External Auditory Canal Dimensions, Age, and Cerumen Retention or Impaction in Persons With Down Syndrome.

OBJECTIVE: To investigate associations between age, external auditory canal (EAC) dimensions, and cerumen retention/impaction among persons with Down syndrome (DS). METHODS: This cross-sectional study evaluated EAC dimensions, cerumen retention/impaction, and middle ear status with pneumatoscopy after extraction in 130 persons with DS. Descriptive and inferential statistics correlated age, presence of impacted/retained cerumen, and EAC diameter. RESULTS: Of 260 ears in 67 males and 63 females with average age of 9.48 years, 72.3% (188) had EAC of ≤4 mm. Those ≤1 year were 4.97 times more likely to have cerumen problems than those >1 year (95% CI, 1.45-17.02, P = .011). The odds of having cerumen problems with an EAC diameter of ≤4 mm were 3.31 times higher than with a diameter of 5 mm (95% CI, 1.46-7.50, P = .004), and odds of having cerumen impaction were as much as 6.19 times higher (95% CI, 2.38-16.08, P < .001). Male gender and low-lying external ear were also associated with increased odds of cerumen problems. CONCLUSION: There is a high prevalence of cerumen retention/impaction in persons with DS compared to the general Philippine population and a higher prevalence rate for EAC stenosis than elsewhere. A canal diameter of 4 mm and below and age 1 year or less are associated with a significantly higher likelihood of cerumen retention/impaction.

Demodex Species Infestation in Patients with Ear Itching and Its Relationship to Itch Severity.

OBJECTIVE: The aim of the present study was to investigate Demodex species infestation in patients with ear itching. The relationship between the severity of ear itching and Demodex spp. positivity has not been previously reported in the literature, and we believe that our study will make a significant contribution to the understanding of the etiology of ear itching. METHODS: Fifty patients with itching ears and 54 healthy control patients were asked to use a visual analogue scale (VAS) to rate the itch, the itching period, and the medication used for the itching. All samples were evaluated for Demodex spp. under a light microscope. RESULTS: There was no statistically significant difference between the groups in terms of numbers of Demodex spp. (p=0.154), and there was no statistically significant difference between the groups in terms of Demodex spp. positivity (p=0.054). Despite the lack of statistically significant differences, Demodex spp. infestations were more common in the affected group than in the control group. A positive and strongly significant relationship was observed between the number of Demodex spp. and severity of ear itch in the patient group based on VAS scores (p=0.0001; r=0.724). CONCLUSION: We found that an increased number of Demodex spp. was strongly related to increased severity of ear itching.

Extracción de la cera de los oídos / Extraction of wax from the ear

A través de cuatro artículos sucesivos pretendemos mostrar los procedimientos que consideramos de mayor utilidad para el diagnóstico y el seguimiento de la otitis media serosa (OMS) por parte de Pediatría de Atención Primaria. En este primero, expondremos la que, a nuestro juicio, es la manera más eficaz de limpiar la cera del oído de un niño. Las conclusiones aportadas conjugan las recomendaciones ofrecidas por las principales guías sobre extracción de cera del oído y las de la revisión bibliográfica efectuada, con la experiencia de un equipo de pediatras y de otorrinolaringólogos de la misma área de salud. Alrededor de un 50% de niños requieren limpiar de cera sus oídos a fin de realizar una correcta otoscopia. Para ello podemos utilizar la instilación de cerumenolíticos, la irrigación, la extracción manual o cualquier combinación. No existe evidencia en la bibliografía de que un procedimiento sea mejor que otro. Conclusiones: tras aplicar las diferentes técnicas de limpieza, consideramos que, si la cera es externa y el conducto auditivo permeable, la mejor manera de eliminarla es mediante el uso de curetas o porta-algodones, pero si la cera es más profunda o está impactada, el método elegido será el lavado con irrigación de agua templada, para lo que un cerumenolítico aplicado previamente es de gran ayuda. Aconsejamos realizar dicha irrigación con una jeringa de 20 cc y un catéter intravenoso Abocat® del 14-16, a fin de evitar riesgos (AU)

