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Research Article
EUROPEAN JOURNAL OF
PHARMACEUTICAL
European
Journal of Pharmaceutical and Medical Research
ISSN
3294-3211
AND MEDICAL RESEARCH
Qadir et al.
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EJPMR
EPIDEMIOLOGY, CLINICAL CHARACTERISTICS, AND MAGNITUDE OF
ECONOMIC BURDEN OF EAR WAX IN KASHMIR.
Dr. Waseem Qadir*, Dr. Omar Shafi, Dr. Manzoor Malik and Dr. Sajad M. Qazi
India.
*Correspondence for Author: Dr. Waseem Qadir
India.
Article Received on 28/06/2016
Article Revised on 18/07/2016
Article Accepted on 08/08/2016
ABSTRACT
Background and Aim: Ear wax impaction is a common condition worldwide with varied presentations. This study
is aimed to document the epidemiology, clinical characteristics and magnitude of economic burden in Kashmir, a
subtropical region with harsh winter. Materials and methods: A retrospective analysis of hospital records of ear
wax clearance for a period of two years was done to note the prevalence, and demographic profile of patients
presenting with ear wax. A prospective analysis was done on 240 serial patients to note the presenting complaint,
duration of symptoms, and type of wax, laterality, and history of any predisposing factors. Complete ear
examination was done and findings were documented in a premade proforma. The cost incurred in clearing the ear
wax was calculated. Results: Out of 1,80,000 patients visiting OPD for a period of 2 years, a total of 12473
patients underwent clearance of ear wax. A prevalence of 6.5% was found. The ages ranged from 5 to 90 years.
The highest number of patients affected were in the age group of 21 to 40 years amounting to 1546(49.40%)
followed by 3769 patients (39%) from 41 to 60 years. The number of patients differed over different months. The
average number of patients seen from March to August was significantly higher than from September to February.
The average per annum cost of managing ear wax impaction amounted to 3816,000 Rupees ($56955). On
prospectively analyzing 240 patients of different age groups, 45.41% patients described their presenting symptoms
as fullness of ear(s), 30.83% patients complained of otalgia and 22.5% of patients complained of decreased
hearing. Of the 187 patients with a unilateral symptoms, 108 (57.75%) had bilateral impacted ear wax. The most
common predisposing factors identified was rinsing with soap in 98 followed by ear bud usage in 80 patients.
Conclusion: Ear wax is a fairly common condition that can be diagnosed and managed by general practioners. Ear
buds remain a preventable predisposing factor.
KEYWORDS: Ear wax, burden, Kashmir.
INTRODUCTION
Ear wax, also referred to as cerumen auris, is a mixture
of secretions from ceruminous and pilosebaceous glands
located within the outer one-third of EAC, together with
desquamated epithelium, dust and other foreign debris. It
is composed of mainly 60% desquamated cells, 12–20%
saturated and unsaturated long‑chain fatty acid and 6–
9% cholesterol.[1-4] Due to its sticky nature it acts as a
lubricant, entraps dust and foreign bodies and also
possesses antimicrobial activities due to fatty acids,
lysozymes and low pH.[5, 6, 7] It gets dried up and falls out
of the external auditory canal with the trapped particles
by conveyor belt process of epithelial migration assisted
by jaw movement during chewing and talking.[8, 9] There
are genetically and racially determined differences in the
physical characteristics of cerumen that vary in
appearance and consistency and may be associated with
immunoglobulin and lysozyme content.[10] Most
Caucasians and Negroes have the so-called 'wet'
phenotype, with moist, pale, honey-colored cerumen that
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sticks to the otoscope. In contrast, mongoloid races tend
to have grey, granular and brittle cerumen (the 'dry'
phenotype). Wet wax has lower concentrations of
immunoglobulin’s and lysozymes, but a higher lipid
content than the dry variety. Cerumen type is determined
by two autosomal alleles, the wet allele being
dominant.[11, 12] Ear wax is normally extruded naturally.
However, it may accumulate and occlude the canal of
one or both ears. Earwax is said to be impacted when its
accumulation in the external auditory canal is
symptomatic or prevent assessment of the canal and
eardrum or both. Impacted earwax causes discomfort
such as irritation, fullness, decreased hearing. Earache,
noise in the ear, chronic cough and dizziness.[13,14,15]
necessitating removal. Wax can be removed from the ear
by ceruminolytics, syringing, suction or hooking it out
under direct vision. The habit of self-cleaning ears by
pointed objects, ear canal abnormalities, excess sebum
production are some of the predisposing factors for wax
impaction. Earwax impaction is one of the most common
ear pathology treated in the otolaryngological clinic
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European Journal of Pharmaceutical and Medical Research
worldwide, in the USA, about 6% of the population
suffer from impacted cerumen with 150 000 ear wax
removals take place each week. In the UK, some 2.3
million people suffer cerumen (‘ear wax’) problems
serious enough to warrant management, with
approximately 4 million ears syringed annually. [16, 17]
Little research has been done on the magnitude and
characteristics of ear wax in a sub-tropical region like
Kashmir. This study is aimed at noting the epidemiology,
clinical presentation, predisposing factors for ear wax
impaction and the magnitude of this condition and its
economic burden on the population in Kashmir.
