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Willems M, van Berlaer G, Maes L, Leyssens L, Koehler B, Marks L. Outcome of 10 years of ear and hearing screening in people with intellectual disability in Europe: A multicentre study. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2021; 35:123-133. [PMID: 34197010 DOI: 10.1111/jar.12923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/18/2021] [Accepted: 06/04/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Undetected ear and hearing problems negatively impact the quality of life of people with intellectual disability. METHODS This multicentre retrospective study describes the outcome of 10 years of ear and hearing screening in athletes with intellectual disability in seven European countries. The screening was conducted by a trained team using a strictly standardised protocol. RESULTS Of 15,363 screened athletes with intellectual disability, more than half (58.7%) needed referral for ear and/or hearing problems, ranging from 51.7% (<20 years old) to 81.4% (≥60 years old). The most commonly detected conditions were excessive/impacted earwax (40.3%), middle ear problems (30.1%) and hearing loss (27.0%), with significant differences between age groups and countries. DISCUSSION This study demonstrates an increased risk of ear and hearing problems in people with intellectual disability as compared to the general population. Considering the unawareness and impact of these problems, it is highly recommended to organise systematic screening. Follow-up for diagnostic elaboration, therapeutic management and long-term guidance should be provided.
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Affiliation(s)
- Melina Willems
- Audiology Department, Artevelde University of Applied Sciences, Ghent, Belgium.,Special Olympics Healthy Hearing Program, Washington, DC, USA
| | - Gerlant van Berlaer
- Department of Emergency Medicine, University Hospital Brussels, Brussels, Belgium
| | - Leen Maes
- Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium.,Ear Nose Throat Department, Ghent University Hospital, Ghent, Belgium
| | - Laura Leyssens
- Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
| | | | - Luc Marks
- Ghent University Hospital, Oral Health in Special Needs, Ghent, Belgium
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Herane-Vives A, Espinoza S, Sandoval R, Ortega L, Alameda L, Young AH, Arnone D, Hayes A, Benöhr J. A Novel Earwax Method to Measure Acute and Chronic Glucose Levels. Diagnostics (Basel) 2020; 10:E1069. [PMID: 33321856 PMCID: PMC7764152 DOI: 10.3390/diagnostics10121069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/27/2020] [Accepted: 11/28/2020] [Indexed: 11/16/2022] Open
Abstract
Diabetes is the fourth cause of death globally. To date, there is not a practical, as well as an accurate sample for reflecting chronic glucose levels. We measured earwax glucose in 37 controls. Participants provided standard serum, glycated hemoglobin (HbA1c) and earwax samples at two time-points, one month apart. The specimens measured baseline fasting glucose, a follow-up postprandial glucose level and a between sample chronic glucose, calculated using the average level on the two occasions. The baseline earwax sample was obtained using a clinical method and the follow-up using a novel self-sampling earwax device. The earwax analytic time was significantly faster using the novel device, in comparison to the clinical use of the syringe. Earwax accurately reflected glucose at both assessments with stronger correlations than HbA1c. Follow-up postprandial concentrations were more significant than their respective fasting baseline concentrations, reflecting differences in fasting and postprandial glycemia and more efficient standardization at follow up. Earwax demonstrated to be more predictable than HbA1c in reflecting systemic fasting, postprandial and long-term glucose levels, and to be less influenced by confounders. Earwax glucose measurements were approximately 60% more predictable than HbA1c in reflecting glycemia over a month. The self-sampling device provided a sample that might accurately reflect chronic glycemia.
