On The Exciting Subject Of Earwax And Unsupported Medical Arguments

Disclaimer: I am not a doctor; even if I’m 100% right in my argument and you are 100% convinced by it, you shouldn’t listen to me over actual doctors; it’s a bad habit that might actually kill you.

With that disclaimer out of the way: Doctors are nearly completely full of shit about Q-tips, and I’m pretty sure I don’t like it. And I’m dragging you along for the ride, so strap yourself in and enjoy the ride.

For context, there are three main problems doctors have with Q-tip use in the ears; the first is that they supposedly cause earwax impaction and block the ear canal and is what this article is about. The second and third are that they can cause physical damage to the ear (by poking or scratching) or infection (by poking, scratching, or if you somehow manage to leave part of the Q-tip in there). If this becomes a series - God help us - I’ll cover the latter two, but for today the first is already sort of a lot and I’m limiting the field so we can all retain some level of sanity here.

The basic medical consensus on using cotton tipped swabs (that’s the generic term for Q-tip) to clean out your ears is pretty much just restating the following quote from this article:

Q-tips can push wax further into the ear canal, which can cause impaction, discomfort, or a rupture in the ear drum. If the wax gets pushed too far into the ear canal, it could require surgical intervention. If left untreated, long-term complications can even lead to infections or hearing loss.'

“Because of the shape of your ear canal, pushing a cotton swab into your ear will remove a small amount of wax, but push a larger amount further down the canal. Over time, this causes cerumen to build up and eventually it can dry up and totally block the ear canal,” said Dr. Lindsay Bondurant, director of the Pennsylvania Ear Institute.

A Google search of “Q-tips earwax” will provide you with hundreds of nearly identical results from pop-health sites. If you prefer something a little more authoritative, there’s this from the American Academy of Otolaryngology cerumen impaction clinical practice guidelines:

Although empirical data are quite limited, consensus opinion from clinicians is that cerumen impaction may be exacerbated by using hearing aids and cotton-tipped swabs.39 A higher incidence of cerumen has been reported in children whose ears were cleaned with cotton-tipped swabs.40

The medical community stands in lock-step solidarity on this one; using cotton tipped swabs to remove earwax does the opposite of what you want, pushing it further in and causing blockages and, to judge by the tone of the ENT doctors involved, near certain death.

Given that there’s basically no dissenters on this particular subject, you would expect that the empirical backing for this particular stance would be iron-clad. Or at least pretty good. Or that there’d be some evidence for it, at all.

You see where this is going.


There’s Basically No Evidence For This

In the guideline excerpt above, the footnote labeled 40 leads to this study, which states:

Forty one children (37%) had cerumen plugs: of these, 37 (90%) had their ears cleaned by cotton tipped swab. Altogether 79 of the 111 children (71%) had ears cleaned by cotton tipped swab, and 37 (47%) of these showed plugs, as compared with four (13%) of the remaining 32 whose ears were cleaned by other methods (flannel, finger, etc.). The difference was significant (x2 = 11.55, p<0.001). The prevalence of plugs did not vary with age.

This seems straightforward enough; kids whose ears were cleaned by cotton tipped swabs were three to four times as likely to have plugs, and that effect is strong enough that we can at least to some extent disregard the small sample size.

But an obvious objection springs to mind - what if causation swings the other way? If the mothers in this survey were more likely to use cotton tipped swabs on kids who had hyper-active earwax production, then the study authors could have their correlation/causation flipped. To their credit, they acknowledge this before saying something seemingly irrational:

Although the strong association suggests cause and effect between plugs and the use of swabs, it does not show which is which. The hypothesis that the use of cotton tipped swabs encourages formation of plugs, and not the reverse was supported by the observation of a clean meatus with plugs found deeper inside on examination by auriscope.

The bolding is mine. The study authors are saying that their hypothesis that the Q-Tips are causing the plugs and not the other way around because the meatus (the “tube” part of your ear) was clean, and the plugs were found deeper inside the ear.

This evidence doesn’t clearly do what they want it to, though. We’d expect to see a clean meatus in either case - either the swab is pushing the earwax down (and leaving a clean meatus) or the swab is cleaning out the meatus and just not scraping close enough to bottom to prevent plugs entirely. Anyone who has ever used a Q-tip on a kid can confirm, but it’s a paranoid experience - you aren’t bottoming that sucker out, for fear you’d bust their eardrum.

