Cotton swab pushing cerumen into the ear canal
We hear it all the time — “My ears don’t have wax, they’re clean!” Healthy ears have some wax in them (Mayo, 2021). Just like your eyes have lubrication to protect them and prevent your cornea from drying out…your nose has mucus….your mouth has saliva…cerumen (ear wax) is the necessary lubrication the ear canal requires to maintain proper pH balance and health. Wax keeps the canal moisturized to alleviate itching, keeps the pH balanced to prevent microbes reproduction, and, I cannot stress this enough- it’s what repels bugs from wanting to climb into your ear canals!
The ear canal is self-cleaning and maintaining. When we tell you not to use cotton swabs in your ears, it’s not just because we don’t want you to potentially poke and damage your eardrum, but it’s because cerumen is necessary and healthy. Cotton can be abrasive, resulting in bruising and irritated ear canal skin, while stripping it of the natural moisture. Cerumen production glands are only in the outer third portion of the ear canal. Cerumen generally works its way out of the ear canal and falls out, but there are instances when it can’t do this on its own and needs help.
Very small canals or canals with very sharp bends can often have accumulation that cannot work its way out. Small canals or not, using cotton swabs can push wax at the entrance back into the canal, preventing it from being able to fall out of the entrance naturally. It will also keep pushing the wax into the canal when you wear hearing aids, in-ear headphones, or in-ear hearing protection. It creates a little mound of ear wax that builds up each time you push it back. As long as there is a space for sound to get to your eardrum you’ll hear normally and will not know it’s occurring. However, if you wear a hearing aid, sound can bounce off of the mound of wax and reflect it out– not only preventing the amplified sound you want to hear from getting down to the eardrum, but it will get into the hearing aid creating feedback whistling. Not to mention the hearing aid components are at risk of being compromised by wax. Once the canal opening is completely blocked (we call this “occluded”) it can decrease your hearing up to 30 dB in the low frequencies (Subha & Raman, 2006)!
How SHOULD you clean your ear canals?
- Consider an over-the-counter option (OTC): Rather than drop a name brand here, ask your local pharmacist to recommend one they have on the shelf. Look for a box with a two-step process (drops and something for flushing the canal, a bulb or syringe). If cerumen has been stuck in there a while, it can start to harden and attach to the skin a bit like a scab. The drops will soften it and help loosen it from the skin. Do one ear at a time so you can sit with that ear pointing up and soaking a few minutes. Step two, grab that bulb syringe or plastic syringe from the box. When ready to irrigate (flush out your ear) make sure to use room temperature or skin temperature water. (This is a very important step. Do not use cold or hot water. If you change the temperature of one ear you can stimulate your balance system causing vertigo. We do this on purpose in a clinical setting if you’ve ever had to have balance testing (Hain, 2021). If you do this unintentionally, you could fall and get hurt.) Lastly, I recommend flushing it out over a bathroom sink where you can close the drain. Gross, I know, but it’s good to know if you’re getting anything to come out and how much. Irrigate your ear numerous times. Pat your ear dry with a hand towel or washcloth, but otherwise let it naturally air out. Don’t forget to do the other ear next.
You may need to do this a few nights in a row if you’re pretty sure there is wax in there but didn’t see any come out into the sink. I recommend doing a few hours before bed when your hearing aids are out for the rest of the night and your ears can finish drying while you sleep. If your ear feels more clogged after trying this option, you’ll need to select one of the options below for a professional to remove it.
- Contact your Primary Care Physician (PCP) or express clinic: Not all offices may perform wax removal (we call it “cerumen management”) or be fully equipped to offer more than irrigation, so ask specifically. I like to point out when your doctor checks your ears for your typical physicals and says, “it looks good!” This does not mean you do not have wax in the ears. They are visualizing if the eardrum looks healthy and you don’t have excessive wax. So just ask them and explain you are a hearing aid user– if you have more than a little, have your ears cleaned so it doesn’t impact your hearing aids negatively or build up in your canal with hearing aid use.
- Contact an Ear, Nose, and Throat Physician (ENT): If you want the tongue twister name, it’s Otorhinolaryngologist…preferably someone who specializes in the “oto” part, that’s the ears! ENTs are medical doctors who see hundreds of ears a week. They’ll have everything needed to go “digging for gold”– magnified head lamps with lights, operating microscopes, suction, tiny forceps, and tools to scrape, scoop, loop, and pull wax out of there. If you have any additional symptoms of canal dryness, psoriasis, itching…they’ll know what they’re looking at and can prescribe medications or make recommendations. If so, discuss if you wear a hearing aid so they can take into consideration any ointments or medications that require bedtime application, after your hearing aids are out for the night and air can circulate into your canal.
- Contact a Doctor of Audiology (Au.D.): This option may vary greatly from state to state, licensing laws, if the professional has been trained, and if it’s a service they choose to offer (ASHA, 2021). You may have to call around, it’s also helpful to ask which methods they perform if you have a preference (for instance, if you don’t want irrigation). Some audiologists may only do simple removals they can easily see and scoop out, but may refer out more difficult or involved cases. While others may have more training and have all the equipment of an ENT at their disposal. Even if they don’t personally perform cerumen management in their office, every audiologist has an ENT they refer their waxy patients to. It’s a great place to call and ask their receptionists if you’re not sure what ear specialists are in your area.
