Self-Ear Cleaning Practices and the Associated Risks: A Systematic Review

Background: Naturally the ear produces soft wax from the sebaceous and ceruminous gland. This is what is referred to as earwax. This wax is important for protection of the ear by trapping dust and other foreign particles that could damage the eardrum. It also has some antibacterial properties. Jaw movements, like during chewing, moves the old earwax from inside the ear canal to the outside and finally flakes off. Build-up of this wax in the ear causes hearing loss, pain in the ear, irritation, dizziness and ringing in the ears. Self-ear cleaning refers to self-insertion of objects into the ear canal, with an attempt to remove the wax to get rid of these symptoms. It is a common practice amongst many individuals. Potentially, this rids the ear of its protective defences in addition to posing a risk of ear related injuries. This review paper aims to determine the prevalence of self-ear cleaning, the common methods used and the complications associated with this practice. Methods: Electronic retrieval of articles for review was done from PubMed, Google and Google scholar with key-ward – self-ear cleaning, ear-wax, cerumen. Many articles were retrieved but only a few were about self-ear cleaning and only seven could be included in this review. The inclusion criteria included: article published in English language; study carried between 2005 and 2020 inclusive; article discussing materials used and complications associated with self-ear cleaning. Articles older than 15 years or published in languages other than English were excluded. Results: On average the prevalence of self-ear cleaning amongst all studies was 76.6%. The commonest method used for ear cleaning was cotton buds with an average of 69.6%. Wax/dirt removal was the commonest reason for engaging in this practice. Several complications arising from this practice included perforation of eardrum, retained foreign body and otitis externa. Conclusion: In addition to ridding the ear of its natural protection, self-ear cleaning is associated with a risk of injury to the ear drum and retention of foreign bodies. Community education to avoid this practice is therefore of paramount importance. Trained health care providers should be consulted whenever someone has a problem related to hearing or any other symptoms.


