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Cotton buds


Every now and then, an article comes along that reminds me that some of the old wives’ tales are true. This is one of them…

My mother (not really an old wife) always used to tell me to put nothing in my ears that was smaller than my elbow. If you read this trawl of the National Electronic Injury Surveillance System, you will see why…

Ameen ZS, Chounthirath T, Smith GA, Jatana KR. Pediatric Cotton-Tip Applicator-Related Ear Injury Treated in United States Emergency Departments, 1990-2010. The Journal of Pediatrics. 2017 May 1.

Over a twenty-year period (1990 to 2010), they found over a quarter of a million (!) cotton-tip applicator (CTA) visits. This amounted to 17.6 injuries per 100,000 children. What is fascinating to me is that the greatest number of these (40.2%) took place in children under three years of age. My children are very curious, but it would seem that a parent’s quest for clean ears might be more to blame.

Cerumen, or earwax, is made from desquamated cells from the stratum corneum of both the deep and superficial auditory canal. These old corneocytes then mix with glandular secretions from sebaceous and ceruminous glands to form earwax. The two different phenotypes of wax – wet and dry – have differing levels of squalene and cholesterol. The wet stuff is dark brown and sticky and contains about 50% lipid. Dry cerumen is flaky and beige and only contains about 20%. A single gene on chromosome 16 seems to encode the type of wax produced.

So, what is the point of ear wax? Other than the removal of flaking cells, it acts to clean and lubricate the external auditory canal. There is little evidence that it is part of the host’s immune defence system. Given that the tiny little hairs in the outer third waft cerumen crumbs out it is a wonder that we need cotton buds.

Leo Gerstenzang, founder of Baby Gays (which were renamed Q-tips© in 1926), is cited as the first to come up with the idea. The apocryphal tale is that he saw his wife wrapping wads of cotton around the end of a toothpick and had a lightbulb moment. In case you are wondering, the Q stands for ‘Quality’.

The study data that we are looking at showed that the main problems caused were retained foreign body, tympanic membrane (TM) perforation and soft tissue injuries. Whilst older children were more likely to get a bit of cotton top stuck in their ears, the younger ones tended to present with a TM perforation.

Parents might think putting a cotton bud in the ear is unlikely to cause harm, but several serious consequences have been reported, including ossicular disruption, hearing loss or the development of a perilymphatic fistula.

Ossicular disruption – poking too hard can dislocate those tiniest of bones.

Perilymphatic fistula – a hole in the round window causes a leak in fluid between the inner and middle ear leading to dizziness, hearing loss and ataxia

Cotton tip applicators should only be used for art and craft projects. The bottom line is, the old wives were right – nothing bigger than your elbow. And next time you are in Japan, don’t go to a mimikaki salon  (thanks, Petria, for the link).


Ameen ZS, Chounthirath T, Smith GA, Jatana KR. Pediatric Cotton-Tip Applicator-Related Ear Injury Treated in United States Emergency Departments, 1990-2010. The Journal of Pediatrics. 2017 May 1.

Foreign Bodies in the Head and Neck – Pediatric Emergency Medicine Playbook by Tim Horeczko

Guest JF, Greener MJ, Robinson AC, Smith AF. Impacted cerumen: composition, production, epidemiology and management. QJM. 2004 Aug 1;97(8):477-88.

Kumar D. Association between use of cotton tipped swabs and cerumen plugs. British medical journal (Clinical research ed.). 1983 Nov 26;287(6405):1628.



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5 thoughts on “Cotton buds”

  1. Wax is completely normal and healthy (as above with Dr Levi). Excessive wax is often a result of cotton tips. Yes wax can be a problem, if one has jammed the wax, or is excessive. And, yes water can become trapped. Wax softeners and a gentle micro ear suction/clean can be the answer. Tissue spears are soft and hence cannot or, rarely cause any problems. Q-tips are abrasive.

  2. What about the Johnson & Johnson cotton buds specifically marketed for babies? I’m talking about those very large bulky ones that have a bolster preventing deeper insertion??

  3. Understood. Of course some wax is normal. is there a case for ever having too much wax?. ie. I have been taught that water and moisture can get ‘trapped’ behind large amounts of wax and this creates a moist environment for Otitis externa…. is that right? I am a child health nurse working in indigenous communities….. what is the advice on using ’tissue spears’ to gently clean the ears? After a bath or shower when the wax is as moist as possible? I am presuming that nothing bigger than your elbow also means ’tissue spears’ as well?

  4. There’s no better alternative to normal. Earwax is produced in outer half of ear canal. The deeper half of ear canal is skin on bone, where nothing should interfere with drum vibration. Ear canal skin migrates outward at the rate of 42 – 205 μm/day, taking wax out with it. Q-tips push wax into the medial canal where wax shouldn’t be. Ear wax is normal, healthy, bacteriostatic, protective and normal. Qtips are not. Qtips are good for jamming wax into deep ear canal against the drums. The ear is a self cleaning system. Our cultural fascination with ear wax can be unhealthy.

  5. Thanks for the post Andy, but I have one beef with current paediatric advice to not put anything in there… We don’t provide parents with a viable alternative. Those wax dissolving drops seem highly ineffective from anecdotal reports (I.e. my husband) and given there’s often 12 month or more waiting lists for ENT clinics for more serious problems, referring for ear toilet is not realistic. Its one thing for us to wag our fingers as all knowing specialists, but what should parents do instead? If we don’t offer a solution of course they’ll look for alternatives.