So we are left with essentially nothing on our first study and move to our second:

Six hundred fifty-one consecutive patients from the general pediatric practice of the Cleveland Clinic aged 2 weeks to 20 years (57% males) answered a questionnaire with their parents' help. Of the 651, 401 (62%) had used CTS during the 2 months before the study. Examiners unaware of the questionnaire results found that 46 (7%) of both right and left ear canals were at least 75% occluded by cerumen. Cerumen occlusion of at least 75% was associated with CTS use on the left side (P = .02), but not on the right side (P = .27). We conclude that cotton-tipped swab use may be associated with cerumen accumulation.

So they have statistical significance on one side, but not the other; you might wonder why. It’s good that someone is, because the study authors don’t begin to try to explain that at all. They do break things down by race:

Nonwhites had higher occlusion levels than whites. This was true for both the right (P = .001) and left (P = .05) ears

There’s that pesky left/right ear difference again. We have to pay attention to this because if we had data on differences on cotton tipped-swab use between the different racial groups, we could use this support or undercut the position that cotton-tipped swab use is causing the earwax problems and not vice-versa. But here again the authors are supremely incurious; they simply don’t gather or share that data.

People reading closely might notice that the difference here between the ears implies there’s a difference in terms of which ear gets cleaned by which hand; a right-handed person would start on their right ear, and do more thorough work due to using their dominant hand and not being tired of the task. The fact that the right ear was more likely to be unblocked here seems to suggest that the swabs are helping, not hurting, the problem. At least, that is, until you consider that these are children between the ages of 2 weeks and 20 years; it suddenly matters a lot whether or not Mom is the one doing the cleaning, in which case the implications of the handedness would flip.

I only found one other study on the subject, and it failed to find an association. So after all this we are left nothing; there’s no study I can find, anywhere, which comes close to providing anything resembling strong evidence that cleaning your ears with cotton tipped swabs also blocks them.


Why does this matter enough to write about?

I want to be clear that you should generally be listening to your doctor over random people on the internet - I even think that in this case, even though I’m usually pretty sure I’m right about stuff like this.

Modern medicine is amazing, and I have two family members who both are alive today after beating forms of cancer that would have been a near-definite death sentence a couple decades ago. It’s amazing what doctors and medical researchers do. But that same general excellence is exactly why I’m very confused about how something like this is possible.

As I mentioned before, it’s reasonable to expect there’s solid evidence behind a stance universally held by doctors, and it’s weird that it’s not the case here. Every doctor I can find talking about this anywhere is repeating with the same absolute assuredness this claim for which there’s absolutely no evidence.

In some ways, I’m tempted to still trust them on this; the accumulated anecdotal belief of thousands of ear, nose and throat physicians must mean something, after all, But that knife cuts both ways - ear injuries and disorders are relatively rare things for most of us, but for someone who specializes in treating them they are a constant to the point of seeming universal.

Where most of our experience with cotton tipped swabs and the cleaning of ears is that we’ve tried it and experienced no problems, pretty much every person who answers “yes” when an ENT asks them if they use Q-tips is also, by merit of talking to an ENT, experiencing other problems. This introduces a chance to build a bias for the ENT that a normal person just doesn’t have.

This bias is true even before we discuss perverse incentives, or rewards that encourage behavior we don’t want. The two studies I listed provided data that proved absolutely nothing, but both made strong conclusions regarding the subject they spoke on using data that didn’t support their positions. Why? I won’t make an accusation against men I’ve never met when it might just be an unconscious mistake, but I can’t ignore the idea that getting published is a strong motivator, and null hypothesis papers just don’t get published as often. The data in papers like this is rarely if ever faked or wrong; it’s the representation of the data and the conclusions drawn that get messed with, precisely because doing so lets you come to a conclusion you like better, or a conclusion that lets you get your work in front of people where it would otherwise be ignored.

I picked cotton tipped swabs and earwax for this because it doesn’t really matter that much; it’s doesn’t have the implications of something like diet, which if we get it wrong (and we have) would become our biggest health crisis (and it has). So while it’s a good idea to trust your doctor (because he’s an expert in a way you aren’t) it’s also a bad idea for everyone to trust them absolutely (because you are less likely to question an expert, and more likely to believe them even when they are wrong).

So read some medical papers; write some articles, ask some hard questions. Make an incentive to authors of papers like this to justify the conclusions they draw with the data they gather, even on a subject like earwax, and one day we may all have a future in which we can clean our ears in peace.