptoms will be manifested, and in the worst case scenario, some amateurs will "manage" even to puncture the eardrum and then "treat" the bleeding with the ear flower geranium. Still these days, including in America, the removal of sulfur plugs from ears is entrusted only and solely to doctors.

As I have mentioned, ear-wax in the auditory canal is a beneficial factor, however there is a range of conditions demanding removal of ear-wax from the external auditory canal. All of these are cases causing the specific symptoms. Ear-wax must be removed if it is necessary to examine the external auditory canal and/or the eardrum. It is a mandatory requirement to remove ear-wax even in small quantities from the external auditory canal for those people, who are using hearing aids to compensate for hearing impairments, especially in the ear hearing aids, because the ear-wax in the auditory canal can result in feedback to the hearing aid, thus decreasing the volume of the hearing aid and can even lead to damaged hearing aid. People using hearing aids should get their ears examined at least once every three months.

What are the methods for sulfur plug removal from the external auditory canal? There are several methods.

1. By using medicines that soften and dissolve ear-wax. These drops can be used at home, however it must be borne in mind that in case of especially large, hard sulfur plugs this cannot be resolved on your own.

2. With medicines softening ear-wax and rinsing of ears performed by a doctor. In this case, the method is particularly effective, because the medicine is administered 15–30 minutes before the ear rinsing procedure.

3. Manual removal of ear-wax using an ear curette. This procedure may be performed by an ear, throat and nose doctor only. This method should be opted for in cases when the external auditory canal is very narrow, if the eardrum has been perforated, as well as if a ventilation tube in the eardrum is inserted. The method is also recommended in people with immune deficiency conditions.


 Article prepared by

 Dr. med. Sandra Kušķe