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Affiliation(s)
- Andrés Herane-Vives
- Institute of Cognitive Neuroscience, Clinical, Educational & Health Psychology Department, Faculty of Brain Disease, University College London, Alexandra House, 17-19 Queen Square, Bloomsbury, London WC1N 3AZ, UK
- Centre for Affective Disorders, Affective Disorders Research Group, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AF, UK; (A.H.Y.); (D.A.); (A.H.)
| | - Susana Espinoza
- Departamento de Clínicas, Facultad de Medicina, Universidad Católica del Norte, Larrondo 1281, 1781421 Coquimbo, Chile; (S.E.); (R.S.); (L.O.)
| | - Rodrigo Sandoval
- Departamento de Clínicas, Facultad de Medicina, Universidad Católica del Norte, Larrondo 1281, 1781421 Coquimbo, Chile; (S.E.); (R.S.); (L.O.)
| | - Lorena Ortega
- Departamento de Clínicas, Facultad de Medicina, Universidad Católica del Norte, Larrondo 1281, 1781421 Coquimbo, Chile; (S.E.); (R.S.); (L.O.)
| | - Luis Alameda
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AF, UK;
- Instituto de Investigación Sanitaria de Sevilla, IBiS, Hospital Universitario Virgen del Rocío, Departamento de Psiquiatría, Universidad de Sevilla, 41013 Sevilla, Spain
- Service of General Psychiatry, Lausanne University Hospital (CHUV), 1008 Lausanne, Switzerland
| | - Allan H. Young
- Centre for Affective Disorders, Affective Disorders Research Group, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AF, UK; (A.H.Y.); (D.A.); (A.H.)
| | - Danilo Arnone
- Centre for Affective Disorders, Affective Disorders Research Group, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AF, UK; (A.H.Y.); (D.A.); (A.H.)
- Department of Psychiatry and Behavioural Science, College of Medicine and Health Sciences, United Arab Emirates University, 5MW2+PW Al Ain, Abu Dhabi, UAE
| | - Alexander Hayes
- Centre for Affective Disorders, Affective Disorders Research Group, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AF, UK; (A.H.Y.); (D.A.); (A.H.)
| | - Jan Benöhr
- Benöhr Design Creatives, Jollystrasse 5, 81545 München, Germany;
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Herane-Vives A, Ortega L, Sandoval R, Young AH, Cleare A, Espinoza S, Hayes A, Benöhr J. Measuring Earwax Cortisol Concentration using a non-stressful sampling method. Heliyon 2020; 6:e05124. [PMID: 33195832 PMCID: PMC7644886 DOI: 10.1016/j.heliyon.2020.e05124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 08/06/2020] [Accepted: 09/28/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND "Short-term" samples are not the most appropriate for reflecting chronic cortisol concentration. Although hair is used for reflecting the systemic level of this hormone, its use as a "long-term" measure appears clinically problematic. Local and systemic stress and non-stress related factors may release cortisol that is accumulated in hair. Non-stressful earwax sampling methods may provide a more accurate specimen to measure chronic cortisol concentration. METHODS Earwax from both ears of 37 controls were extracted using a clinical procedure commonly associated with local pain. One month later, earwax from the left ear side was extracted using the same procedure, and earwax from the right ear side was more comfortably obtained, using a novel earwax self-sampling device. Participants also provided one centimetre of hair that represented the retrospective month of cortisol output, and one serum sample that reflected the effect of systemic stressors on cortisol levels. Earwax (ECC), Hair (HCC) and Serum (SCC) Cortisol Concentration were correlated and compared. Confounders' effect on cortisol levels were studied. RESULTS The highest levels of cortisol concentration were found in serum, and the lowest in hair (p < 0.01). Left-ECC was larger than Right-ECC (p = 0.03). Right-ECC was the only sample unaffected by confounders (all p > 0.05). A Pearson correlation showed that Right-ECC and HCC samples were moderately correlated between them (r = 0.39; p = 0.03). CONCLUSIONS The self-sampling device did not increase cortisol locally. It provided the cortisol level that was least likely to be affected by confounding factors over the previous month. ECC using the novel device might constitute another accurate, but more suitable and affordable specimen for measuring chronic cortisol concentration.
