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Current and emerging management strategies in chronic

ear disease: Proceedings of a clinical symposium

Update on cerumen and ceruminolytics

Michael Hawke, MD

The term cerumen is generally considered to be synonymous with earwax, but

technically it is not. Cerumen refers only to the secretory product of the ceruminous
glands in the external auditory canal, and it is just one component of earwax. Other
components include large sheets of desquamated keratin squames (the dead, flattened
cells on the outer layer of the skin), sweat, sebum, and various foreign substances. These
foreign substances can include any exogenous matter that is capable of entering the
external ear canal—for example, hair spray, shampoo, shaving cream, bath oil,
cosmetics, dirt, and the like. The primary component of earwax is keratin.
The distinction between cerumen and earwax notwithstanding, for the purposes of this
article, I will refer to both as cerumen.

Physical properties of cerumen

Cerumen has a surprising variety of colors, ranging from golden-yellow to light brown
to dark brown to black. The true color of a cerumen bolus cannot be determined by just
looking at it; you must smear a sample so that it thins out in order to determine its true
color. The pigment responsible for the color of cerumen has yet to be identified.
One can look at the external ear canal as a simple skin-lined tube. The skin that lines
the external ear canal is contiguous with the skin that covers the surface of the body.
The epithelium of the skin on all other parts of the body sheds its keratin squames in
response to friction caused by bathing, contact with clothing and bedding, etc. However,
there is no friction inside the ear canal to promote the shedding of the superficial layer
of keratin. In response to this limitation, the ear canal has developed a technique called
migration . Migration is a mechanism by which the superficial keratin squames move
laterally from the eardrum to the outer ear.

Figure. The two types of wet cerumen are soft (A),

which is more common in children, and hard (B), which
occurs more often in adults.

Different types of cerumen

Cerumen is classified as either dry or wet. Wet cerumen is subdivided as either soft or
hard.
Dry vs wet. Orientals have a much different type of cerumen than do non-Orientals.
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The cerumen in Orientals—and only in Orientals—is a dry, flaky, golden-yellow keratin
squame known as rice-bran wax. Cerumen in non-Orientals is brown and wet, and it can
be either soft or hard (figure). There is a hereditary mechanism behind the development
of cerumen in that the dry cerumen allele is recessive to the wet allele. Interestingly
enough, rice-bran wax is associated with a lower incidence of breast cancer. But perhaps
this should not be surprising because both the ceruminous glands and the breasts are
exocrine glands.
Soft vs hard. Aside from the obvious, several factors differentiate soft and hard
cerumen:

• Soft cerumen is more common in children, and hard cerumen is more common
in
adults.
• Soft cerumen is moist and sticky, whereas hard cerumen has a dry, desiccated
consistency.
• In soft cerumen, the sheets of keratin squames are small. In hard cerumen, the
sheets
are large, dense, and much more prominent.
• The corneocytes are expanded in soft cerumen, but not in hard cerumen.
• Hard cerumen is more likely to be impacted, and it is the type we usually see in
office
practice.

Causes of accumulation
The cause of cerumen accumulation is probably a failure of corneocyte separation.
Dermatologists see a number of conditions that they call corneocyte retention disorders,
and that is what cerumen accumulation appears to be.
Keratosis obturans. Some patients have a plug in the ear canal that is pearly white and
is completely made up of densely compressed keratin squames. This type of plug is
extremely difficult to remove. Left untreated, the keratin sheets will continue to
desquamate into the lumen of the external auditory canal and the mass will continue to
enlarge. Over time, the pressure of this expansion can cause erosion of the bony canal.
While doing research at the University of Toronto, we hypothesized that cerumen
impaction is not a result of overproduction in the ceruminous glands, but a failure of
individual corneocytes in the stratum corneum to separate. In normal individuals,
corneocytes separate from each other as the stratum corneum migrates laterally from the
deep external auditory canal through the deep superficial junction. As a consequence of
this failure to separate, the large keratin sheets are not carried out by normal migration.
Instead, they accumulate in the deep canal.
We postulated that patients whose corneocytes fail to separate probably lack some
substance that destroys the attachments that bind individual corneocytes to each other,
thereby maintaining the integrity of the superficial keratin layer. We called this missing
ingredient keratinocyte attachment-destroying substance (KADS). It is our theory that
KADS releases those attachments and allows the cells to break down into individual
flakes and desquamate. In patients who do not have KADS, the keratin sheet does not
break down as it reaches the superficial canal; instead, it maintains its integrity. As a
result, it tends to roll back on itself, accumulate, and become coated with cerumen.
Eventually, it forms a plug.
Our theory holds that cerumen accumulation is a medical disorder rather than a natural
phenomenon. It is probably a disorder of the migratory epithelium in the superficial
external auditory canal, and it is probably genetic.
Possible KADS. We believe that there might be more than one KADS and that one of
these substances might be steroid sulfatase, which is an aryl-sulfatase-C enzyme. Steroid

