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© 2016 Nigerian Journal of Surgical Research | Published by Wolters Kluwer - Medknow© 2016 Nigerian Journal of Surgical Research | Published by Wolters Kluwer - Medknow
43
ABSTRACT
Background: The use of cotton bud for self‑ear cleaning is a common practice among many people despite its attendant
ill‑effects. This study examined the prevalence, attitude toward the use of cotton buds, and reasons for the use of cotton buds
and problems or ill‑effects associated with its use among medical doctors working at Aminu Kano Teaching Hospital.
Materials and Methods: A descriptive cross‑sectional study was carried out among a randomly selected sample of 130 medical
doctors working in Aminu Kano Teaching Hospital spread across several departments in the hospital using a self‑administered
semi‑structured questionnaire. Data were analyzed using MINITAB statistical software and the results summarized using measures
of central tendency while Chi‑square test was used to assess for associations between categorical variables.
Results: The respondents’ age ranged from 25 to 55 years with a mean age of 33.6 ± 5.4 years. Most of the respondents were
males (68.0%) The prevalence of cotton bud use was found to be 76.3% and for many, the frequency of use of cotton buds was
once daily, and both ears were frequently cleaned. A common problem encountered with cotton bud use was retention of the
bud as a foreign body. There was an association between owning a cotton bud and using it (χ2 = 38.317, P = 0.001). There was
also a signicant association between the use of cotton buds and the department where the respondent works (χ2 = 19.28,
P = 0.0001).
Conclusion: The use of cotton buds for self‑ear cleaning is surprisingly prevalent among medical doctors working at Aminu Kano
Teaching Hospital. There is a need for health education and promotion strategies for health workers in the hospital community
that ear cleaning is best done by trained personnel.
Key words: Complications, cotton bud, prevalence, self‑ear cleaning
Prevalence and Attitude of Self‑ear Cleaning with Cotton
Bud among Doctors at Aminu Kano Teaching Hospital,
Northwestern Nigeria
Mukhtar Gadanya, Sanusi Abubakar, Abdulazeez Ahmed1, Amina Zangina Maje2
Departments of Community Medicine and 1Otorhinolaryngology, College of Health Sciences, Bayero University/Aminu Kano
Teaching Hospital, 2Department of Community Medicine, Faculty of Clinical Sciences, College of Health Sciences, Bayero
University/Aminu Kano Teaching Hospital, Kano, Nigeria
INTRODUCTION
Anecdotally among the lay public, it is believed
that the ear needs to be cleaned frequently to
rid it of dirt in the form of ear wax. This is usually
achieved by the insertion of objects into one’s own
ears most often with Q-tips also known as cotton buds.
Ear wax or cerumen auris is a mixture of ceruminous
gland secretions, squames of epithelium, dust, and
other foreign debris.[1] It serves to protect, clean, and
lubricate the skin of the ear canal.[2] Furthermore, the
ear canal has a “self-cleaning” mechanism for ear wax,
aided by jaw movement, “a conveyor belt” phenomenon
of epithelial migration from the drumhead toward the
external auditory meatus until it akes off. There is a
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DOI:
10.4103/1595-1103.194215
Address for correspondence: Dr. Abdulazeez Ahmed,
Department of Otorhinolaryngology, College of Health Sciences, Bayero University/
Aminu Kano Teaching Hospital, Kano, Nigeria.
E‑mail: drahmedzizo@yahoo.com
How to cite this article: Gadanya M, Abubakar S, Ahmed A, Maje AZ.
Prevalence and attitude of self-ear cleaning with cotton bud among doctors
at aminu Kano teaching hospital, Northwestern Nigeria. Niger J Surg Res
2016;17:43-7.