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Affiliation(s)
- Andres Herane-Vives
- Institute of Cognitive Neuroscience, University College London, UK
- Affective Disorders Research Group, Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Lorena Ortega
- Departamento de Clínicas, Facultad de Medicina, Universidad Católica del Norte, Coquimbo, Chile
| | - Rodrigo Sandoval
- Departamento de Clínicas, Facultad de Medicina, Universidad Católica del Norte, Coquimbo, Chile
| | - Allan H. Young
- Affective Disorders Research Group, Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Anthony Cleare
- Affective Disorders Research Group, Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Susana Espinoza
- Departamento de Clínicas, Facultad de Medicina, Universidad Católica del Norte, Coquimbo, Chile
| | - Alexander Hayes
- Affective Disorders Research Group, Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Jan Benöhr
- Benöhr Design Creatives, München, Germany
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Morley H, Panak V, Mulders WHAM, Goulios H, Martini A, Langdon C. Non-chewing diets and cerumen impaction in the external ear canal in a residential aged care population. Australas J Ageing 2019; 39:131-136. [PMID: 31691470 DOI: 10.1111/ajag.12736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/26/2019] [Accepted: 09/13/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine whether diets involving reduced chewing affect the degree of cerumen impaction in older people in residential care. METHODS A total of 51 people (53% male) over 65 years (80.5 ± 9.3) were recruited from two residential aged care facilities in Perth, Australia. Participants were classified as "chewers" (on unrestricted or soft food diets), or "non-chewers" (on pureed or nil by mouth diets), and completed a survey about predisposing factors for cerumen impaction. Otoscopy and tympanometry were used to assess cerumen impaction and ear canal occlusion. Participants with excess cerumen were referred for wax removal. RESULTS No significant difference in cerumen accumulation was found between groups. However, 57% of participants showed excess cerumen requiring removal. CONCLUSION Diets involving reduced chewing are not associated with increased cerumen in older people in residential care. The prevalence of cerumen impaction is high in this population, and improved cerumen screening and management is needed in residential aged care.
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Affiliation(s)
- Hannah Morley
- School of Human Sciences, University of Western Australia, Crawley, WA, Australia
| | - Vanessa Panak
- School of Human Sciences, University of Western Australia, Crawley, WA, Australia
| | - Wilhelmina H A M Mulders
- School of Human Sciences, University of Western Australia, Crawley, WA, Australia.,Ear Science Institute Australia, Subiaco, WA, Australia
| | - Helen Goulios
- School of Human Sciences, University of Western Australia, Crawley, WA, Australia
| | | | - Claire Langdon
- School of Surgery, University of Western Australia, Crawley, WA, Australia
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Shokry E, Filho NRA. Insights into cerumen and application in diagnostics: past, present and future prospective. Biochem Med (Zagreb) 2019; 27:030503. [PMID: 29180914 PMCID: PMC5696747 DOI: 10.11613/bm.2017.030503] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 09/16/2017] [Indexed: 12/11/2022] Open
Abstract
Cerumen or earwax is an emerging bio-fluid in clinical diagnosis that has been very little exploited during the past decades in spite of its high diagnostic potential. It is highly abundant in diagnostic biomarkers such as genetic material, lipids, proteins, chemical elements, internal and external metabolites (e.g. hormones, volatile organic compounds, amino acids, xenobiotics etc.) reaching earwax from the blood circulation. Thus, it is able to reflect not only physiology, pathophysiology of the human body but can also detect recent and long term exposure to environmental pollutants, without the need of invasive blood tests and in the same time overcoming many disadvantages faced by using other diagnostic biological fluids. This review discusses the biology, functions, chemistry of earwax, past and current approaches for the study of its chemical composition, emphasizing how a detected variation in its composition can offer information of high clinical value, which can be useful in diagnosis of many diseases such as metabolic disorders and tumours as well as in forensic applications. It also presents details about techniques of sample collection, storage, and analysis. Moreover, it highlights concerns about the use of earwax for diagnostic purposes, which should be addressed to make earwax diagnostics a reality in the future.