Regardless of the method used, make sure before you leave someone has checked to verify the wax has been removed and is not still stuck in there (you’d be surprised how many people were told they were all done, only for the next professional to find it is all still stuck in there!). They might send you home with drops to soften the wax and come back if necessary. It’s very important if they did use a rinsing method (or have you using drops a few days) not to put anything in your ears those days—including your hearing aids—so make sure you have your Eargo portable charger with you so you have somewhere safe to put them when you take them out. It’s not just that we don’t want you to get moisture in the electronics, it’s because trapping moisture in that small, warm, dark place is the perfect breeding ground to brew up a fungal or an outer ear canal infection called “Otitis Externa” (Schaefer & Baugh 2012). Not to be confused with “Otitis Media” which is an infection of the middle ear, often associated with sinus, allergy, or cold symptoms.
Precautions to consider
It’s important to note, if you have a known or suspected perforation (a hole) of your eardrum, your ear canal cannot be irrigated by you or a medical professional. This includes if you have had a myringotomy performed (surgical incision on your eardrum) with or without a tube placement. Also, you should not submerge your head underwater when swimming or bathing as well. The middle ear space on the other side of the eardrum should not get wet. Wax in these cases must be removed with tools or suction from a professional.
Before anyone starts to poke around in your ear, always let them know if you are diabetic or on blood thinners. If we use any tools to remove the wax, it can pull at the skin and we need to consider more risks involved if your skin might tear more easily and bleed. If your professional does let you know you have some bleeding, don’t freak out. We might have to apply pressure and soak it up so you don’t end up with a pool of dried blood in your canal– and now you have that instead of wax. You may see some kind of anticoagulation spray used as well to stop the bleeding. If you are on blood thinners or diabetic, we might send you to the ER as a precaution if we can’t get the bleeding to stop before you leave the office, or if you see the bleeding start again later.
If you’re not grossed out yet by all the talk about ear wax, I’m about to step it up a notch, so hold onto your lunches, folks! In the event you ever see a different consistency or color of wax coming out of your canal or on your hearing aids—or you experience pain, drainage, bleeding, or if it has an odor—you’ll want to see a medical doctor or an express clinic so they can check your ears for infection, and if necessary, prescribe medications to treat it (audiologist do not have prescription rights, so they’d have to refer you, so you might as well go straight to the source for this one).
If you ever experience a noticeable decrease in hearing, we all like to think it’s a wax blockage, but on rare occasions, it could be related to a sudden hearing loss. Sudden hearing loss affects the organ of hearing (called the cochlea) in the inner ear and can sometimes be resolved, at least partially, if diagnosed and treated within the first 24-48 hours with high dose steroids (Leung et al., 2016). After this time period, the chance of hearing recovery is minimal. So if you are ever in this situation, you want to immediately call a local ENT where it’s important that you advocate for yourself and tell them you’re experiencing a sudden hearing loss. They will likely squeeze you in immediately or advise you to get to an ER for treatment.
Cost and long term management considerations
Keep in mind cost considerations may vary. Your Primary Care Physician is your PCP copay, but an ENT is considered a specialist, so you may have a higher copay for specialists. You can see if your insurance covers cerumen management, but make sure to ask what kind of professionals they will reimburse for this. If you see an audiologist, they often are not part of allowable reimbursement for this service and you may have to pay out of pocket. For reference, in one clinic I worked, we charged $40 per ear that needed to be cleaned, while in another clinic, we charged a $65 flat rate for one or both ears. Where an ENT may charge $250, but for instance, might receive 80-100% reimbursement from your insurance, you may be responsible for paying the difference. You might have to call your insurance and call around to local offices, to do the math to find the best long-term solution for you if you need cerumen management frequently.
Once you see how much wax you had in your ear, how hard or easy it was to get out, and consider your payment options—stay on a schedule. Some need a professional to clean out their canals once a month, some can perform OTC themselves once a year. In all cases, if your hearing aids are continually in disrepair or require a lot of extra cleaning and troubleshooting, go to the source and maintain the environment you place your hearing aids in. Think of it this way, no matter which make or model of car you have, if you drive on a highway covered in potholes every day, you’re going to blow a tire eventually. It doesn’t mean the car is a “lemon,” or that you didn’t keep up with proper maintenance. You can even try top-of-the-line tires, but it would make more sense to drive on a highway with fewer, or no, potholes! A pair of hearing aids is an investment—averaging $2,500 for Eargo, and up to $7,000 for a pair of hearing aids purchased through a traditional route. Protect your investment.
What do I know, right? Well, I’ve worked for one of the five major hearing aid manufacturers, as well as with Eargo’s Quality Team, and can assure you, 9 out of 10 hearing aids that come back to a manufacturer have been compromised by wax. As part of my doctoral training as an audiologist, I completed a 30-hour, hands-on certification in Cerumen Management. In addition, I have worked in hospitals, clinics, VA, and ENT settings in four states with varying requirements for cerumen management. I worked several years in a clinic and cerumen management was my favorite service to perform. I had at my disposal an operating microscope, suction…and all the different tools to be able to get a bit of wax off the eardrum!
