ZACH: Let's start out with what is earwax? Is it really wax, is my first question?

DR. LIN: Not wax in the sense of a candle. It is a natural product that your body makes over time. It's really just a combination of dry skin that sheds off the skin of the ear canal mixed in with some oils that your body is naturally producing. So, the end result is the consistency, in some people, that resembles wax — which is where I imagine the name came from. But it's not wax that's going to burn like a candle.

ZACH: It's something that we all want to maintain, right? Because no one wants, you know, too much coming out of their ears. And, so, I don't know where it starts in our lives, but at some point, it becomes some kind of habit. Like, always clean your ears, right? And when I think of cleaning my ears, I think of cotton swabs. It's like A/B, those are connected, right? Bacon and eggs, death and taxes — that kind of thing. Not necessarily the case, though, is that correct?

DR. LIN: Well, I would agree that the most people will connect the two. And I would be curious to see the history of whether there's any advertising or what kind of influence started that association with the ear canal so much.

ZACH: Do you know why we all started doing this thing?

DR. LIN: To be honest, I don't. That might be something worth a deep dive into the history at some point.

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KATIE: We took Dr. Lin up on that, because it's a question that kept coming up. Why (and when) did we start sticking cotton swabs into our ears? From what we can tell, the story starts in 1923, when a man named Leo Gerstenzang saw his wife applying wads of cotton to the ends of toothpicks and — rumor has it — using those cotton-laden toothpicks to clean their baby's ears. If I were Leo, I know I would have been thinking that there's got to be a better method. And, in a way, there was: The cotton swab. And these swabs began being marketed for baby care a few years later. A 1923 print ad in the Pittsburgh Post-Gazette stated, “Cotton swabs can be used for the eyes, nostrils, ears, gums and many other uses.” They were marketed to adults, as well. An ad from 1956 reads, “Dad has found the ideal blotter for water in the ear.” Now, it's worth mentioning that for the ear doesn't mean inside the ear canal. And, as far as we can tell, cotton swabs have never been advertised as such. But other uses they have been advertised for include hobbies and crafts, applying makeup, cleaning nooks and crannies… [trails off] And it seems that “for the ears” and “nooks and crannies” became one in the same at some point. Most people who use cotton swabs stick them well into their ear canal, as far as they'll go sometimes. It's not how manufacturers ever meant for them to be used, of course. By the 1970s, some version of “Do not insert swab into ear canal” had appeared on the packaging. Yet many people still do it under the guise of hygiene. Which brings up another question: Do our ears even need cleaning?

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DR. LIN: As far as cleaning the ears, I certainly understand that everyone wants to feel like they're doing something productive. They feel like if they don't do anything, it's embarrassing to have wax coming out of the ears — or just feels uncomfortable. And, so, I know a lot of people get into a habit of doing something to clean their ears.

ZACH: My entire life I've been using cotton swabs to clean my ears. And, as I understand it, you're supposed to pretty much kind of brush around the ear lobes and that kind of thing, but never really go into the ear canal. Is that correct? I've been using cotton swabs wrong my entire life, you're telling me?

DR. LIN: The official recommendation is that we would like everything and anything to stay outside of the ear canal itself. Now, it's totally fine to clean around the outside of the year. We would call that the auricle, inside the folds of the ear. But the concern — and jumping to the kind of the bottom line — is that if you insert into the ear, depending on the shape or the way that you're using it, you're more likely than not pushing some wax back into the ear. And, in rare cases of something happens, someone bumps you, you go too far, it’s even possible to injure your eardrum and the bones of hearing connected to the surface of the eardrum.

ZACH: You know, you go to the dentist and you get your teeth cleaned. And you go to the optometrist and you get your eyes checked. But you don't really — and maybe I've been missing out, maybe I should be doing this — but I don't really go anywhere to have my ears checked on an annual basis or anything like that. Should we be doing that as people trying to maintain our health?

DR. LIN: 99% of people — even those that use cotton swabs — will never actually run into the issue of wax building up to such a degree where you do need to do that. So, perhaps that's why we don't make it a routine habit of getting your teeth checked or your teeth cleaned, which everyone needs. Now, certainly, there are certain risk factors for why one person might have more issues with wax. One being that if your canals are small or narrow to start with, if you've ever had ear surgery, if you have skin within the ear canal that's been disrupted from a surgical procedure, the body may not be able to push the wax out on its own as it should. Other changes that happen over our lifetime as we get older…older adults have less oil production, and so their wax becomes drier and it clumps and sticks more within the ear canal. And then, finally, some people just have…the shape of their ear canal is just curved in such a way where there's something — the hairs in the ear canal, something — is trapping and catching it and blocking it from coming out. That being said, the normal procedure, or the normal way that the body is cleaning out the ear, is that the wax is gently being pushed outwards gradually over time. So, it is completely natural and normal to occasionally see flakes of wax or feel that there is wax coming out of the ear. That's the normal response of the body.

