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Antimicrobial properties of human cerumen

Article · January 2018

DOI: 10.4103/am.am_69_18

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Original Article Review Article Original Article

Chronic subdural Chondrocalcinosis Drug sensitivity of

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Singh et al
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 Review Article

Antimicrobial Properties of Human Cerumen

Santosh Kumar Swain, Mahesh Chandra Sahu1, Priyanka Debta2, Manash Ranjan Baisakh3
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), 1Medical Research Laboratories, IMS and SUM
Hospital, Siksha “O” Anusandhan University (Deemed to be), 2Department of Oral Pathology and Microbiology, IDS and SUM Hospital, Siksha “O” Anusandhan
University (Deemed to be), 3Department of Pathology, Apollo Hospital, Bhubaneswar, Odisha, India

Abstract
In daily clinical practice, clinicians and otolaryngologists often confront with cerumen or earwax. Cerumen is formed by sebaceous glands
and ceruminous glands at the outer one‑third of the human external auditory canal and creates an acidic coat which aids in the prevention
of infections of the external auditory canal. The cerumen forms a physiological barrier between the external environment and deeper part
of the ear. The chemical composition of the cerumen has been thought to be of antibacterial and antifungal properties, although it is under
controversy. Other than antibacterial and antifungal activities, it also protects the eardrum by acting as a physical barrier. Cerumen cleaning is
not advisable unless it is causing symptoms such as otalgia or hearing loss. A large percentage of people believe in self‑cleaning of the ear canal
with different objects, which is really harmful, so they should be counseled against the habit of self‑cleaning of the external auditory canal.

Keywords: Antibacterial, antifungal, antimicrobial effect, cerumen

Introduction function of the cerumen/earwax against the microorganisms

Cerumen or earwax formation at the ear canal is a normal
physiologic process. Cerumen or earwax is formed by
sebaceous glands, ceruminous glands, and apocrine glands,
which are present at the outer one‑third of the human external
auditory canal and creates an acidic coat which aids in the
prevention of infections of the external auditory canal.[1]
The function of the cerumen to prevent the ear canal against
the invasion of microorganisms has long been a subject of
controversy. Lack of earwax may cause infection as it serves
antimicrobial property by physiological protection of ear canal,
creating a low pH and inhospitable atmosphere for pathogens
and creating antimicrobial substance such as lysozyme,
so its absence leads to ear canal‑susceptible infections.[2]
Earwax or cerumen is a naturally occurring substance in the
external auditory canal which cleans, protects, and lubricates
the ear canal. Cerumen or earwax is a common cause for
conductive hearing loss and sometimes presents with tinnitus,
irritation, otalgia, and vertigo.[3] In most of the cases, there
are no symptoms at all. Cerumen is formed from glandular
secretions from outer one‑third of the external auditory canal
and exfoliated squamous epithelium, which migrate out of the
ear canal due to jaw movement.[4] Impacted wax occurs due
to the failure of self‑cleaning mechanism in the ear canal. The
invading the ear has long been a subject of controversy. The
cerumen in the external auditory canal does not require removal
unless it causes any problem. This review article reviews the
antibacterial and antifungal properties of the cerumen and its
clinical utility. This review article presents a baseline from
where further prospective trials can be designed and help as a
spur for further research in this commonly encountered clinical
entity where not many studies are done.
Methodology
For searching the published article, we conducted an electronic
search of the Medline, SCOPUS, and PubMed databases. The
search term in the database included earwax, cerumen, and
antimicrobial property. The abstracts of the published article
are identified by this search method and other articles were
identified manually from the citations. This review article
reviews the antibacterial and antifungal properties of the
cerumen and its clinical utility. This review article presents a
Address for correspondence: Prof. Santosh Kumar Swain,
Department of Otorhinolaryngology, IMS and SUM Hospital,
Siksha “O” Anusandhan University (Deemed to be), Kalinga Nagar,
Bhubaneswar ‑ 751 003, Odisha, India.
E‑mail: swainsantoshbbsr@yahoo.com

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DOI:
10.4103/am.am_69_18 How to cite this article: Swain SK, Sahu MC, Debta P, Baisakh MR.
Antimicrobial properties of human cerumen. Apollo Med 2018;15:197-200.