Introduction
Self-ear cleaning is the practice of inserting an object into the ear canal with the aim of cleaning the internal part of the ear. However, this practice potentially compromises the integrity of the natural cleansing mechanism of the ear, and pose a risk to possible injuries (Khan, Thaver, & Govender, 2017). It is not uncommon for people to get rid of wax in their ears and it is a global assumption that wax is considered dirt, despite its physiological usefulness of protecting the ear from dust and foreign bodies. The ear has a physiological, natural cleansing mechanism, thus the practice of inserting objects into the ear canal for cleaning it is not necessary and may be harmful. There are risks of inflicting injury to the ear and in worse cases these complications may need urgent medical attention i.e., tympanoplasty or instrumental removal of retained objects. These complications may lead to life-long sequelae, such as hearing impairment (Khan, Thaver, & Govender, 2004). Common objects inserted into the ear canal include cotton buds, matchstick, broomsticks, tree twigs, towel tips, ball pen tips or their covers and the fingers. Inserting these objects into the ear may disturb its normal pH, function and anatomical structure (perforation). In a prospective study done in Nigeria, amongst patients and healthy individuals (staff and students) from Usmanu Danfodiyo University Teaching Hospital (UDUT), 19.5% (n=39) did not engage in self-ear cleaning practice while 80% (n=160) practiced self-ear cleaning (Amutta et al., 2013). The participants were in the age range of 18-60 years with mean age of 30.29 years old. There were more females than males, n=107 (53.5%) and n=93 (46.5%) respectively. In descending order, the methods or objects used for self-ear cleaning were cotton buds (n= 146; 91.2%), biro cover/tip (n=6; 3.7%), feather (n=3; 1.9%), broom stick (n=2; 1.3%), finger (n=2; 1.3%) and match stick (n=1; 0.6%). The reasons for performing self-ear cleaning were removal of dirt with n=65 (40.6%), itchy ears (n=48; 30%), ear wax (n=25; 15.6%), ear blockage (n=22; 13.8%), and water in the ear (n=10, 6.2%). Out of the160 respondents who admitted to self-ear cleaning practices, 25% (n=40) of them experienced complications. The complications included otitis externa 10.6% (n=17), retained object in external auditory canal (EAC) 6.9% (n=11), pain 6.3% (n=10) and bleeding from EAC 1.2% (n=2).
In a descriptive cross-sectional study amongst a group of medical doctors at Aminu Kano Hospital in Nigeria by Gadanya, Abubakar, Ahmed, and Maje (2016), out of a total of 118 participants, 44.9% (n=53) admitted to having done self-ear cleaning before. All of them used cotton buds. The reasons given for self-ear cleaning included keeping good hygiene 54.7% (n=29), removal of ear wax 28.3% (n=15), itchiness 3.8% (n=2) and other reasons13.2% (n=7). In this group, complications from the practice that required urgent medical attention included retained foreign body (n=48) and trauma to the ear (n=29).
A cross-sectional study involving 141 (94 males and 47 females) Health professionals at Jos University Teaching Hospital in Nigeria by Adoga and Nimkur (2013), demonstrated that 91.5% (n=129) of the participants practiced self-ear cleaning. The participants were in the age range 25-59 years with mean age of 42 years. 89.1% (n=115) of those who practiced self-ear cleaning used cotton buds. Other methods/materials used included spatula, ball-pen covers, ball-pen tips, matchsticks, bobby pins, chicken feathers, fingers and car keys. This study did not explore the reasons for self-ear cleaning. Only 9.3% of those who practice self-ear leaning reported complications including abrasion to EAC, perforated tympanic membrane and wax impaction.
In a cross-sectional study involving 1012 young educated participants (488 male and 508 females) in Nigeria by Olaosun (2014), found that 929 (93.4%) of all participants (465 males and 464 females) practiced self-ear cleaning.
In this study the commonest object, 85.1%, used were cotton buds. This study also did not explore the reasons for self-ear cleaning.
A prospective study involving 50 outpatients (25 males and 25 females) in Kuala Lampur, Malaysia by Lee, Govindaraju and Hon (2005) demonstrated 36% (n=18) practiced self-ear cleaning practices. Their age range was 15-74 years with a mean range of 40.7 years. Of those who practiced self-ear cleaning, 85% used cotton buds. Other objects used included towel (6%), metal probe (6%) and finger (2%). The reasons for self-ear cleaning identified in this study were wax (70%), itchiness (15%), water in ear (6%), and dirt in ear (9%). Only one respondent reported a complication of otitis externa as a result of self-ear cleaning. In a prospective study carried out at the Tundun-wada community and National Ear Care Centre, Kaduna by Abdulrahmnam and colleagues, about 27% had ear discharge, 22% wax impaction and 12% had foreign bodies as complications resulting from self-ear cleaning. In this study there was a total of 372 participants with age range 1-76 years, a mean age of 30.37 years, median age 29.00 (S.D. = 13.79) and M:F ratio of 1:1. Mothers responded for their children except for grown up. About 47.3% of the subjects were unemployed and these were either children or complete house wife. About 90% of the subjects interviewed practiced self-ear cleaning and over 90% believed the ear should be cleaned to remove wax, over 50% because of itchiness or for cosmetic reasons. Cotton bud was the commonest material used for cleaning.

Prevalence of self-ear cleaning
The findings in the articles reviewed showed the prevalence of self-ear cleaning to be persistently above 90%.
Only two studies (Lee, Govindaraju &Hon, 2005 andGadanya et al., 2016) had lower prevalence of 36% and 44.9% respectively. It is, therefore, evident that the self-ear cleaning is a common practice. Since these studies were conducted in different settings (educated population, health professionals, university students, rural settings), it can be deduced that the practice of self-ear cleaning is common in all social backgrounds. The prevalence is mainly high in those in their 2 nd -3 rd decades (Amutta et al., 2013;Khan, Thaver, & Govender, 2017;Gadanya et al., 2016;Adegbiji et al., 2018;Olaosun, 2014). Only two studies (Lee, Govindaraju, & Hon, 2005;Adoga & Nimkur, 2013) had peaks in the prevalence in the practice in the 4 th decade. Regarding gender, only one study by Olaosun (2014) analysed gender difference and found that females are more likely to perform self-ear-cleaning than males. According to Adegbiji et al. (2018), however, females are generally more active in personal hygiene compared to males.