Through four successive articles we aim to show the procedures we consider to be most useful for the diagnosis and follow-up of otitis media with effusion (OME) by Primary care Pediatrics. In the first one, we expose what we believe is the best way to clean wax from the ear of a child. The conclusions provided combine the recommendations offered by the main guides on extraction of wax from the ear and the literature review carried out, with the experience of a team of pediatricians and otolaryngologists from the same Healthcare Area. Around 50% of children require clean wax from their ears in order to perform a correct otoscopy. To do this we can use the instillation of cerumenolytics, irrigation, manual removal, or any combination. There is no evidence in the literature that a procedure is better than another one. Conclusions: after applying different cleaning techniques, we believe that if the wax is external and the ear canal permeable, the best way to remove it is by the use of blunt ear curettes or applicator with triangular tip, but if the wax is deeper or is impacted, the better choice will be washing with warm water irrigation, in this case, the previous application of a cerumenolytic will be of great help. We advise to perform such irrigation with a syringe of 20 cc and an intravenous catheter Abocat® 14-16, in order to avoid risks (AU)

Middle ear and hearing disorders of schoolchildren aged 7-10 years in South Sinai, Egypt.

Hearing loss among schoolchildren in developing countries is reported to be a significant health problem. Data on child hearing loss in South Sinai, a remote governorate of Egypt, are lacking. Middle ear diseases and hearing impairment were assessed among 453 primary-school children aged 7-10 years in South Sinai (906 ears). Otoscopic examination, tympanometry and pure tone audiometry (PTA) were done. Ear disease was found in 27.5% of the ears examined. The commonest cause was secretory otitis media (10.8%), followed by occluded earwax (9.5%). Mild and moderate hearing loss affected 8.5% of the sample, while sensorineural hearing loss affected 2.4%; only 0.4% had moderate and severe hearing loss. Hearing impairment affects 19.3% of this age group in South Sinai. None of the children with hearing impairment had been previously diagnosed or was receiving treatment and support. Hearing and middle ear screening at schools is recommended for early detection and management of middle ear and hearing problems.

The earwax-associated SNP c.538G>A (G180R) in ABCC11 is not associated with breast cancer risk in Europeans.

Genetic polymorphisms of human ABC-transporter genes have been suggested to modulate breast cancer risk in the general population. In particular ABCC11 (MRP8), which is highly expressed in breast cancer tissue and involved in the efflux of conjugated estrogen metabolites such as estrone-3-sulfate and estradiol-17beta-glucuronide, has recently been proposed as a potential risk factor for female breast cancer. The wet earwax-associated G-allele of the c.538G>A polymorphism was associated with an increased risk for breast cancer in Japanese women. In contrast, no evidence for such an association could be observed in Caucasian women. We aimed to confirm/refute the association of the c.538G>A variant in ABCC11 with breast cancer risk and/or histo-pathological tumor characteristics in an independent population-based breast cancer case-control study from Germany comprising 1021 cases and 1015 age-matched controls. No association for allele and genotype frequencies of the 538G>A variant in ABCB11 with breast cancer risk was found. Our data suggest that the c.538G>A variation in ABCC11 does not contribute to breast carcinogenesis in women of European descent.

Antibacterial and antifungal properties of human cerumen.

OBJECTIVE: To assess the antibacterial and antifungal properties of human cerumen by studying its effect on the growth of Staphylococcus aureus, Esherichia coli, Pseudomonas aeruginosa and Candida albicans. MATERIALS AND METHODS: Cerumen samples were collected from 75 normal, healthy subjects aged from seven to 80 years, without ear pathology, who attended the ear, nose and throat out-patient clinic of the University Malaya Medical Center from May 2006 to October 2006. Of these 75 samples, 31 had no growth when cultured on nutrient agar. Inhibition studies on these 31 samples were performed for Staphylococcus aureus (American Type Culture Collection (ATCC) 25923), Esherichia coli (ATCC 25922), Pseudomonas aeruginosa (ATCC 27853) and Candida albicans. Nutrient agar was used to conserve all three bacterial strains and Sabouraud dextrose agar was used for Candida albicans. RESULTS: A decrease in Staphylococcus aureus growth was observed for 27 of the 31 samples. All 31 samples induced decreased growth of Pseudomonas aeruginosa, while 29 induced decreased growth of Candida albicans. However, only four samples induced decreased growth of Escherichia coli. CONCLUSIONS: Cerumen was demonstrated to have potential antimicrobial effects on strains of Staphylococcus aureus, Pseudomonas aeruginosa and Candida albicans.