ZACH: Our impulse is, “What is this foreign thing in our body?” But it's really not foreign. It's actually getting rid of the foreign objects…

DR. LIN: The natural process is that the wax will be pushed out of the ear canal. That begs the question, why is it there in the first place, right? There is no clear or single consensus. There are people that make very little wax and don't seem to have any issue with their ears. But the thoughts are…there are a couple of thoughts on why we make your wax in the first place. The first is that it's just natural because skin anywhere in the body has to shed. And dry skin, dead skin accumulates in the ear canal as wax. Some people feel that — when they've tested and studied, ear wax has a slightly acidic component to it — which they think might be antibacterial. And then still others just think that having wax almost acts as a filter and prevents dirt and dust from getting down and settling onto your eardrum. So, in a way, it helps keep the ear clean, the parts of the ear that are important to hearing.

ZACH: What kind of warning signs are there if you have too much? Other than the visual, of course — as far as like, “Oh, I have too much wax, I should go to a physician,” and perhaps even have a more in-depth removal of your wax.

DR. LIN: So, most people that come in with earwax problems are coming in because they are feeling like their ears are clogged or muffled in terms of their hearing, especially if water gets into the ear. And, so, — you can imagine — water in the ear causes the earwax to expand. And if it's at a point where there is enough blockage of the ear canal, that can almost feel like it seals off the ear canal. And you're listening is muffled, as if you are listening underwater. So, hearing changes is probably the most common reason that I see patients with excessive ear wax. Other people, the wax can at times start to cause irritation, pain or discomfort. You know, those are really the two main reasons.

ZACH: What are some good alternatives to cotton swabs, perhaps hydrogen peroxide or something like that?

DR. LIN: What we generally recommend as an alternative, if you want to be doing something proactive, is to use something like mineral oil or baby oil inside of the year. The idea of using the oil is that it acts as a lubricant. It softens the wax, and it prevents it from sticking or clumping. But I have to be honest, there isn't a single way that is going to be very effective at getting the wax out of the ear. You may have seen different ads on Instagram or Twitter of these devices — I saw one recently that looked like a Roto-Rooter, basically spinning in circles around the ear and kind of trying to pull the wax out that way. They all make me a little bit nervous. The honest answer is that there isn't a single safe way that you're going to get the wax out yourself. If the wax is not coming out on its own, unfortunately, that is something that may require a trip in to see your family doctor or even an ENT.

ZACH: Yeah, I've seen those remedies, as well — little mini vacuum cleaners almost. And one that really fascinates me is the ear candle. Are you familiar with this?

DR. LIN: I have never tried it myself. I have many patients that have described it to me. My understanding of how it works is that you're using a heat source — a candle — and holding it up close to the ear and basically softening — or in a way almost liquefying — the wax so that it would drain out. It seems to work for some people, but again, just the thought of applying high heat close to the ear…again, makes me very nervous.

ZACH: Right. I wouldn't try that myself. So, a lot of people will be listening to this on their earphones. Me, personally, AirPods are my favorite invention of all time. I'm on the go a lot. I love listening to things and every mobile phone, cell phone comes with earbuds — whether wired or not wired. And, so, a lot of us spend a lot of our time each day with earbuds inserted into our ear. What kind of side effect does this have as far as maybe ear wax or even hearing goes long-term?

