Cotton tip applicators

Cotton tip applicators (CTA) have long been used for manual cleaning of the ear despite reports of ear injuries such as eardrum perforation, inflammation of the ear canal and impaction of ear wax. A recent study assessing pediatric ear trauma found that over 260 000 children under the age of 18 were treated at US Emergency Departments for CTA-related ear injuries, and that the most common circumstance behind those injuries was manual cleaning of the ear canal.


Since it’s conception, the cotton tip applicator (CTA) (or Q-tips, as they are more commonly known) was destined to be used as a tool in the maintenance of ear hygiene. Its creator was inspired by his wife’s use of a cotton wrapped toothpick to clean their infant’s ears. After widespread adoption of the behaviour, a link was identified between the use of cotton tip applicators for ear hygiene and ear injury, including otitis externa (an inflammation of the ear canal), ear wax impaction, or perforation of the tympanic membrane (eardrum). The occurrence of these injuries led clinicians to advise against the use of CTAs inside the ear canal, and even prompted manufacturers to place warning labels on their product’s packaging. Despite this, use of CTAs in the ear canal continues to be the most common cause of accidental penetrating ear injury in the pediatric population (children 17 and under).

A study by Ameen and colleagues published in the Journal of Pediatrics sought to investigate the epidemiology of ear trauma in children relating to CTA use, and any associated trends. They obtained data from the National Electronic Injury Surveillance System (NEISS), a database organized by the US Consumer Product Safety Commission with the aim of monitoring consumer product-, sports-, and recreational activity-related injuries. Data that can be obtained through the database includes: patient demographics, the body part injured, the product(s) involved, diagnosis of injury and a case narrative. Ameen and colleagues looked at emergency department (ED) data from the period 1990-2010.

The results from a search for ear injury cases which involved only trauma or injury to the ear (impaction/infection/inflammation results were excluded) were sorted into three age groups that reflect different levels of self-care; 0-3 years (mostly parental care), 4-7 years (children doing some self-care), and 8-17 years (independent self-care). Researchers then used the case narratives to creates codes for variables, such as, person handling the CTA at the time of injury, circumstances surrounding the injury, and diagnoses (type of injury).

From their search and analyses, researchers found that approximately 263 338 children under the age of 18 were treated in US EDs for CTA-related ear injuries during this 20 year period (an annual average of 12 540 injuries per 100 000 children). A decrease in the number of injuries from the years 2001-2010 was noted. When assessing the place in which injury took place, of the 61.7% of reported injuries that documented location, 99.4% occurred at home. The average age of the children treated for CTA-related ear injuries was 6 years old. A large part of the injuries occurring in the younger subset of the population (0-7 years) occurred in males, while females accounted for the majority of CTA-related ear injuries in the subset aged 8-17 years. In assessing circumstances surrounding injury, the researchers found that among the 31.3% of reports which documented circumstances, 73.2% were associated with cleaning of the ears, and of the 60.4% of cases where the person handling the CTA was identified, the children themselves were handling the CTA in 76.9% of the cases. In terms of cleaning-specific injuries, parents were handling the CTA in a large majority of the cases involving children under the age of 4 (79.1%), but only 10.3% in the cases of children between the ages of 8 and 17. The authors reported that more than two-thirds of the injuries occurred in children under the age of 8, and that children between the ages of 8 and 17 were more likely to be diagnosed with the presence of a foreign body (swab), while those in the 0-7 years age bracket were more likely to be diagnosed with perforation of the eardrum.

In summary, the evidence from this study supports the advice that CTAs should not be used for ear hygiene, especially when the hygiene is being undertaken by the child. It is a commonly held belief that wax should be cleaned out of the ear canal, despite the fact that evidence indicates it serves a purpose, and that the body has a self-cleaning mechanism. If cleaning is necessary, safer alternatives should be sought, for instance, gentle irrigation, preferably under the supervision and care of a qualified professional.

The study has some limitations, as indicated by the authors. The first relates to the lack of details in the case narratives. The authors used the narratives to create variables for their analyses (i.e. injury circumstances; person handling CTA), and lack of data for these variables in some instances means it is not a representative sample of all CTA-related ear injuries. Another limitation is the underestimation of the total number of CTA-related ear injuries in a given year, as NEISS data only provides those cases reporting to EDs, and does not account for those presenting to another healthcare setting or those who did not receive medical care. It also does not account for more severe injury diagnoses, which may have come from specialist referrals after the initial ED diagnosis. Lastly, NEISS’ suspension of data coding for CTA-related injuries after 2010 does not allow for the authors to provide trends or analysis on more recent data. Despite these limitations, the findings from this study are quite valuable in that they highlight potential complications that arise from the use of CTAs for a purpose that has no scientific basis. Furthermore, these findings may form the basis of awareness and education campaigns that could encourage the public to seek alternative methods of ear care, a movement that the authors hope would lead to further reductions in the number of injuries relating to CTA-use.


Written By: Sara Alvarado BSc, MPH

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