This is an open access article distributed under the terms of the Creative
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For reprints contact: reprints@medknow.com
Original Article
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Gadanya, et al.: Prevalence, attitude toward, and associated practices of self‑ear cleaning with cotton bud among doctors
Nigerian Journal of Surgical Research
Jul-Dec 16 Issue 2 / Vol 17
44
growing body of evidence that inadvertent and frequent
use of cotton buds is associated with some ear diseases
such as wax impaction, ear infection, facial nerve palsy,
dizziness, perforation of the ear drum, perilymphatic
stula, trauma to the ear canal, and deafness.[3-8]
The most common object used for self-ear
cleaning by majority of the population is the cotton
bud. In a survey involving 239 responders in Southeast
England,[9] 68% admitted to using cotton buds in their
ears while in Kaduna and Osun states in Nigeria, 90%
and 93.4% of respondents respectively used cotton
bud for self-ear cleaning.[7,10] Cotton buds consist of
small pad of cotton wrapped around one or both ends
of a short rod usually made of either wood, rolled paper,
or plastic.[10] The Cotton bud was said to have been
developed in 1923 by Leo Gerstenzang to facilitate
cleaning of his baby’s ear.[11] Medical concerns over
the use of cotton buds and consequent complications
were rst reported in 1972, with reports of tympanic
membrane perforation, otitis externa, and cerumen
impaction.[3,12,13] Nowadays, cotton bud‑related injuries
have become a common reason for attendances at
ear, nose, and throat clinics.[14] In a study, from the
United States cotton-buds were associated with 75%
of cerumen occlusion on the left side, but not on the
right side. More so, cotton bud-induced injury was
reported to be common.[5,14]
Awareness of cotton bud-related complications is
an important public health problem. Whereas trends
in cotton‑bud usage in Nigeria have been variously
studied, they have mostly focused on patients and
health workers.[7,15-18] One study also looked at educated
cohorts from a population-based survey[10] and the
prevalence in these reported studies have all been
quite high. The use of cotton bud for cleaning the ears is
quite popular and practiced by both literate and illiterate
individuals with the general belief that the practice is
“harmless” and/or in some instances believed to be
“benecial,”[19] this belief is surprisingly held even among
healthcare professionals.[18]
However, the use of cotton buds among medical
doctors, in particular, have been poorly researched and
because they are expected to give medical advice on
cotton-bud use. It is important to assess the attitudes
and practices of ear self-cleaning with cotton buds
among medical doctors. This study assessed the
prevalence, attitude toward, and associated practices
of self-ear cleaning with cotton bud among doctors at
our institution.
MATERIALS AND METHODS
This was a cross-sectional descriptive study among
medical doctors from different specialized departments
in Aminu Kano Teaching Hospital. The hospital has a
total staff strength of 1443 (all categories of healthcare
workers), out of which 865 are senior staff and 643 are
junior staff.
The calculated minimum sample size of doctors
required for the study was arrived at using the Fisher’s
formula[20] which gave an estimated sample size of
123. To account for nonresponse, approximately
10% of the calculated number was added to the
estimated sample to give a total of 130 respondents.
Using a multistage sampling technique in the first
stage, 5 out of the 16 departments were selected by a
one-time ballot, thereafter 130 validated semi-structured
self-administered questionnaires were distributed
among the 5 selected departments with a probability
proportional to the population size of doctors in each
of the 5 selected departments. For inclusion, members
of the department who were health workers and adults
were included whereas nondepartmental members and
clerical staff were excluded from this study.
Ethical statement
Ethical approval for this research was granted by
the Health Research and Ethics Committee of Aminu
Kano Teaching Hospital and the informed consent of all
respondents before administration of the questionnaires.
This study conformed to the Code of Ethics of the World
Medical Association 2013 (Declaration of Helsinki).
Data analysis
The collected data were entered into a
Microsoft Excel spreadsheet and analyzed using
MINITAB (statistical software version 12 – MINITAB Inc.,
Pennsylvania, USA). The obtained result was presented
in the form of tables and charts using Microsoft Word
and Microsoft Excel, respectively. Quantitative data
were summarized using range, mean and standard
deviation. Categorical data were summarized using
frequencies and percentage. The Chi-square test of
statistical signicance was used to determine signicant
associations between categorical variables. P ≤ 0.05
was considered statistically signicant.
RESULTS
Socio‑demographic characteristic of respondents
A response rate of 90.8% was obtained in this study.
The ages of the respondents ranged from 25 to 55 years
with a mean age of 33.6 ± 5.4 years. Majority (68.0%) of
the respondents were males while (32.0%) are females,
giving a male:female ratio of 2.1:1.
Prevalence
The prevalence of cotton bud usage for self-ear
cleaning was 76.3%, among the respondents [Tables 1-4
and Figure 1].
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45
Nigerian Journal of Surgical Research
Jul-Dec 16 Issue 2 / Vol 17
DISCUSSION
Following this survey, it was evident that self-ear
cleaning with the cotton bud is a common practice among
physicians working at our institution, with a prevalence
of 76.3%. Moreover, most of the respondents were
long‑term habitual users; most have been using cotton
buds to clean their ears for well over 10 years. The
most common ill-effect noted was accidental retention
of cotton bud in the ear canal which commonly presents
as a complaint of a foreign body in the ear.