DR. LIN: As far as the ear wax, we do know that, I’ll kind of draw a similar analogy to this, but older patients that use hearing aids — so this is kind of an extreme example of what you're asking — [but] these people are wearing their earpieces from the hearing aids, 10, 12, 14 hours a day. And, in this group, we do see that there is a higher rate of wax buildup. And so certainly having something inside the ear canal, whether it's an earbud or a hearing aid over time, does prevent the natural progression of wax from all the way exiting the ear. So, yes, whether it's because moisture or humidity gets trapped inside of the ear because of earbud use or just that there's a physical obstruction, there is, I think, a higher incidence of wax building up. Your second question regarding hearing: The answer there is that earbuds aren't necessarily more dangerous to your hearing, in terms of use. What we keep our focus on and when patients ask me this, what I really tell them is it's about the volume — no matter what source of sound you're listening to, whether it's a speaker in your in your living room, whether it's a headphone over the ear or in the ear. At the end of the day, it’s what volume is being delivered to the ear. Certainly, with something as close to the ear, if you accidentally had your volume maxed on your phone it might, in that moment, be more dangerous because the volume was delivered in a very focused way and very, very loudly. But, to that end, I know companies like Apple have taken measures there. I believe there’s a default setting that — even if you left your volume on too high — you plug in headphones or connect to your AirPods and it actually resets it down to a reasonable volume. So, it prevents such an exposure as that.

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ZACH: More with Dr. Lin after the break.

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ZACH: So, Katie, what kind of headphones do you prefer? Are you more of a inside the ear, earbud, listener? Are you more of an over-the-ear, earmuffs, headphone kind of listener?

KATIE: I kind of think I was always using earbuds. Maybe when I was really young, I think over-the-ear headphones were more common — or that's how I perceive it to be at least. But probably in college switched to earbuds. They feel like…they just fit snugly. I think it comes from when I'm running or working out, the jostling of the over-the-ear headphones is kind of annoying, I think. I mean, I'm sure they're better now, but I think that's probably when I switched.

ZACH: Yeah, I remember when I was younger, you got your Sony Walkman and you try to go to sleep listening to stuff, and you can't you can't sleep on your side because there's a headphone thing and it's just very…but earbuds — like no matter where you are, what you're doing — earbuds will fit inside your ear. And they're — like you said, running — or doing things around the house or sleeping or whatever they're just so convenient. When I got my first smartphone — I think was in college — they all come with earbud headphones now. So, ever since then I was like, “Why would I ever go back, right?” So, unless I'm doing some kind of professional editing — like on this podcast I’ll be wearing headphones. But outside of that, for personal stuff, I definitely use earbuds.

KATIE: Yeah, I'm probably the same. I think, arguably, when the first smartphones were coming out, some of the earbuds that would come with them were a little uncomfortable. But nowadays they're just much cozier, in my opinion.

ZACH: So when it comes to things in your ears, over your ears, things like that, I've seen a lot of parents recently — probably the last, I don't know, 10, 15 years — when they're bringing small children to sporting events, they have like noise canceling headphones, right? To kind of protect them from these loud noises. I mean, I remember when I was a kid, I went to a basketball game for the first time. It was so loud. It’s such an intimidating experience for your ears, like, “Am I going to go deaf now?” Because it's — there’s fireworks and loud music and things in an enclosed space — and I think like ear protection and all that really plays into talking about all these things that go inside your ear. And when you're hearing gets overwhelmed like that, it can lead to ringing and that kind of stuff. That's, you know, that's really concerning because you're like, “Is this just going to stay forever or is a temporary thing,” right? Dr. Lin goes into that and he talks about when your ears are ringing what that means. But it's like a warning sign and what steps you should take after that.

[Sound effect signaling return to interview]

DR. LIN: When your ears are ringing, that's actually an early sign. Your body's telling you [that] you had a little bit too much. The ringing of the ears is a symptom of mild irritation, even inflammation, to the nerve of hearing and the hair cells of hearing. And in movies they simulate this. When there's an explosion, something goes off, the first thing that happens is it goes quiet. And then the first thing that they bring back in is that high-pitched ringing, and ringing we call tinnitus. And that ringing is a symptom that your ears are stunned or irritated from the sound exposure. And, so, we call this an acoustic trauma. Generally, at a low dose or low exposure, this ringing goes away after 5, 10, 30 minutes. You may notice it the next morning, and then things kind of restore back to normal. But repeated and continued exposures of sound — for example, if you’re a season ticket holder to the Rockets and you did this 40 times a year over many years — that is unfortunately going to cause hearing loss. So, we do want to caution and recommend listeners to minimize that as much as possible and take precautions if that is something that you're routinely being exposed to.

ZACH: So, tinn-it-us or tin-itus, because I've never — no pun intended — never heard that out loud before. I've only read it. So how do you pronounce it?

DR. LIN: Both are accurate. Probably one is a British pronunciation, but we use both interchangeably.

