Wednesday, April 30, 2014

Bad news

You know that feeling when your doctor says something like, "Please sit down, I have some bad news we need to discuss."

You know how your vision gets a little fuzzy, your ears feel this strange pressure with a humming vibrato in the background, your knees get shaky, and you want to vomit?

I know you know it.

You were already feeling pretty anxious driving in for the appointment. The waiting room didn't help. You jumped to the worse possible conclusion. It's bad, really bad. 

Receiving bad news is tremendously difficult. It's impossible to listen, even harder to understand.

Well, I have something to tell you.

It's no fun for the doctor either.

Granted, the implications are less personal, less life-altering. But needless to say,  I, your doctor, lay in bed awake last night at 3am thinking about you. Wondering how best to present the information in such a way that is listenable without being watered-down, in a manner that offers support and reassurance without being overly optimistic, in words that are honest without being hurtful.





I hate being the bearer of bad news.

And I really want to get it right. But I don't always.

I don't want to tell you that your pregnancy isn't viable.
That you have diabetes.
That you need an operation.
I definitely don't want to be the one to tell you there might be something wrong with your beautiful baby.
That it may be serious. 
I hate telling you you have cancer.
Or that the cancer has spread.
Or come back.
I would rather not tell you that your heart isn't pumping like it should be.
That your toe needs to be amputated.
That your mind is going.

I tell you all this not because I want your sympathy-- after all, you are the one receiving the news. It's your body, your health, your illness. The journey will be yours to bear.

I just want you to know-- um, well-- I just want you to know that I care.

Tuesday, April 8, 2014

The Meaning of Ear Wax

Poor earwax.
Yes, this came out of my 3-year-old's ear.

He is forever being talked about, dug out, probed at, messed with, dripped on, picked at and judged.

We think he's dirty, crusty, gross.

We want him out.

Out of our own ears. Our partner's ears. Our kids' ears.

He is not a hero.
In fact, though we all have some amount of earwax, studies show that around 5% of adults, 10% of children, up to 57% of older patients in nursing homes, and 36% of patients with mental retardation complain of earwax problems. Of those, about 4% consult a primary care physician for help with dealing with their ear wax-- and that translates to millions and millions of visits to the doctor every year.

What is ear wax?
Our ear canal is a literal cul-de-sac.  On the normal highways, byways, and side streets of our skin (think face, arms, legs, even between your toes), the stratum corneum-- the outermost layer of our skin, composed mostly of flat dead cells filled with keratin-- slough off with physical erosion.

In other words, we run around, we shower, and we shed.

But the unfortunate reality about life in a cul-de-sac is that the dead cells have nowhere to go. No job to serve and not much to do but to just hang out.

Enter Captain Cerumen (aka earwax), that very villain you have been acculturated to abhor!

He is a hero!  (Well, sometimes).

This unlikely hero is specially designed to help us shed our ear canal's stratum corneum. He is a mixture of oily fats (like cholesterol), proteins, glandular secretions from hair cells and other types of technical "gunk".

There are two main types of ear wax: wet and dry. Wet wax, which is brown and sticky, has a higher concentration of fat and pigment. Dry wax, more grey-tan and brittle, has less fat. There are ethnic differences too: wet wax tends to be most frequent in Whites and African Americans, dry  in Asians and Native Americans. Kiddos tend to have wetter wax (easier to break up than adults)-- thank goodness for those of us trying to get that wax out!

In addition to helping abrade the canal, Captain Cerumen cleans and lubricates the ear canal. Some scientists have theorized that wax is actually antibacterial, though studies have shown lots of different types of bacteria growing in wax, so how effective it is in protecting us against bacterial and viral illness is controversial.

Earwax isn't inherently problematic
If earwax does it's various jobs, it isn't actually problematic. After all, we all have some! It's when earwax gets impacted (in other words, stuck deep inside the ear canal) that people complain of problems: itchiness, pain, hearing loss, ringing, dizziness.

How does earwax get impacted?
As in many things in life, genes play a big role; our behaviors can exacerbate the issue. The same can be said for dental cavities, weight, and even perfect skin. Some of us happen to be lucky to have big open ear canals and soft wet wax, just like some of us were born with teeth of steel, skinniness we couldn't fatten up if we wanted to, and smooth, unblemished faces.

You have poor grounds for bragging rights just because your ear canals are clean (and your partner's aren't). You are mostly just lucky!

In the case of impacted earwax:
  • Some people just have biologically small or twisted ear canals (yes, blame your mother). 
  • Some people just have dryer thicker, more keratinous (and less waxy) wax (this time, maybe, blame your father).
  • Some people stuff the wax in their with cotton swabs (aka qtips)-- This is why the doctor is always telling you not to put qtips in your ear. Not only because you could bust your eardrum with one (you can, but that's rare), but more because you think you are pulling ear wax out, and mostly you are probably stuffing it in further, particularly if you have that dry thick stuff

People do all kinds of strange things to get rid of their earwax.
 Here are a few of my favorites:

Chinese ear picks: Cute and very commonly used, particularly by Asian mamas to dig their kiddos' earwax out; may be dangerous in the wrong hands, but plenty of (particularly Asian) mamas swear by them (and are pretty skilled at these little buggers). Here's another example.