The prevalence from our survey (76.3%) was
less than the values reported in Sokoto (91.2%)[21] and
Osun (93.4%)[10] states, respectively. The relatively
low prevalence in this study may be explained by the
population surveyed. Moreover, it will be logical to
presume that the prevalence from this study should
have been much less considering the fact that our
respondents are health professionals. However,
a slightly higher prevalence 115 (81.6%) was also
reported from Jos among a near similar cohort of
health professionals (Intern Doctors, Nurses, and
Resident Doctors).[18] We hypothesize that perhaps
the knowledge of the ill-effects of cotton bud usage is
lacking, not only just among the educated populace[10]
but also among health professionals as well.
Furthermore, another study[12] recorded a lower
prevalence (53%) than that seen in this study; this
Table 1: Distribution of respondents within the hospital
Variable Frequency (%)
Grade
House ofcer 15 (12.7)
Medical ofcer 12 (10.2)
Registrar 82 (69.5)
Consultant 9 (7.6)
Departments
Family medicine 20 (17)
Paediatrics 26 (22)
ENT 7 (5.9)
O and G 25 (21.2)
Internal medicine 40 (33.9)
ENT: Ear, nose and throat, O and G: Obstetrics and gynaecology
Table 2: Attitudes of doctors towards using cotton buds
Variables Frequency (%)
Attitude towards ear cleaning with cotton bud
Users of cotton bud 53 (44.9)
None users of cotton bud 65 (55.1)
Reasons for self‑ear cleaning (n=53)
Hygiene 29 (54.7)
Ear wax removal 15 (28.3)
Itchiness 2 (3.8)
Others* 7 (13.2)
Reasons for none self‑ear cleaning (n=65)
Wax impaction 20 (30.8)
Trauma 14 (21.5)
Infection 14 (21.5)
Foreign body 8 (12.3)
Others* 9 (13.9)
*ENT doctors discourage so, not safe, not necessary. ENT: Ear, nose and throat
Table 3: Practices associated with the use of cotton buds
Variable Frequency (%)
Use cotton bud for self‑ear cleaning
Yes 90 (76.3)
No 28 (23.7)
Duration of use of cotton bud (years)
>10 47 (52.2)
<10 43 (47.8)
Frequency of using cotton bud for ear
cleansing
Use cotton buds occasionally 80 (88.9)
Use it daily 8 (8.9)
Use twice daily 1 (1.1)
Use more than twice daily 1 (1.1)
Ear frequently cleaned with cotton bud
Clean both ears equally 82 (91)
Clean their right ears more 6 (7)
Clean their left ear 2 (2)
Ownership of cotton buds
Own cotton buds 68 (57.6)
Did not own cotton bud 50 (42.4)
The relationship between ownership of cotton bud and cotton bud use by the respondents
also revealed a statistically signicant association (χ2=38.317; df=1; P<0.001)
Table 4: Association between departments and cotton
bud use
Departments†Use cotton
bud (%)
Do not use
cotton bud (%)
Total (%)
ENT doctors 1 (12.5) 7 (87.5) 8 (6.8)
Non‑ENT
doctors
89 (80.9) 21 (19.1) 110 (93.2)
Total 90 (76.3) 28 (23.7) 118 (100.0)
†The respondents were divided into two broad departments; ENT department
5.9% (n=7) and non‑ENT 94.1% (n=111). The non‑ENT departments included medicine
33.9% (n=40), O and G 21.2% (n=25), pediatrics 22% (n=26), family medicine
17% (n=20). χ2=19.28, df=1, P=<0.0001.
48
29
2
10
23
27
0
5
10
15
20
25
30
35
40
45
50
Retained as
foreign body
Trauma to
the ear
Tinnitus Discharge Wax
impaction
Others
Number of respondents
Figure 1: Ill-effects experienced following the use of cotton
buds in the ear
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Gadanya, et al.: Prevalence, attitude toward, and associated practices of self‑ear cleaning with cotton bud among doctors
Nigerian Journal of Surgical Research
Jul-Dec 16 Issue 2 / Vol 17
46
may be due to a high dropout rate despite the large
sample size for the survey (325 respondents). In this
study, more than half of the respondents have been
using cotton bud for over 10 years, and perhaps this
long duration predates this habitual use to a very young
age. This is quite possible, since the average age of our
respondents was 34 ± 5 years, and expectedly family
influence[19] from young age to adulthood cannot be
ruled out. In a study,[10] mean age at commencement
of self-ear cleaning was reported to be 7.6 years
reenforcing the importance of conditioning during
childhood as an important factor in the development of
the habit. This is also in keeping with the study done
in Kaduna[7] where about one-third of the respondents
reported that they had practiced the habit of self-ear
cleaning with cotton bud for over a 10 years duration.