ABCC10, ABCC11, and ABCC12.

Multidrug resistance protein (MRP)7, MRP8, and MRP9 (gene symbols ABCC10, ABCC11, and ABCC12) are recently identified members of the MRP family that are at relatively early stages of investigation. Of these proteins, a physiological function has only been established for MRP8, for which a single nucleotide polymorphism determines wet vs dry earwax type. MRP7 and MRP8 are lipophilic anion pumps that are able to confer resistance to chemotherapeutic agents. MRP7 is competent in the transport of the glucuronide E(2)17betaG, and its resistance profile, which includes several natural product anticancer agents, is distinguished by the taxane docetaxel. MRP8 is able to transport a diverse range of lipophilic anions, including cyclic nucleotides, E(2)17betaG, steroid sulfates such as dehydroepiandrosterone (DHEAS) and E(1)S, glutathione conjugates such as leukotriene C4 and dinitrophenyl-S-glutathione, and monoanionic bile acids. However, the constituent of earwax that is susceptible to transport by MRP8 has not been identified. MRP8 has complex interactions with its substrates, as indicated by the nonreciprocal ability of DHEAS to stimulate E(2)17betaG transport. Similar to the case for other MRPs that possess only two membrane spanning domains (MRP4 and MRP5), MRP8 is a cyclic nucleotide efflux pump that is able to confer resistance to nucleoside-based agents, such as PMEA and 5FU. The functional characteristics of MRP9 are currently unknown.

Diagnóstico y tratamiento antimicrobiano de las otitis externas / Diagnosis and antibiotic treatment of external otitis

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A SNP in the ABCC11 gene is the determinant of human earwax type.

Human earwax consists of wet and dry types. Dry earwax is frequent in East Asians, whereas wet earwax is common in other populations. Here we show that a SNP, 538G --> A (rs17822931), in the ABCC11 gene is responsible for determination of earwax type. The AA genotype corresponds to dry earwax, and GA and GG to wet type. A 27-bp deletion in ABCC11 exon 29 was also found in a few individuals of Asian ancestry. A functional assay demonstrated that cells with allele A show a lower excretory activity for cGMP than those with allele G. The allele A frequency shows a north-south and east-west downward geographical gradient; worldwide, it is highest in Chinese and Koreans, and a common dry-type haplotype is retained among various ethnic populations. These suggest that the allele A arose in northeast Asia and thereafter spread through the world. The 538G --> A SNP is the first example of DNA polymorphism determining a visible genetic trait.

Impacted cerumen: composition, production, epidemiology and management.

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. Impacted cerumen is a major cause of primary care consultation, and a common comorbidity in ENT patients, the elderly, infirm and people with mental retardation. Despite this, the physiology, clinical significance and management implications of excessive and impacted cerumen remain poorly characterized. There are no well-designed, large, placebo-controlled, double-blind studies comparing treatments, and accordingly, the evidence surrounding the management of impacted cerumen is inconsistent, allowing few conclusions. The causes and management of impacted cerumen require further investigation. Physicians are supposed to follow the edicts and principles of evidence-based medicine and clinical governance. Currently, in patients with impacted cerumen, the lack of evidence makes this impossible.

[Chronic recurrent otitis externa. Excessive ear hygienic care can have sequelae]. / Chronisch rezidivierende Otitis externa. Ubertriebene Ohrhygiene kann sich rächen.

Numerous factors may be involved in the development of chronic recurrent otitis externa: altered pH of the cerumen, increased susceptibility to contact allergens (e.g. nickel ear-rings) in atopic patients, the use of instruments for cleaning out the auditory canal, the presence of a foreign body, congential narowing of the auditory canal, or systemic diseases (in particular diabetes mellitus). For diagnostic purposes, the use of the otoscope is mandatory, and swabs to determine the presence of bacteria or fungi are to be recommended. Treatment is dictated by the clinical picture presenting, and may comprise the local application of antibiotic cortisone containing or antimycotic preparations and temponade of the auditory canal (acute inflammatory phase) or pH-stabilizing lotions (chronic dry inflammatory phase) with the aim of ameliorating the frequently highly troublesome pruritus.