MATERIALS AND METHODS
This study was done in the SMHS hospital associated
with GMC Srinagar the capital of Kashmir province a
sub-tropical area with particularly harsh winter. This
hospital is a tertiary care center catering to needs of 5
main districts. This study was done in the OPD of ENT
& HNS. A retrospective analysis of data of patients who
underwent wax removal by syringing or other methods
was done for a period of 2 years ranging from May 2013
to May 2015. The demographic data which included age,
gender, month of visit and residence was collected. A
prospective observational study for a study group of 240
serial patients which included 60 each of patients from
age groups 0 to15 years, 15 t0 25 years, 25 to 60 years,
and more than 60 years was done. The presenting
complaint, duration of symptoms, type of wax, laterality
and history of any predisposing factors was recorded in a
premade proforma. A complete ear examination and
otoscopic examination was done. Patients with history of
ear discharge, any previous ear surgery, suspected EAC
cholesteatoma and bilateral asymptomatic ears and ear
clearance by methods other than ear syringing were
excluded from the prospective study. All the patients
were treated by wax softeners ear drops for duration of
5 days and ear wax was removed by syringing with
normal saline after proper temperature control. Patients
presenting with otalgia and positive tragal test were
treated by antibiotics before using ceruminolytic agents.
RESULTS
In a retrospective analysis of Hospital records, it was
noted that a total of 12473 patients underwent clearance
of ear wax. The total number of patients visiting the OPD
during this period is 180,000. The prevalence of the ear
wax in our study was 6.93%. the number of males was
6426(52%) and number of females was 6047 (48%) with
no significant difference in prevalence between male and
female population. The age range varied from 5 months
to 90 years. The number varied according to the age as
shown in table 1. The highest number of patients affected
were in the age group of 21 to 40 years amounting to
1546(49.40%) followed by 3769 patients (39%) from 41
to 60 years. The extremes of ages amounted to only 8%
of our study. The number of patients differed over
different months. The average number of patients seen
from March to August was significantly higher than from
September to February as shown in the fig 1.The
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approximate cost incurred per month was Rs 318,00.
And average per annum cost amounted to3816,000
rupees ($56955) as described in table TABLE 2.We
prospectively analyzed 240 patients of ear wax 60 each
from 0 to15 years, 15 t0 25 years, 25 to 60 years and
more than 60 years with 109 males and 131 females.
The presenting complaints is as shown in FIG 2. 45.41%
patients described their presenting symptoms as fullness
of ear(s), 30.83% patients complained of otalgia and
22.5% of patients complained of decreased hearing. 103
patients complained of symptoms in their right ear, 84
patients complained of left ear symptoms and 53 patients
complained of bilateral symptoms. Of the 187 patients
with a unilateral symptoms, 108 (57.75%) had bilateral
presence impacted ear wax.
The most common predisposing factors identified was
Ear bud usage in 80 patients, rinsing with soap in 98,
hirsute canal in 25, narrow canal in 10 patients, use of
hearing aid in 5 patients. No probable causes could be
identified in 50 patients as shown in table 3. The relation
of type of ear wax with presenting symptoms, duration of
presentation age, gender and recurrence is as shown in
Table 4. No significant difference could be found
between duration of presentation and type of ear wax.
There were a total of 71 patients who had underwent ear
syringing more than once in their life time. 40 patients
were undergoing it for second time. As shown in figure 2
a total of 49 patients complained of some form of
complication. 30 patient’s complained of vertigo which
was self-limiting. 15 cases presented with otitis externa
and were treated with analgesics and local antibiotics. 3
patients developed ear perforation. One case developed
malignant otitis externa. On investigation patient had
undiagnosed diabetes mellitus of unknown duration. The
patient was admitted and treated by injectable antibiotics.
Table 1: Age Range Distribution Of Study Group
Age range
Number
Percentage
0-10
481
3.85%
11 --20
1546
12.30%
21-40
6167
49.40%
41-60
3769
30.20%
61-80
510
4.08%
Total
12473
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European Journal of Pharmaceutical and Medical Research
prevalence of ear wax in our study is least in 3.85% up to
10 years. Approximately half of our patients (49.40%)
were in the age group of 21 to 40 years. The prevalence
noted in elderly patients is 4.08% which is less than in
other studies which can be explained by the decrease in
cerumen production with age. The decrease may also be
due to recall bias. The older patients tend to reveal their
age lower. The number of patients seen in a particular
month showed a pattern in our study. The number of
patients is least during winter months and gradually rises
in spring and mid-summer and least in autumn. The
pattern is largely due to harvest season, decreased
activity, decreased bathing frequency in winter.
