British Tinnitus Association

O P Tungland MD - Consultant Audiological Physician

Our bodies are confined by skin which is waterproof and an effective barrier to most harmful external agents. The ear canal is lined with skin, which, unlike skin elsewhere, cannot be reached.
While the skin is growing from the deepest layers to the surface, it also grows sideways and migrates out of the ear canal. This has been illustrated by placing a drop of Indian ink on the ear drum. If inspected daily over a period of weeks, it appears to move along a spiral path and eventually drops out of the ear. This process, unimpeded, normally keeps the ear clean by carrying away any debris and wax on the surface of the skin as it migrates. Therefore, generally there is no need to clean the ears, other than by a wet flannel passed over the ear canal opening. However, if this self-cleaning system fails for any reason, or if the wax is pushed back into the canal by a misunderstood or overenthusiastic cleaning, the wax accumulates and may stop this process and block the canal.

Occasionally wax does produce problems, either by itself or by trapping water in the ear canal. This can give a slight degree of hearing impairment. In people with troublesome tinnitus, this change in hearing may be sufficient to increase the apparent loudness of the tinnitus.

Sometimes tinnitus is triggered by this change in hearing or even by the removal of the wax, in particular by syringing. Most people, whose ears are blocked by wax, however, benefit from having it removed.

Removal can sometimes be achieved by simply softening the wax with bicarbonate of soda solution (available from chemists). The softened wax will be transported out of the ear canal as a brownish liquid with a slightly unpleasant odour. There are also a number of commercial ear drops available. Occasionally these cause a problem, as they contain chemical additives to which the skin may be sensitive and, once instilled, they cannot be easily removed.

People who have eczema or dermatitis of the ear are likely to have a reaction to some of the additives, resulting in itching, pain or discharge from the ears. For this reason ear drops should only be used when there is good reason for removing the wax and only if there is no known tendency to skin problems. Even if the drops are used, they do not always clear the wax.

The most common alternative is syringing. Water, at body temperature, is injected through the nozzle of a syringe into the ear canal. Under the gentle force of the syringe, it runs into the deepest part of the canal where it forms eddies which dislodge the wax. The wax is carried out of the canal by the continuous flow of water for as long as the syringing continues. If the wax seems hard, it is best to soften it by the use of drops for one or two days prior to the syringing.

In competent hands and with a relaxed subject, the procedure is usually painless and effective. Considering the vast numbers who have their ears syringed each year (perhaps a million in the UK) the numbers of serious complications are small. However, there seems to be a very small number of cases where the procedure coincides with the onset or aggravation of tinnitus. The reason for this is not clear. Pain in the ear canal does not "cause" tinnitus. The noise of syringing has been measured and it is not very loud, certainly not loud enough to cause noise-induced damage. It has been suggested that there may be nervous reflexes, perhaps to the temperature of the water used, either too warm or too cold, but there is no proof, so this remains a theoretical possibility only. Perhaps the most likely explanation is that syringing, especially if unpleasant for any reason, can act as a trigger to bring the patient's attention to nervous activities which are already present, but previously not audible. The emotional response to pain or anxiety which can accompany syringing may be sufficient to make the hearing mechanism more sensitive, enough to detect and amplify these faint auditory signals, which once heard, become established in the consciousness as tinnitus.

If the tinnitus is seen as a result of damage caused by syringing, understandable, but perhaps misplaced, anger will ensue. This may prevent habituation (the process by which we cease to listen to boring background noise of no significance), and the tinnitus will become more intrusive and persistent, the more the emotions gets involved and the checking of its presence takes place.
There are alternatives to syringing. Wax can be removed with a metal probe or hook. In skilled hands, this is easy and effective, but likely to be more painful. It is used far less than syringing, and it too may sometimes be associated with the onset of tinnitus. Suction, through a narrow tube, is another method used in ENT departments to clean ears. This is the safest method. It is noisier, but not damaging to the hearing. Like the other methods, it too has occasionally been associated with tinnitus.

To summarise
• If the wax is not a problem, it is best left alone
• If removal is justified for medical reasons, ears drops should be tried
• For those few people for whom drops are inadvisable, or where drops have been tried and failed, or where immediate removal of wax is necessary for some reason, careful syringing by someone who has been properly instructed in the technique is the best option
• Other methods are best reserved for use in ENT departments

Reviewed June 2008 © British Tinnitus Association

This information is not a substitute for medical advice. You should always see your GP / medical professional