© 2018 Apollo Medicine | Published by Wolters Kluwer - Medknow 197

 Swain, et al.: Antimicrobial properties of human cerumen
baseline from where further prospective trials can be designed
and help as a spur for further research in this commonly
encountered clinical entity where not many studies are done.
Composition of the Cerumen
Cerumen or earwax [Figure 1] is a mixture of desquamated
keratinocyte from the outer part of the external auditory canal
and secretions from sebaceous glands along with apocrine
sweat glands. It creates a gray‑brown‑to‑grayish‑black‑colored
tick substance and deposited at the external auditory canal.
Glandular secretions coming from the hair follicles of the
external auditory canal also mix with the cerumen and make
it a sticky substance which is known as cerumen.[5] Cerumen is
present in 10% of all the pediatric age group and up to 57% of
the older persons.[6] Cerumen or earwax is a yellow‑brownish
waxy substance and protects the skin of the ear canal from
water and infection. It prevents infection by trapping the
microorganisms, sweat, dirts, dead skin cells, oil, and hair.
The outer ear canal is lined with hairs called cilia which
push the offending particle toward the ear opening where the
wax can be washed off. There are two different forms of the
human cerumen and these are dry and wet which are often
associated with race and decided by two autosomal alleles.
The wet earwax is light or dark brown and sticky in nature,
possessing high concentration of lipid and pigment granules.
The dry allele is most often seen in mongoloid people of Asia
and in American Indians, whereas the wet variety is common in
Caucasian and Negro populations. Cerumen consists of amino
acids, neurostearic acid, cerotic acid, triglyceride, cholesterol,
hexone bases, lysozyme, immunoglobulin, glycopeptides,
copper, and others.[7] The dry earwax is gray or tan and brittle
and possesses less lipid and pigment granules. Dry wax
contains approximately 20% lipid in comparison to 50% in the
wet wax.[8] Cerumen or earwax is formed from a combination
of glandular secretion of the lateral one‑third of the external
auditory canal and exfoliated squamous epithelium, which
migrates of the external auditory canal by self‑cleaning
mechanism during jaw movement.[9]
Figure 1: Brownish wax extracted from the ear canal
198
Antimicrobial Properties of the Cerumen
Cerumen is a hydrophobic protective barrier in the external
auditory canal. It shields the skin of the ear canal from water
damage, trauma, foreign bodies, and infections. Cerumen also
lubricates and cleans the ear canal, traps dusts, and repels
water for entering inside the canal.[10] Cerumen also protects
the middle ear against bacteria and fungus.[11] Hence, cerumen
plays an important role biologically and clinically for host
defense although it is relatively weak. Cerumen or earwax
creates an acidic barrier in the external auditory canal which
prevents infection.[1] There are many contradictory reports on
the antibacterial activity of cerumen. The antibacterial nature
of cerumen is based on the consideration that the high nutrients
of cerumen which enable bacteria and fungi to grow, which is
against the antibacterial property of the cerumen.[12] However,
some hold a view that cerumen contains antimicrobial property
which prevents infections at the external ear.[13] Cerumen is
slightly acidic in nature, which discourages the growth of
bacteria and fungus in the moist and dark environment of the
external auditory canal. It is almost impossible to avoid infection
at the ear canal without the presence of cerumen.[14]  An enzyme
called lysozyme present in the cerumen, so without presence
of earwax make the ear canal vulnerable for infection. It is
expected that if cerumen provides immunity, its composition
should alter in response to infection and exposure to bacteria
and should induce antibacterial components of the cerumen
at the ear canal. However, in otitis externa, cerumen does not
provide antibacterial polyunsaturated fatty acids than without
any infection at the external auditory canal.[15] Cerumen inhibits
the growth of bacteria and fungi at various concentrations.
Few studies demonstrated the antibacterial and antifungal
properties which show its protective role toward the external
auditory canal. One study also proved the antibacterial
property of earwax in some mammals.[16] One study shows
the mycobacterial effect of earwax, which is consistent with
our study.[5] The human earwax shows more antibacterial
property in comparison to the antifungal property and this
may be due to some protective mechanism of the fungus,
leading to lower inhibition of fungal growth as compared to
bacteria. In one study, authors demonstrated the bactericidal
properties of earwax on Pseudomonas aeruginosa.[5] Some
other studies reported that cerumen has no bactericidal effect on
P. aeruginosa.[17] Cerumen inhibits the growth of Escherichia
coli, which is consistent with other study,[18] whereas one
study shown insignificant bactericidal effect and stated that
E. coli is not a normal commensal bacterium in the external
auditory canal and so may not be considered by the immune
system of the ear canal.[17] Human cerumen has antibacterial
and antifungal properties against common bacteria and
fungi as done in a study, which was in the following order:
E. coli > P. aeruginosa > Staphylococcus aureus > Candida
albicans.[13] As cerumen is secreted in the external auditory
canal, it often does not come in contact with bacteria in
middle‑ear infection. Immunohistochemical studies of cerumen
show that antibody‑mediated immune reactions rather that
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 Swain, et al.: Antimicrobial properties of human cerumen
earwax protect the ear canal from infective microorganisms.
The epidermis and dermis of the skin lining the external