Ear candling: A little weird, right? This method has lots of believers (something to do with creating negative pressure, vacuum, blah blah blah) without much data, studies show it's as effective as placebo and may be dangerous. Careful!

Q tips: I am the biggest hypocrite doctor on the planet, advising my patients not to use, but oh, qtips feel so good. . .it's hard to resist these useful little guys after a long hot shower

Hydrogen peroxide: This is my hubby's favorite. He loves the bubbling sound in his ear. . .

What actually works?

Doing nothing: Most people don't actually need to do anything to their earwax. Unless it's literally causing you problems (pain, itchiness, hearing problems, etc), leave it alone. Having earwax doesn't mean you are dirty or unhygienic. It's normal and healthy! And check this out: even for those who presented to the doctor with problematic earwax, a study showed complete resolution in 5% of patients and moderate resolution in 25% after a few days of doing absolutely nothing. Take home: if you procrastinate, it may just resolve itself. Our body is powerful!

But. . .for those of you who feel compelled to do something about your earwax, there are few studies actually comparing what works best.

Manual removal (i.e. scoop it out): Manual removal refers to literally having someone dig out your ear wax. It should be distinguished from home tools like q-tips and Chinese ear picks; safe manual removal should be done by someone who can visualize your eardrum (i.e. not yourself) and who actually knows what he/she is doing so as not to cause more problems. It also requires a "cooperative patient" (i.e. not a tantruming, squirming, screaming child). I do this with some frequency in my office (especially if I am trying to evaluate a child for an ear infection and cannot see his/her eardrum);  my son's pediatrician has done it for my son (for the same reasons), and otolaryngologists (ears nose and throat docs) are definitely qualified to do this, particularly for someone with a complex ear history. No one know if this is a better way than the others listed below, but it's quick, safe if done by someone who knows their anatomy, and usually not terribly uncomfortable. Also, it avoids the use of moisture, which may be associated with increase risk of infection in certain cases.

Ceruminolytics (i.e. soften it/break it up): "Cerumen", as you know, means wax, and "Lytic" means literally "break up". These cerumnolytics include all those products you see in the "ear section" at the drug store, including Debrox, Cerumal, and Earax, as well as home remedies like hydrogen peroxide, mineral oils and olive oils. Most ceruminolytics are thought to help make wax softer and, well, more waxy than it may be naturally.

There are three types: oil-based, water-based, and non-oil non-water based. There are a few small studies comparing different types, and most studies are pretty equivocal (in other words, they are all the same). Buy the cheaper one. Or the one you like the most. I have found that individuals (including myself) have super strong opinions about what actually works. Probably whichever type you use, the longer you use it (i.e. for several days in a row) is the most important factor in how successful you are.

Just a note: my favorite ceruminolytic is olive oil. It's cheap, easy, you already have some at home (or you better, because it's one of the best oils to be cooking with), it's has minimal side effects, and it works pretty well. Try it! Just a few drops (with a dropper or a small syringe) in each ear.

Irrigation (i.e. spray it out): Irrigation, also, should be done by someone with some experience. Though you can certainly try this at home, the tools we have in the office (fancy water bottles with specially designed tips) are probably more effective and safer. There are a variety of products on the market designed to limit trauma to the ear and maximize effectiveness. My medical assistant is a super professional with the ear irrigator and can clear almost anyone with enough time to hang in there with her. (I've been trying to get my husband to see her for years). It's considered effective and safe, though anyone with a known ruptured eardrum should stay away. One study found it worked alone 70% of the time. Irrigation should NOT be done in someone with ear tubes or with a questionable ruptured ear drum. It has been associated with a low risk of infection of the ear canal.

Ceruminolytics + irrigation: If irrigation works about 70% of the time, then irrigation after a course of ceruminolytics is thought to increase the probability of success to about 97%. Putting in some lytic about 15-30 minutes before irrigation has been shown to be more successful than doing it immediately and not any better than in the days leading up. So, I might suggest that at the start of your visit, ask the medical assistant to instill a ceruminolytic of your choosing. You can meet with your primary care provider for 15-20 minutes, and then finish up with an irrigation. Walk out of the office feeling like a new guy/gal. Voila!


In truth, people have an unbelievable attachment to their earwax. Or perhaps the proper term is detachment. They grant earwax a ton of negative attention and more meaning than it merits without appreciating it for its inherent utility. And everyone always want to talk about it (comes up in my office at least 3 or 4 times a day)!

Most of you should just LOVE your earwax-- after all, it serves a good purpose. Plus, there is no real point in having spick and span ear canals. Earwaxlessness=overrated.

Those of you with issues, though, consider something cheap and easy (e.g. olive oil) or go see your primary care provider and ask for a washout. The visit may also be a good opportunity to talk about your weight, your mood, or your blood pressure. While that ceruminolytic is soaking in. . .

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