The last time he came to the clinic, his ear had been diagnosed with a middle ear infection (otitis media). He had taken two courses of antibiotics, was starting a third, and had been told in advance: if this course didn’t help, the pus would have to be drained. At that point he needed a hearing aid to hear other people talk.
This time he came back, again because of ringing in the ear (tinnitus). The symptom was the same as before, but the cause was completely different, and it took a careful examination to see it.
The first visit: the middle ear, the stapes and the skull
When we reassessed him, we found problems at several points along the path that sound travels. The outer ear had a problem, and so did the middle ear and the stapes (the stirrup bone). Even the skull, including the part involved in regulating the nervous system, was not yet in balance.
He was treated with Applied Kinesiology and functional neurology techniques, combined with an herbal decoction. The formula he took was Si Jun Zi Tang plus Er Chen Tang (四君子汤加二陈汤 / 四君子湯加二陳湯; Four Gentlemen Decoction plus Two Aged Herbs Decoction), prescribed for his constitution at that time. Other people should not take it on their own.
One week after treatment, he could hear clearly again and stopped using the hearing aid. He no longer needed the pus drained. At his follow-up visit, he rated his own overall health as improved to 8.5/10.
That was his result alone. Every person with a middle ear infection follows a different course, and the decision about antibiotics or a procedure still needs an ear, nose and throat (ENT) doctor to follow it.
The follow-up visit: the same ringing, a different cause
With a history that clear, it would be easy to assume the ringing this time came from the same place and to treat it exactly as before. Dr. Dinh Ngoc Duc (MD, MSc in Traditional Medicine) took his history again and examined each part again as if he were a new patient, including a careful look into the ear canal.
This time the cause was earwax. The wax had built up into a plug that blocked the ear canal. Because his ear had had a middle ear infection, Dr. Duc referred him to an ENT specialist to remove the earwax, and he used ear drops as the specialist prescribed. Afterward he messaged the clinic: his ear was fine, and he could hear well again, as before.
If the step of looking into the ear canal had been skipped, he might have gone through a whole new course of treatment for a lump of earwax, and the ringing would still be there.
Normal earwax, and when it causes trouble
Earwax (cerumen) is a normal secretion in the outer part of the ear canal. It keeps the skin of the ear canal from drying out and traps dust and bacteria. The skin of the ear canal moves outward very slowly, and together with jaw movement when you eat and talk, this gradually pushes the wax out. Most people don’t need to do anything about earwax at all.
Only when wax builds up and causes symptoms, or covers the eardrum so the doctor cannot examine it, is it called cerumen impaction. The 2017 clinical practice guideline of the American Academy of Otolaryngology–Head and Neck Surgery (Schwartz et al.) reports this condition in about 1 in 20 adults, and more often in older people.
People with cerumen impaction often complain of ringing in the ear, reduced hearing (especially on one side), a feeling of fullness or of the ear being plugged, and itching or discomfort in the ear canal. Some also have a reflex dry cough or mild dizziness.
The Patient History by Henderson and Tierney, a book on differential diagnosis in internal medicine that the clinic consults, lists cerumen impaction among the most common causes of conductive hearing loss in adults. The book also points out that when you see earwax in someone with ear pain, the wax needs to be removed to look behind it, because the real problem may lie behind the eardrum.
How to care for your ears at home
Don’t remove earwax yourself with sharp objects or candles. Cotton swabs, ear picks, tweezers and ear candles (ear candling) often push the wax deeper and can scratch the ear canal or damage the eardrum. The 2017 guideline mentioned above recommends against ear candling, because there is no evidence of benefit and there is a risk of harm.
At home, all you need is a soft, slightly damp cloth to wipe the outer ear and the opening of the ear canal after a shower. The inside of the ear canal doesn’t need cleaning if you have no symptoms, and don’t rinse your ears yourself with a pressure device. Ear irrigation should be left to health professionals, after they have confirmed the eardrum is intact.
Some ear drops soften earwax, but use them only when you are sure the eardrum is intact. People who have had a middle ear infection, a perforated eardrum, ear surgery or ear tubes, and people who have ear pain or discharge from the ear, should not put drops in themselves but should see a doctor first.
Hearing aids, noise-blocking earplugs and in-ear headphones all sit in the ear canal and make it harder for wax to get out. That is why people who wear hearing aids, as he did the first time, build up wax more easily. If you often use these devices, have a doctor check your ear canals regularly and keep the devices clean.
When to see a doctor soon
See a doctor the same day if you have any of these signs:
- Hearing loss that comes on suddenly, especially in one ear.
- Spinning dizziness (vertigo), nausea, unsteady walking.
- Severe ear pain, fever, pus or blood coming from the ear.
- A drooping face, or weakness on one side of the face.
- Ringing in one ear that lasts a long time, or ringing that pulses with your heartbeat.
If the ringing in your ear comes back, have a doctor look into the ear canal first.
References
- Schwartz SR, Magit AE, Rosenfeld RM, et al. Clinical practice guideline (update): earwax (cerumen impaction). Otolaryngol Head Neck Surg. 2017;156(1_suppl):S1-S29. DOI 10.1177/0194599816671491. Đính chính: DOI 10.1177/0194599817725542.
- Henderson MC, Tierney LM Jr, et al. The Patient History: An Evidence-Based Approach to Differential Diagnosis (mục nghe kém và đau tai).