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sulfatase is normally present in epithelial cells, fibroblasts, and leukocytes. It is the only
enzyme known to be involved in the process of epidermal cell desquamation.
The cohesion of the cells of the stratum corneum is maintained by cholesterol sulfate,
which acts as an intercellular cement. Steroid sulfatase is believed to block the action of
cholesterol sulfate and allow the bonds to become free of each other. Our research
shows that in normal individuals, steroid sulfatase activity is greater in the epithelium of
the deep external auditory canal than it is in the superficial external canal. Therefore,
steroid sulfatase appears to be responsible for the separation of the keratinocytes as they
migrate outwardly. Steroid sulfatase is responsible for an X-linked recessive ichthyosis
(a corneocyte-retentive condition in which scales of keratin adhere to the skin). Over
time, these keratin scales accumulate and turn dark brown. We believe that a similar
mechanism is primarily responsible for cerumen accumulation.

Ceruminolytics
There is a great need for a better ceruminolytic. A ceruminolytic should disrupt the
structural integrity of the keratin sheets and thereby soften, loosen, liquefy, and/or
dissolve cerumen and perhaps even float it out. The integrity of the cell membrane is
thus reduced, which allows water to pass into the corneocytes along an osmotic gradient.
The hydration causes the corneocytes to swell and fragment. The aim of ceruminolysis
is to disrupt the keratinocytes on the outside of the plug, as well as those that are located
between the plug and the ear canal. Once this is accomplished, the cerumen can be
removed by curettage, aspiration, or microdebridement.
The two types of available ceruminolytics are aqueous and organic. Among the
aqueous solutions are ordinary water, 10% sodium bicarbonate, 3% hydrogen peroxide,
2% acetic acid, and a combination of 0.5% aluminum acetate and 0.03% benzethonium
chloride. Overall, aqueous solutions do a fairly good job of expanding and loosening or
dissolving cerumen plugs. Oil-based organic solutions include olive oil, glycerin,
propylene glycol, spirit of turpentine, and liquid paraffin. They basically do nothing but
lubricate. They do not dissolve or expand corneocytes, and as a result they have no
effect on the structural integrity of keratin squames.
Some ceruminolytics—particularly the organic solutions—can cause sensitivity
reactions, such as contact dermatitis. Also, a failure to remove cerumen completely can
result in a fungal superinfection. Another possible complication is ototoxicity, which
can occur if a perforation is present. In many patients, a cerumen plug blocks the view
of the tympanic membrane, so we cannot know for certain whether a perforation is
present. Nevertheless, we can make an educated guess with a reasonable degree of
reliability.
The speed of a particular ceruminolytic's action depends on the removal technique you
will use, the amount of cerumen, the hardness of the cerumen (i.e., its keratin content),
and the temperature of the ceruminolytic.

Comments
Dr. Croxson: Aside from being more comfortable for the patient, why does warming
a ceruminolytic help?
Prof. Hawke: I'm not sure why it works, I just know that it does. We know that
cerumen stays hard longer in a cold ceruminolytic. Perhaps there is some substance in
cerumen that is temperature-sensitive.

ENT-Ear, Nose & Throat Journal • August 2002

Supplement

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