Materials used for Self-Ear Cleaning
Several methods/materials were found to have been used for self-ear cleaning in these studies, but what came most commonly were cotton buds. Significantly, however, a study by Adegbiji et al. (2018) carried out in the rural community showed that sticks were more commonly used (43.3%), followed by fingers (33.8%) and cotton buds (26.3%). It, therefore, can be deduced that the object used is dependent on the environment and the socio-economic status of the population. Hence, sticks, feathers and fingers are more commonly used in rural areas whereas cotton buds are commonly used in urban settings (Adegjibi et al., 2018).

Reasons for Self-Ear Cleaning
In the articles that were reviewed, there were several reasons for individuals to practice self-ear cleaning. The commonest reason was to remove dirt/wax from the ear. Wax is wrongly perceived as dirt or debris and thus the urge to remove it. The other reasons were itchiness, feeling of water in the ear, soothing, and ear blockage or impaired hearing. It is evident in several studies that earwax is believed to be dirt and unhygienic due to its brown sticky characteristic. However, Cerumen (earwax) is a normal physiologic excretion from the ceruminous and the sebaceous glands forming part of the outer third of external auditory canal. Earwax is composed of glycopeptides, lipids, hyaluronic acid, sialic acid, lysosomal enzymes and immunoglobulins. Earwax serves a protective function, by maintaining an acidic environment (pH of 5.2 -7.0) in the external auditory canal as well as lubricating the canal. Additionally, earwax has antibacterial and antifungal properties (Oladeji, Babatunde, Babatunde, & Sogebi, 2015). According to Khan et al., (2017), self-ear cleaning practices has evidently been found to compromise the integrity of the ear's self-cleansing mechanism.

Complications of Self-Ear Cleaning
Some subjects from all articles reviewed have had complications resulting from self-ear cleaning. According to Khan et al. (2017), the most frequently seen complications in the ENT departments are retained cotton bud ends as well as match stick ends stuck in the ear. Other complications of self-ear cleaning include perforated tympanic membrane and otitis externa. Majority of patients who get complications are from the rural setting (Adegbiji et al., 2018). Nonetheless, most of these complications are self-limiting. In a study by Khan et al. (2017), however, 5 of 206 participants had serious complications two of whom experienced perforated tympanic membrane and one required tympanoplasty.

Recommendations
Based on the literature, there is no doubt that self-ear cleaning is a common practice. It is also evident that risks such as injuries to the inner ear and complications such as perforation of tympanic membrane and retention of foreign bodies are real. We therefore recommend the following: • Health education against self-ear cleaning. It is recommended that priority be put on teaching primary school pupils to avoid putting objects in their ears. They should as well be made aware of the possible dangers/complications of doing so right from the young age such that the vice should not be done in adulthood.
• For adults and the general public, health education against self-ear cleaning could form part of health promotion package given at primary health care facilities. The community should be sensitized about the danger and the complications that may occur because of self-ear cleaning practices. Ear, nose and throat (ENT) department should create awareness campaign conveying basic information on the danger of self-ear cleaning practices; people should be encouraged to develop a health seeking behaviour from trained health personnel.
• Health professionals need to promote safe practices for the public to follow. The review has shown that some health professionals also practice self-ear cleaning yet they know that it is harmful. This habit should be discouraged, as it is a slow otologic poison leading to potential risks of ear injuries (Afolabi et al., 2009).

Conclusion
The practice of self-ear cleaning among all ages is common. In addition to ridding the ear of its natural protection, self-ear cleaning is associated with a risk of injury to the ear drum, retention of foreign bodies and other complications as someone blindly inserts objects into the ear canal. Community education to avoid this practice is therefore of paramount importance. Trained health care providers should be consulted whenever someone has a problem related to hearing or any other symptom.