Has cerumen a protective role in recurrent external otitis?

PURPOSE: We investigated the bactericidal activity of the cerumen in patients with recurrent otitis externa. MATERIALS AND METHODS: Cerumen samples were collected from 2 groups. Group A (n = 20) consisted of patients with recurrent otitis externa (2 or more acute otitis externa attack in the current year) and group B (n = 30) consisted of cerumen from a healthy population. We examined the bactericidal activity against the common microorganisms (Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli, Pseudomonas aeruginosa, and Enterococcus) that encounter the recurrent otitis externa. RESULTS: A significant decrease in the count of S epidermidis was observed in group A (P <.05) and B (P <.01) was observed. A comparison of decreases and increases in the percentages of microorganisms between the groups A and B showed that there was a significant difference only in the count of E coli (P

Earwax and level of paralysis.

STUDY DESIGN: Inception cohort. OBJECTIVES: The clinical impression that earwax is uncommonly frequent among spinal cord injury patients with high levels of paralysis was tested. SETTING: Veterans Administration Hospital, USA. METHODS: A cohort of 15 chronically paralyzed patients, motor complete, living as residents in a long-term care facility was offered monthly irrigations of the ears for removal of wax over a 6-month period. The number of requests was tabulated. All ears were examined once on a single day to determine point prevalence. The accumulated wax graded as absent or small, moderate or large. RESULTS: Two patients with C2 lesions, aged 37 and 52 years and paralyzed 15 and 16 years, were compared with 13 patients at C4-T6 aged 44-78 years, median 62 years, and paralyzed 2-33 years, median 24 years. Over a 6-month observation period, 10 irrigations were requested by the C2 patients and three by the C4-T6 patients. The reasons were hearing loss. Wax was found and removed, and symptoms were relieved in all instances, P&<0.001. The spot survey revealed earwax of moderate or large amounts in four of four C2 patient ears and in two of 24 C4-T6 patient ears, P=0.001. CONCLUSION: Patients with C2 tetraplegia accumulate more earwax and request its removal more often than patients with lower levels of paralysis.

In pursuit of ceruminolytic agents: a study of earwax composition.

OBJECTIVE: To assess the protein and simple sugar content of earwax in pursuit of better ceruminolytic agents. STUDY DESIGN: Collected earwax specimens were tested in several media for dissolution before being analyzed for amino acid and carbohydrate content. PATIENTS: The samples were obtained from eight random patients requiring ear plug removal. RESULTS: The amino acid composition differs considerably from hair and stratum corneum of glabrous skin. Sugar analysis revealed high levels of galactosamine and galactose. CONCLUSIONS: This analysis of proteins and carbohydrates further characterizes earwax. Future ceruminolytic agents must dissolve lipid, keratin, and a monolayer of lipid covalently bound to the epidermal cells, which encourages cellular aggregation.

Influence of human wet cerumen on the growth of common and pathogenic bacteria of the ear.

The available data on the effect of human wet cerumen on bacterial growth are not conclusive. Nevertheless it is widely accepted that cerumen has a bactericidal effect. In this study the activity of human wet cerumen on bacterial growth was assessed by applying cerumen suspensions to bacterial cultures. Bacterial counts were performed before and after application of cerumen suspensions. A total of 383 assays was carried out with 73 pools of cerumen that were tested against cultures of Staphylococcus aureus, Staphylococcus epidermidis, Corynebacterium spp., Escherichia coli, Proteus mirabilis, Pseudomonas aeruginosa and Serratia marcescens. An increase in growth occurred much more frequently than a decrease in growth in almost every microrganism tested, with the mean increase percentage being much higher than the mean decrease percentage, except in the case of S. aureus. The largest average growth increase was obtained with E. coli. The largest average decrease in bacterial growth was recorded with S. marcescens. Our study does not support the conception of a decrease in bacterial growth produced by humen wet cerumen. In vitro, the most observable effect was in fact an increase in microbial growth.