1. MAJOR ZEESHAN AYUB CL ENT SPECIALIST CMH RAWALPINDI
CERUMEN/ EAR WAX
MAJOR ZEESHAN AYUB
CL ENT SPECIALIST
CMH RAWALPINDI

2. DEFINITION
Earwax, also known by the medical term cerumen, is a yellowish, waxy substance secreted in the ear canal of humans and many other mammals.
It plays an important role in the human ear canal, assisting in cleaning and lubrication, and also provides some protection from bacteria, fungus, and insects.

3. PRODUCTION & COMPOSITION
Cerumen is produced in the outer third of the cartilaginous portion of the human ear canal.
It is a mixture of viscous secretions from sebaceous glands and less-viscous ones from modified apocrine sweat glands. The primary components of earwax are the final products in the HMG-CoA reductase pathway, namely, squalene, lanosterol, and cholesterol
The primary component of ear wax is keratin (derived from dead skin). Ear wax thus differs slightly from cerumen which is the secretory product of the ceruminous glands in the external auditory canal

4. DIFFERENT TYPES
Two distinct genetically determined types of earwax are distinguished –
Wet type: which is dominant; Caucasians and Africans are more likely to have the wet type (honey-brown to dark-brown and moist). Dry wax, also known as "rice-bran wax", contains by weight about 20% lipid (fat).
Dry type: which is recessive. Asians and Native Americans are more likely to have the dry type of cerumen (grey and flaky). Wet wax consists of approximately 50% lipid

5. FUNCTIONS
1. Cleaning
Cleaning of the ear canal occurs as a result of the "conveyor belt" process of epithelial migration, aided by jaw movement.
Cells formed in the centre of the tympanic membrane migrate outwards from the umbo (at a rate equivalent to that of fingernail growth) to the walls of the ear canal, and accelerate towards the entrance of the ear canal.
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. Jaw movement assists this process by dislodging debris attached to the walls of the ear canal, increasing the likelihood of its extrusion.

6. 2. Lubrication
Lubrication prevents desiccation and itching of the skin within the ear canal (known as asteatosis).
The lubricative properties arise from the high lipid content of the sebum produced by the sebaceous glands. In wet-type cerumen at least, these lipids include cholesterol, squalene, and many long-chain fatty acids and alcohols.

7. 3. Antibacterial and antifungal roles
Recent studies have found that cerumen has a bactericidal effect on some strains of bacteria.
Cerumen has been found to be effective in reducing the viability of a wide range of bacteria (sometimes by up to 99%), including Haemophilus influenzae, Staphylococcus aureus, and many variants of Escherichia coli.[
The growth of two fungi commonly present in otomycosis was also significantly inhibited by human cerumen. These antimicrobial properties are due principally to the presence of saturated fatty acids, lysozyme and, especially, to the relatively low pH of cerumen (typically around 6.1 in normal individuals).

8. SYMPTOMS partial hearing loss, may be progressive
tinnitus, noises in the ear
earache
fullness in the ear or a sensation the ear is plugged

9. TREATMENT
CERUMENOLYSIS
SYRINGING
INSTRUMENTAL MANUPULATION

10. CERUMENOLYSIS
It is usually necessary to soften wax before its removal. This process is referred to as cerumenolysis, and is achieved using a solution known as a cerumenolytic agent which is introduced into the ear canal.
The most common home-remedy for this purpose is olive oil. Other commercially available and common cerumenolytics include:

11. [under multiple brand names] Carbamide peroxide (6.5%) and glycerine
Sodium bicarbonate B.P.C. (sodium bicarbonate and glycerine)
Various organic liquids (glycerol, almond oil, mineral oil, baby oil)
Cerumol (arachis oil, turpentine and dichlorobenzene)
Cerumenex (Triethanolamine, polypeptides and oleate-condensate)
Exterol, Otex (UK brand name) (urea, hydrogen peroxide and glycerine)
Docusate, an active ingredient found in laxatives
A cerumenolytic should be used 2-3 times daily for 3-5 days prior to the cerumen extraction.

12. SYRINGING
Irrigation or "syringing" is a standard method of wax removal.
Approximately 150,000 ears are irrigated each week in the United States (Grossan, 1998).
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.
Technique of syringing

13. CURETTE METHOD/ INSTRUMENTAL MANUPULATION
Should always be done by skilled hands
Cerumen hook, scoop or Jobson-Horne

14. FOREIGN BODIES OF EAR

15. Anatomy and Physiology
Auricle is mostly skin-lined cartilage
External auditory meatus
Cartilage: ~40%
Bony: ~60%
S-shaped
Narrowest portion at bony-cartilage junction

16. TYPES
NON-LIVING
LIVING

17. NON-LIVING FOREIGN BODIES
CHILDREN:
Children usually place things in their ear canal because they are bored, curious, or copying other children.
Sometimes one child may put an object in another child's ear during play.
There may also be a link between chronic outer ear infections and children who tend to place things in their ears.
Insects may also fly into the ear canal, causing potential harm.  
Any child with a chronically draining ear should be evaluated for a foreign body.

18. Some of the items that are commonly found in the ear (usually the canal) of young children include the following: food, insects, toys, buttons, pieces of crayon, and small button-shaped batteries.

19. ADULTS May present with broken end of match stick
Vegetable foreign bodies may swell up with time and get tightly impacted in the ear canal or may even suppurate.

20. METHODS OF REMOVAL Forceps removal (crocodile forcep) Syringing
Microscopic removal with special instruments
Post aural approach

21. All impacted foreign bodies or in those where earlier attempts at extraction have been made, it is preferred to use GA & an operating microscope.
Unskilled attempts may lacerate the mucosal lining, damage the TM or the ear ossicles.

22. LIVING FOREIGN BODIES Flying or crawling insects or an ant.
Causes intense irritation & pain
No attempts should be made to catch them alive. First kill them by instilling oil, spirit or chloroform water. Once killed can be removed by any method already described.

23. MAGGOTS IN EAR
Flies attracted to foul smelling ear discharge and lay eggs over there which hatch into larvae called maggots.
Commonly on months of Aug, Sep & Oct.
Pain, swelling & blood stained discharge
Instill chloroform water to kill and removal by forceps.