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Affiliation(s)
- Engy Shokry
- Laboratório de Métodos de Extração e Separação, Instituto de Química, Universidade Federal de Goiás, Goiânia, Brazil
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Ping C, Yanling H, Youhua W, Shufen W, Zhinan W, Zhongfang X. Epidemiology of cerumen impaction among municipal kindergartens children in Wuhan, China. Int J Pediatr Otorhinolaryngol 2017; 100:154-156. [PMID: 28802363 DOI: 10.1016/j.ijporl.2017.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/05/2017] [Accepted: 07/07/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To investigate the epidemiology of cerumen impaction among children of municipal kindergartens in Wuhan. METHODS The ear canal of children of municipal kindergartens in Wuhan was examined using an electric otoscope by the same otologist in 2005, 2006 and 2012, with age, gender, ears and the nature of cerumen (dry cerumen or wet cerumen) recorded. A chi-square test was performed to investigate for significant differences between cerumen impaction rates and the recorded variables. RESULTS A total of 1,214, 1863 and 5205 children were examined in 2005, 2006 and 2012, and cerumen impaction prevalence rates for each year were 17.2%, 15.4% and 10%, respectively. Prevalence of cerumen impaction was significantly lower in 2012 than in 2005 or 2006. In 2005, dry cerumen impaction accounted for 22.2% of the total dry cerumen, while wet cerumen impaction only accounted for 5% of the total wet cerumen, showing a statistically significant difference. CONCLUSION The prevalence of cerumen impaction among children of kindergartens in Wuhan is higher than 10%, and children with dry cerumen are more prone to cerumen impaction. Annual otological examination of kindergarten children is recommended. And improved community ear health promotion activities should reduce the avoidable prevalence of cerumen impaction in pediatric population.
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Affiliation(s)
- Chen Ping
- ENT Department of Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science & Technology, China.
| | - Hu Yanling
- ENT Department of Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science & Technology, China
| | - Wei Youhua
- ENT Department of Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science & Technology, China
| | - Wang Shufen
- ENT Department of Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science & Technology, China
| | - Wang Zhinan
- ENT Department of Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science & Technology, China
| | - Xia Zhongfang
- ENT Department of Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science & Technology, China
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In-depth proteomic analysis of the human cerumen—A potential novel diagnostically relevant biofluid. J Proteomics 2013; 83:119-29. [DOI: 10.1016/j.jprot.2013.03.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Revised: 03/07/2013] [Accepted: 03/09/2013] [Indexed: 11/17/2022]
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Abstract
A prospective study was done to access the efficacy of ceruminolytic agents, i.e 2% paradichlorobenzene, 10% sodium bicarbonate, 2.5% acetic acid and normal saline. All score 4 hard impacted ear wax cases in the adult population (>20 years) were accrued for the assessment of the relative efficacy. Upon analyzing the comparative efficacy of four ceruminolytic agents, by taking into consideration three parameters (post) ceruminolytic cerumen score, attempts of syringing required to extrude the cerumen mass, post-ceruminolytic use and appearance of the removed cerumen mass. 2% paradichlorobenzene emerged as the most superior ceruminolytic, closely followed by 10% sodium bicarbonate. 2.5% acetic acid fared moderately while normal saline emerged as the least efficacious ceruminolytic agent.
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Investigation of age, sex and menstrual stage variation in human cerumen lipid composition by high performance thin layer chromatography. The Journal of Laryngology & Otology 2007; 122:881-6. [PMID: 17931445 DOI: 10.1017/s0022215107000783] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The objective of the study was to correlate quantitative changes in the lipid composition of human cerumen with changes in age, sex and menstrual cycle stage. DESIGN Cerumen samples were collected from the external ear canal and analysed using sequential, one dimensional, high performance thin layer chromatography. SUBJECTS The following age groups of both sexes were investigated: one to 10 years; 11-18 years; 19-40 years; and 40 years and over. Additionally, cerumen samples from subjects in three stages of the menstrual cycle were compared. RESULTS In the cerumen samples, the peak values for wax ester and cholesterol occured between the ages of one and 10 years for both sexes. However, squalene and triglyceride content reached maximum levels at puberty. Men aged 19-40 years had a significantly greater percentage of cerumen lipid squalene content than women from the same age group; however, their cholesterol content was found to be lower. Regarding the various menstrual cycle stages, cerumen samples taken at the follicular stage from women aged 19-40 years had a significantly lower free fatty acids content, and higher cholesterol and squalene levels, compared with samples taken in the luteal or menstrual stages. CONCLUSION The proportions of the lipid constituents of cerumen varied with age, sex and menstrual stage. In cerumen, the main lipid constituent stimulated at puberty appears to be squalene, not wax esters as reported for sebum. The relevance of lipid constituents to cerumen's protective role is discussed.