auditory canal contain ceruminous and sebaceous glands as
well as piliary follicles which are capable of activating local
immunity by immunoglobulin (Ig) A and IgG.[19] However,
it needs more studies to confirm the nature of host defense
in this anatomical location. There are many controversial
reports in medical literature explained on the basis of culture
media, methodology, and virulence of microorganisms.
Microorganisms such as S. aureus, P. aeruginosa, and
C. albicans are common microorganisms that cause otitis
externa, whereas their presence in cerumen in the external
auditory canal reduces the chance of infection.[5]
Antibacterial Properties of the Cerumen
There is little known about the chemical composition of the
human cerumen and its antimicrobial role. Several proteins are
found in the cerumen such as antimicrobial peptides of human
beta defensin (hBD) 1‑3, lactoferrin, LL‑37, bactericidal
permeability‑increasing (BPI), hSLPI, and HNP1‑3. All have
some role to prevent bacteria and fungi those causing infections
at the external auditory canal. If this local defense system gets
disturbed, infections of ear canal occur.[20] These proteins are
described below.
Antimicrobial peptides
There is little known about the chemical composition of the
human cerumen regarding the antimicrobial peptides. Different
antimicrobial peptides from cerumen are hBD1‑3, lactoferrin,
LL‑37, BPI, hSLPI, and HNP1‑3. The antibacterial peptides
in cerumen prevent bacteria and fungi from causing infections
in the ear canal.[20]
Human beta defensins
The hBD is named after beta sheet structure which is
stabilized by intramolecular disulfide bonds. It has strong
antimicrobial property on Gram‑negative bacteria.[21] hBD2
has a strong antimicrobial effect on E.  coli, P. aeruginosa,
and C. albicans, whereas a weak effect on S. aureus. hBD3
induced by tumor necrosis factor‑alpha attaches with P.
aeruginosa or S. aureus, for example, keratinocytes.[22] hBD3
has antimicrobial properties against S. aureus including
methicillin‑resistant S. aureus, Streptococcus pyogenes, P.
aeruginosa, E. coli, Haemophilus influenzae, C. albicans, and
vancomycin‑resistant Enterococcus faecium.[23]
Human LL‑37
Human LL‑37 (LL‑37) is a 37‑aminoacid long C terminus
which has active antimicrobial component of the human
cathelicidin antimicrobial peptide 18 (Hcap‑18).  This protein
is expressed on leukocytes like neutrophils, monocytes,
B‑cells and T‑cells), epithelial cells like skin, respiratory tract
and gastrointestinal tract which is secreted into the wound
and surface fluid.[24] It has antibacterial activity against
Gram‑positive and Gram‑negative bacteria. LL‑37 also plays
a role in angiogenesis, cancer development, and neutralization
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of bacterial lipopolysaccharide and chemotactic for monocytes,
neutrophils, and CD4 T‑lymphocytes.[25]
Human lactoferrin
Human lactoferrin can be seen in saliva, tears, milk, nasal
mucosa, neutrophils, and granulocytes.[26] The antibacterial
spectrum of human lactoferrin includes Streptococcus mutans,
Vibrio cholera, E. coli, Actinobacillus actinomycetemcomitans,
Enterobacteriaceae, Legionella pneumophila, C. albicans, and
P. aeruginosa.[20]
Human secretory leukoprotease inhibitor
Human secretory leukoprotease inhibitor (hSLPI) is a heavy
protein particle expressed on macrophages, epithelial cells,
and neutrophils. It has antimicrobial properties against
Gram‑positive and Gram‑negative bacteria at the N‑terminal
domain of the protein. hSLPI blocks the viral DNA synthesis
and inhibits human deficiency virus.[27]
Human bactericidal permeability‑increasing protein
This is a single‑chain cationic protein which is divided
by proteolysis into two segments with antibiotic‑ and
endotoxin‑neutralizing functions in the N‑terminal segment.[28]
BPI is mainly seen in the granules of neutrophils, dermal
fibroblasts, and excretory lacrimal gland and often selective
to the Gram‑negative bacteria.[29] It has significant protective
effect in meningococcal infection.[30] Cerumen has a protective
antimicrobial potency, and cleaning the ear canal by rinsing
with water leads to a complete elimination of the cerumen,
which leads to alteration of the physiological pH. This explains
why otitis externa occur after cleaning the ear canal with
water. Removal of the earwax or cerumen manually by a hook
and leaving some wax in the ear canal would maintain the
physiological antimicrobial potency of the ear canal.
Conclusion
Variable results have been obtained from different authors
regarding the antimicrobial nature of the cerumen. However,
most of the authors strongly believe in the antimicrobial nature
of the cerumen which does inhibit the microbial growth.
Cerumen of the human has both bactericidal and fungicidal
properties. Apart from being a physical barrier of cerumen in
the ear canal, it also acts as a protective agent against bacteria
and fungi. This may provide prevention or eradication of the
infections of the external ear such as otitis externa. Hence,
routine wax removal from the ear canal should be discouraged
unless it is impacted leading to hearing loss or earache. An
extensive study should be done to reveal the bactericidal and
fungicidal roles of cerumen or earwax. The different outcome
among documented literatures may be due to the fact that
earwax from different persons varies in it composition and
contents of inhibitory factors due to the different genetic profile
of the patients. Finally, since different levels of health‑care
providers are involved in managing patients with cerumen
or earwax impaction, they should have awareness about the
antibacterial property of the cerumen.
199
 Swain, et al.: Antimicrobial properties of human cerumen
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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