As an ENT specialist removal of impacted wax can be a very gratifying experience, as the patient goes from having difficulty hearing to completely normal hearing as soon as the offending wax has been removed.

Below is a poem penned by a patient and General Practitioner the late Dr Joe Lazarus, and given to me, that I think many will identify with.

“ SHARON WILLIAMS

My gratitude is most profound

For all your great decoking.

When they talk all around

And you can’t hear a sound

It’s really no matter for joking.

But your suction wax clearing

Has given me hearing

Each time my acoustics were flagging

I hear people swearing

And without really caring

I even hear marital nagging.

Joe Lazarus.”

Symptoms of wax impaction include deafness, tinnitus, reflex cough through stimulation of the vagus nerve, earache or fullness in the ear and occasionally vertigo.

Ear wax is a mixture of secretions from different types of glands within the external audiotory canal (ie. ear canal) and shedded squamous epithelium (skin cells), as well as dust and other foreign particles.

Skin is shed in the deep canal & works its way to the external surface, in the process it gets mixed with ”waxy” secretions produced by 2 different types of glands, ceruminous & sebaceous glands within the skin of the outer two thirds of the external auditory canal. Wax has a protective function as it contains various substances that can kill bacteria and by moving outwards towards the entrance of the ear canal it gets rid of trapped particles & cleans the ear canal. This outward movement of wax is aided by movement of the jaw & hairs in the outer part of the ear canal.

Putting any foreign body, for example cotton ear buds in the ear canal can injure the delicate skin & allow for infection to enter the skin causing a very painful outer ear infection. It is mistakenly believed that we need to clean our ears, in spite of the magnificent design of our bodies, making ear canals self-cleansing.  In the main cotton ear buds push the wax deeper into the canal & repeated use can over time impact the wax causing hearing loss, as sound waves are unable to get to the tympanic membrane (ear drum), impairing hearing.

Interestingly, genetic factors influence the consistency and composition of the wax, giving researchers a tool to track the migration of various racial groups from our distant past.

In the main persons of European and African origins produce a “wet” wax characterised by a moist, honey to dark brown coloured sticky wax. Whereas people of Asian / Eastern extract tend to produce dry, greyish, brittle wax.

Some people may secrete excessive quantities of wax predisposing them to greater wax accumulation and so may increase the risk of wax impaction, due to overloading the clearing mechanism. It is felt that this excessive wax production may be due to irritation.

The ear canal is not a straight canal, but has a bend in it, where the cartilaginous & the bony canal meet & in some individuals the ear canal can be more tortuous than normal, or it can be very narrow. Both of which will predispose to wax accumulation.

As we age, wax becomes dryer, possibly as a result of a reduction in the number and the activity of the wax producing glands. Wax impaction appears to be more common in males and it has been suggested that this may be due to the larger and coarser hairs in the external auditory canal preventing the natural dislodgement of wax, ie. trapping the wax instead.

Other ear issues that can alter the self-cleansing ability of the ear canal are bony ingrowths ie. exostosis and surgically created mastoid cavities. Wearing hearing aids or noise attenuators   tend to not allow the wax to work its way out by physically obstructing the ear canal.

Wax absorbs water (ie.is hygroscopic) and so showering or swimming, getting water into the ear canal, may result in sudden complete occlusion of the external auditory canal, if the ear canal was previously partially blocked.

As ear wax character & production, as well as reasons for the self cleansing system not working optimally are individual specific an individual specific approach to remove wax is employed.

The picture shows wax plugs from 2 individuals, one waxy & the other of a slighter drier consistency with more of a skin component. Also illustrated are various instruments that can be used to remove wax in the ENT ‘s consulting room.

That protuberance on our face that identifies or defines our origins ie. genetics & gives us a sense of pride or shame, in itself it is an emotional organ, eliciting emotional responses & responding to our emotions physiologically by running and or blocking. It also defines our sexuality, often being labelled a masculine or a feminine nose.

Looking beyond the external appearance of our noses it can be considered the protector –  Filtering & trapping, humidification, olfaction. (Olfaction – our sense of smell -to be covered in a later post).

When breathing in air, this air filled with pollutant particles, bacteria, viruses & allergens (microscopic particles like pollen that have the ability to cause an immune reaction), is firstly filtered by our nasal hairs. Yes, those very hairs that we often feel are unsightly & trim, have a very important purpose.

Thereafter smaller particles are trapped in what we term the mucous blanket, a thin layer of mucous found within the nasal cavity that traps smaller microscopic particles and then it is the microscopic cilia that sweep this mucous with all the trapped impurities, particles & organisms backwards to the back of the nose & down the throat to be swallowed, so entering the digestive tract where they are destroyed due to the acidity of the stomach & so are unable harm us.

Linked to the filtration function of the nose is humidification.

Consider the fact that we breathe 6 to 7 L of air in a minute at rest and this would increase significantly with exercise to 50-60 litres a minute for strenuous exercise. All this air needs to be humidified to protect the intricate fragile internal structures of the lungs where oxygen exchange takes place i.e. the alveoli. The nose needs to work efficiently as a humidifier and uses approximately 1 and a 1/2 litres a day to fulfil this purpose. To ensure that this amount of liquid is available, it is important to make sure that we are well hydrated and this can be done by drinking water or steaming, breathing in and out through the nose.

As a result of some turbulence within the air flow through the nose, structures in the nose called the turbinates which are incredibly vascular structures warm and humidify the air we breathe in. Regardless of the environment we live in, across the earths diverse climates the nose adjusts the temperature of the air we breathe in, close to normal body temperature and humidifies the air to about 98% humidity.

Breathing out through the nose much of the moisture  and heat in the expired air is reclaimed in the nasal cavity by the nasal turbinates, to humidify the air that is breathed in again, (inspired air), in the next breath and so on.

If one breathes out through the mouth, as in strenuous exercise, then this moisture is lost and more water will be required by the body not only to replenish the water lost due to sweating but the water not reclaimed by the nasal structures due to mouth breathing.

We all experience that very dry mouth when we breathe in and out through our mouths when our nose is blocked. Although it is claimed that the pharynx i.e. the back of the throat which is usually moist, contributes to humidification of inhaled air it certainly is not as efficient as the nasal cavity.

Interestingly what we assume to be a very efficient system pales in comparison to the efficiency of the humidification in mammals.

We take the efficient functioning of the nose for granted until we are symptomatic, as in the complaint of a post nasal discharge.