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Abstract
We performed a study to determine if cerumen in the ear canal causes significant hearing loss and to ascertain if there is any correlation between the amount of cerumen and the degree of hearing loss. Our study was conducted on 109 ears in 80 patients. The results indicated that impacted cerumen does cause a significant degree of conductive hearing loss. We found no significant correlation between the length of the cerumen plug and the severity of hearing loss. Nor did we find any significant correlation between the presence of impacted cerumen and variables such as age, sex, ethnicity, or affected side.
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Affiliation(s)
- Sethu T. Subha
- Department of Surgery (Otorhinolaryngology), Faculty of Medicine and Health Sciences, University Putra Malaya, Hospital Kuala Lumpur, Malaysia
| | - Rajagopalan Raman
- Department of Surgery (Otorhinolaryngology), Faculty of Medicine and Health Sciences, University Putra Malaya, Hospital Kuala Lumpur, Malaysia
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Lorente-Guerrero J, Sabater-Mata F, Rodríguez-Martínez R, Pou-Fernández J, López-Avila J, García-Criado E. Diagnóstico y tratamiento antimicrobiano de las otitis externas. Med Clin (Barc) 2006; 126:507-13. [PMID: 16624232 DOI: 10.1157/13086848] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Guest JF, Greener MJ, Robinson AC, Smith AF. Impacted cerumen: composition, production, epidemiology and management. QJM 2004; 97:477-88. [PMID: 15256605 DOI: 10.1093/qjmed/hch082] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In the UK, some 2.3 million people suffer cerumen ('ear wax') problems serious enough to warrant management, with approximately 4 million ears syringed annually. Impacted cerumen is a major cause of primary care consultation, and a common comorbidity in ENT patients, the elderly, infirm and people with mental retardation. Despite this, the physiology, clinical significance and management implications of excessive and impacted cerumen remain poorly characterized. There are no well-designed, large, placebo-controlled, double-blind studies comparing treatments, and accordingly, the evidence surrounding the management of impacted cerumen is inconsistent, allowing few conclusions. The causes and management of impacted cerumen require further investigation. Physicians are supposed to follow the edicts and principles of evidence-based medicine and clinical governance. Currently, in patients with impacted cerumen, the lack of evidence makes this impossible.
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Affiliation(s)
- J F Guest
- CATALYST Health Economics Consultants, 34b High Street, Northwood, Middlesex HA6 1BN, UK.
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Campos A, Arias A, Betancor L, Rodríguez C, Hernández AM, López Aguado D, Sierra A. Study of common aerobic flora of human cerumen. J Laryngol Otol 1998; 112:613-6. [PMID: 9775288 DOI: 10.1017/s002221510014126x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cerumen is the product of the secretion of the sebaceous, ceruminous or apocrine glands together with cells exfoliated from the cornified stratum of the epithelium of the external auditory canal (EAC). In the present study we identified and quantified common flora of human cerumen. The mean count obtained was 10(6) microorganisms per ml of cerumen suspension. In 24 pools of cerumen (33.3 per cent) the isolates were monomicrobial, Staphylococcus epidermidis (12), Corynebacterium spp (10), Staphylococcus aureus (1) and Streptococcus saprophyticum (1). In 48 pools (66.6 per cent) we found polymicrobial isolates. The most commonly isolated bacteria in these polymicrobial isolates were S. epidermidis (35) and Corynebacterium spp. (43). It is noteworthy that there were isolates of Candida albicans in three cases; in one case of Pseudomonas stutzeri, in one case of Pseudomonas aeruginosa, and, on seven occasions, of S. aureus. The organisms isolated as common bacterial components of human cerumen in our experience were similar to those found by other authors. However, the mean count was much higher. This could be related to climatic conditions and to the length of time the cerumen had remained in the external auditory canal.
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Affiliation(s)
- A Campos
- Department of Preventive Medicine & Public Health, University of La Laguna, Spain
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