Both ears are frequently cleaned as reported by the
respondents; this accounts for 91% of the responses
while a few of the respondents clean either the right
or the left ears. This is corroborated by previous
studies[7,21,22] where majority of their respondents, also
cleaned both ears. It is perhaps unusual, for one to pick
up cotton bud to clean only one ear while leaving the
other. This may explain the very low frequency recorded
in this study for cleaning only one ear. The choice and/
or preference for which ear to be cleaned also depends
on the otological reason why the ear was tampered with
in the rst instance, for example, persons with otitis
externa in one ear, this will then determine cleaning of
the affected ear only.
Although the use of cotton bud is very common,
majority (55.1%) of the respondents reported that
cleaning the ear with cotton bud is not a good practice.
However, in another study,[10] 24.8% of the respondents
in that study think it is benecial to use cotton buds,
while 74.2% think otherwise. However, despite these
responses, this did not correlate with the level of cotton
bud usage found in that study. Interestingly, in this study,
those respondents who said that self-ear cleaning with
cotton bud is “beneficial,” thought it was beneficial
for hygienic purposes (54.7%) and these were in the
majority followed by wax removal purposes and then
for remedying an itching episode. Other respondents
feel that using cotton bud had become a habit, partly
because it is convenient and easy to use. Recent
studies have also documented this same feeling in
other respondents who reported that it is part of their
normal/routine habit on daily basis and is good for ear
cleaning.[19,23] However, some of the respondents think
it is harmful to use cotton buds for self-ear cleaning,
and they expressed how they think this is so, while
some think it is harmful because their colleagues in
Otolaryngology discourage such acts.
There is a general belief in our society that there is
nothing wrong with using cotton buds, and this worsens
the habit of using cotton buds simply to alleviate
symptoms such as itching, removal of dirt and perhaps
even with claims of perceived benefits.[7] Itchy ears
were the commonest reason reported by a study,[7] as
well as itching from neurodermatitis and otitis externa
of the ear canal by other studies.[6,24] While earwax was
the predominant reason for using cotton buds reported
from other studies.[23,25]
The ill-effects of cotton bud use include retention as
a foreign body in the external ear canal (40.7%) followed
by trauma (24.6%) to the ear canal. Others include
tinnitus, discharge, wax impaction, pain, deafness, and
fungal infection notably otomycosis. Similar reports
of these complications have also been reported by
several other studies.[22,24] Conversely, during a recent
study (22.5%) of the respondents admitted to having
had any complications following the use of cotton
buds.[19]
There is a signicant statistical association between
the department where the respondents are working and
cotton bud use. Another association also indicated
that owning a cotton bud was strongly associated
with its use. This underscores the need for raising
awareness within the hospital community, especially
during activities organized to mark the World Hearing
Day, Medical students annual Health Week to mention
but a few.
It will be erroneous to assume from the above
narrative that cotton bud use is always harmful to
the ear, in fact, under professional guidance, it could
serve as a drug delivery agent in the ear canal. This
therapeutic value is well exemplied by a study that
compared patient’s self-medication with clotrimazole
antimycotic solution used on Q-tips with physician–
inserted ear wicks; in terms of safety, efficacy, and
patient satisfaction. The authors then theorized that
self-medication with antimycotic solution on Q-tips gives
more patient satisfaction and less rate of otomycosis
recurrence.[26]
This survey is not without limitations; the major
limitation was that it is a self-reported behavior of
current and previous practices (i.e., use of cotton bud)
which can be easily inuenced by social desirability and
recall bias. Further studies will be needed to assess
the prevalence of cotton bud use among other health
professionals within the hospital so as to have a better
picture of the problem and to help in the planning of a
more comprehensive intervention.
CONCLUSION
The outcome of this study shows that there is a
high prevalence of cotton bud use for self-ear cleaning
at Aminu Kano Teaching Hospital. This finding has
wider implications as doctors are looked upon by the
lay public and other health workers as role models
and reliable sources of health information for primary
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Gadanya, et al.: Prevalence, attitude toward, and associated practices of self‑ear cleaning with cotton bud among doctors
47
Nigerian Journal of Surgical Research
Jul-Dec 16 Issue 2 / Vol 17
ear care. There is a need to plan and map out health
education and promotion strategies that will disseminate
key messages to doctors and other health workers in
the hospital community that ear cleaning is best done
by trained personnel. This is in addition to providing
targeted ear care messages during health campaigns
such as World Hearing Day, Continued Professional
Development programs for annual licensure for doctors,
etc., while reviewing and including best ear and hearing
care practices in our undergraduate curricula.
Acknowledgment
Sincere gratitude to all the Doctors in Aminu Kano
Teaching Hospital for taking time out to participate in
this survey.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
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