ZACH: Tomayto, tomahto situation, okay. Yeah, because, there are times when there's no sound going on and you still kind of hear a little bit something and that…

DR. LIN: That's exactly what tinnitus is and, out of the people that have that type of ringing sound in their ears, about 95% are going to be associated with some degree of high frequency hearing loss. I actually tell patients that the ringing that they have is a symptom of their hearing loss. Both are, at the end of the day, likely to be signs that there has been a mild injury to the nerve of hearing. And the first recommendation if you're experiencing the ringing is to see an audiologist — have your hearing checked and just to make sure that, especially the high frequency hearing, is still in line. Or, if you're starting to have signs of an early hearing loss, to have that discussion.

ZACH: I have one last question for you. Is there any psychological study or reasoning why it feels so good to clean your ears with cotton swabs, beyond just the cleanliness? There's a certain kind of like nerve response or something…it’s just…a very good feeling washes over you when you use these — apparently in the in the improper way. So, is there any sort of reason why that people enjoy that?

DR. LIN: I can't say that I haven't done it before either, right? Absolutely, it feels great. Especially, for example, people go swimming, they get out of the water and they feel like there's just water in their ears and that that feeling is very uncomfortable. My personal feeling on that is I think a lot of us get into this habit related to that sensation of having water in the ears — whether it's after being in the pool or after being in the shower — you feel like that causes your hearing to be a little muffled. It feels like you need tug on the ears, get something out of the ears.

ZACH: Yeah.

DR. LIN: And I think that is the impulse that kind of drives this this habit to start. And once you get into the habit of it, it just becomes — for a lot of people — a habit of just like drying your hair after a shower.

ZACH: That's my habit. I get out of the shower, you know, dry off, and then here come the cotton swabs. Don't do that is what you're telling me, though.

DR. LIN: There are other options. People definitely feel like they want to be doing something proactive. And, again, the situation usually arises as people feel like they want to clean the water out of their ears after being in the pool or after a shower. There are a couple of suggestions. One — an easy one — is you can take a hair dryer, keep it on the low setting, and hold it at arm's length and just let it run for a minute or two. The warm air will help the water or moisture inside of the ear to evaporate. Other products that you may see at the pharmacy — if your goal is to dry the years after a shower — you can use alcohol drops. Just like wiping a table with alcohol, you'll notice that evaporates very quickly and that will help the moisture to evaporate. The last kind of category of products that you often see at the pharmacy are going to be peroxide based. Peroxide drops don't help as much for drying or getting wax out of the ear necessarily. It is a softener of the wax. In some cases, if you have a lot of wax, it may help the wax to fall out. But, more frequently, it just softens the wax and causes the wax to form or even move around within the ear canal. And I've had patients tell me that it actually feels worse after using [it] because the wax moved around and now it may be sitting on the eardrum and it causes a pressure and a change in hearing.

ZACH: Yeah. And speaking of removing it, I've seen that people can go in and have procedures where the ear wax is taken out of their ear. This is only for pretty extreme cases then?

DR. LIN: Typically, when we're looking to remove wax it's because the wax is covering 60, 70+ percent of the ear canal. And we suspect that it might be getting to the point where it's affecting your hearing. Now, I know there are certain clinics, even CVS or Walgreens — kind of walk-in clinics — that do offer wax cleaning. I know that a lot of family practices or even urgent cares will offer wax cleaning. And then certainly your ENT will do wax cleaning. There are some differences in techniques that you may expect at the different locations, depending on where you go. For the most part at your family practice or at an urgent care, most of the providers will be using water and an irrigation system to try to flush out the ear — and that works in about 80 to 90 percent of the cases. But if there is a really bad impaction of wax, going to a local ENT is probably your best bet. The advantage that we as ENTs have over your family doctor or your urgent care provider is that we have microscopes that allow us to see exactly what is happening — where the wax is, what the consistency of it is. And then we have different options of how to get that out. The tools that I use will range from a small suction, essentially a vacuum cleaner, to remove focal areas of wax. Or, we have different instruments or loops — or curettes — that we can use to scoop the wax out, if needed.

ZACH: So, some takeaways. Ear wax: Naturally occurring, don't be afraid of it. If you feel like you have too much, go to a primary care physician and they might refer you to an ENT or another specialist to have it medically properly removed — supervised by medical professionals…don't try this stuff you see on the internet. Use cotton swabs, but don't insert them directly into the ear. And, yeah, just protect your hearing. You know, hearing is important. We want you to listen our podcast. So, take care your hearing and there we go. So, thank you so much, Dr. Lin, for your time today.

DR. LIN: Thank you. It's been a pleasure.