Fig 2 Presenting Complaints Of Patients
TABLE 2 predisposing factors
predisposing factor
Frequency
Ear bud usage
80
Rinsing with soap
98
Use of hearing aid
5
Hirsute canal
25
Narrow canal
10
Dermatosis
5
No cause identified
50
perecentage
33.33%
40.83%
2.08%
10.21%
4.16%
2.085
20.83%
DISCUSSION
Ear wax is a common otological problem in people of all
age groups. Earwax impaction is one of the most
common
ear
pathology
treated
in
the
otorhynolaryngological clinic worldwide, in the USA,
about 6% of the population suffer from impacted
cerumen with 150 000 ear wax removals take place each
week. Many studies from Europe put the prevalence of
ear wax between 2 to 6%. A few studies from African
continent put the prevalence from 10 to 20%.[18] The
prevalence also varies between different age groups. The
prevalence of cerumen impaction varies greatly,
approximately 10% of the children, 5% of normal
healthy adults, up to 57% of older patients in nursing
homes and 36% of patients with mental retardation.[19]
The prevalence in our study is 6.92% and is largely
comparable with rest of the world. The age wise
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Ear wax is seems innocuous but due to sheer magnitude
of this condition and cost of its management it is a
sizable burden on the resources of health care systems all
over the world including the developed nations. To
calculate the direct cost on health care we included the
cost of skilled manpower involved, the cost of
commodities utilized and patient cost incurred in visiting
a doctor to remove the ear wax. The approximate cost
incurred per month was ₹ 31800. And average per
annum cost amounted to ₹3816000 ($56955) as
described in table. In a study done in Oman the average
cost incurred calculated was $20 per patient and total
estimated cost in population amounting to staggering
$3.6 million.[20] Of the 250 patients of the prospective
arm of study, majority of patients (61) complained of
unilateral symptoms. 103 patients has symptomatic ear
wax on right side and only 84 on left side, Ibiam Fa[21] in
their study found that bilateral ear affection by wax was
twice as common as either right or left ear presence of
wax accounting for 60.1% of all cases seen. Zeba et al [22]
in their study also found that bilateral ear impaction was
commoner than either right or left ear affectation.
Patients seek treatment for cerumen impaction for a host
of symptoms. Pain, itching, sensation of fullness,
tinnitus, odor, drainage, cough and dizziness have all
been reported. In our study most common symptom is
sensation of fullness, followed by otalgia and decreased
hearing. Complete occlusion can result in significant
hearing loss.[23] Hearing loss can range from 5 to 40 dB
depending on the degree of occlusion of the canal with
cerumen.[24]
The most common predisposing factors identified was
Ear bud usage in 80 patients, rinsing with soap in 98,
hirsute canal in 25, narrow canal in 10 patients, use of
hearing aid in 5 patients. No probable causes could be
identified in 50 patients. Waheed Atilade[25] in their
study reveals 74.4% of participants cleaning their ears by
cotton tipped swab and other object. This could be
explained by 72.5% of the participants, who believed
that earwax is harmful and 87.4% believe it is dirt or
dust. Cotton tipped swabs and other object used may
push earwax further into the canal and potentially foiling
the natural earwax removal phenomenon and causing
earwax impaction.[26][27]
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All 250 patients underwent syringing with water after
proper temperature control. A total of 49 patients
complained of some form of complication. 30 patient’s
complained of vertigo which was self-limiting. 15 cases
presented with otitis externa and were treated with
analgesics and local antibiotics. 3 patients developed
tympanic membrane perforation. One case developed
malignant otitis externa. Sorenson has assessed the
pressure developed during routine ear syringing and
found it safe for normal ears. But he did note that it may
present a risk of perforation when the tympanic
membrane is atrophic.[28] Commonly reported significant
complications are perforation (0.2% in Pavlidis series)
and vertigo (0.2% in Pavlidis series)[29] Sharp et al
estimated that only 1 in 1000 episodes of aural irrigation
resulted in a complication significantly severe to require
specialist referral.[24], Similarly, Bird asserts that major
complications occur in 1 in 1000 ears syringed.[30]
Roland et al reported a total of six adverse events in 74
patients who had cerumen removed with cerumenolytics
followed by aural irrigation.[31] All were minor (3 puritis,
1 dermatitis, 1 vertigo, 1 discomfort) and resolved
spontaneously. Tympanic membrane perforation with
serious injury to the middle and inner ear is rare but has
been reported on a number of occasions. Bapat et al[32]
have reported fracture of the stapedial footplate with
subsequent profound neurosensory hearing loss
following aural irrigation using an ear syringe, and
Dinsdale et al have reported a similar complication
resulting in profound deafness following the use of an
oral jet irrigator. In our study we report one case of
malignant otitis externa in a 72 year old female with
previously unknown diabetes mellitus. Patient required
admission and treatment with intravenous antibiotics and
insulin for control of raised blood glucose.
CONCLUSION
We conclude that though an innocuous disease ear wax
impaction is a burden on health care. In our study the
young productive age groups from 20-60 years were
more commonly affected and each visit to hospital
amounted to a work day loss. A sudden Fullness of ear
following bathing and decreased hearing were most
common symptoms of presentation. The prevalence of
ear wax was seen to increase after winter months
probably due to decrease in bathing frequency and
limited transportation. A significant proportion of
patients were in the habit of using ear buds. Treatment of
ear wax by ceruminolytic followed by syringing is quite
safe. Ear wax can be diagnosed and managed by general
practitioners at peripheral hospitals to reduce the burden
on tertiary care ORL centers.
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