|Year : 2019 | Volume
| Issue : 4 | Page : 220-225
Knowledge, attitudes, and practices pertaining to cotton-bud usages and the complications related to their mi suse among outpatients in an ear, nose, and throat clinic
Maha Saleh Alrajhi1, Bader Mohammed Alim2, Sara Dokhayel Aldokhayel1, Leena Mohammad Zeitouni1, Layan Khalid Al Tawil1, Farid A Alzahrani2
1 Medical Interns, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Otolaryngology Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Web Publication||4-Oct-2019|
Bader Mohammed Alim
King Saud University, Riyadh
Source of Support: None, Conflict of Interest: None
Introduction: Cotton buds are small plastic rods with cotton-covered tips. They have been widely misused since their development. Objectives: This study aims to determine the prevalence of cotton bud usage and examine patients' attitudes toward their utilization. It also aims to investigate the complications associated with their misuse. Methodology: This cross-sectional observational study was conducted in King Abdulaziz University Hospital, on patients attending the ear, nose, and throat outpatient clinics between January and March 2018. Data were collected using paper-based questionnaires and analyzed using SPSS. Results: A total of 378 patients completed the survey. Most respondents (69.6%) confirmed that they had used cotton buds previously. However, only 18% of the respondents suffered ear canal complications associated with cotton bud use. Respondents reported ear wax impaction as the most common complication (41.2%), followed by ear pain (39.7%). The majority (63.2%) of the respondents stated that they had received at least one educational session warning them against improper cotton bud use. Almost half of the patients were unsure whether cotton buds could cause complications or not. The mean overall rating of the attitude of the patients toward using cotton buds resulted in a score of 12 out of 20, thereby denoting that these patients were slightly inclined toward using cotton buds. Furthermore, patients who reported having used cotton buds had significantly greater attitudes toward cotton bud usefulness (mean, 13.4; standard deviation, 2.8; P < 0.001). Conclusion: Overall, patients seem to have relatively insufficient knowledge and lax attitudes toward cotton bud usage and the complications related to their use. Further studies on a broader scale are warranted to evaluate the extent of cotton bud use.
Keywords: Cerumen, cotton fiber, ear canal, ear injury, health behavior
|How to cite this article:|
Alrajhi MS, Alim BM, Aldokhayel SD, Zeitouni LM, Al Tawil LK, Alzahrani FA. Knowledge, attitudes, and practices pertaining to cotton-bud usages and the complications related to their mi suse among outpatients in an ear, nose, and throat clinic. J Nat Sci Med 2019;2:220-5
|How to cite this URL:|
Alrajhi MS, Alim BM, Aldokhayel SD, Zeitouni LM, Al Tawil LK, Alzahrani FA. Knowledge, attitudes, and practices pertaining to cotton-bud usages and the complications related to their mi suse among outpatients in an ear, nose, and throat clinic. J Nat Sci Med [serial online] 2019 [cited 2021 Sep 20];2:220-5. Available from: https://www.jnsmonline.org/text.asp?2019/2/4/220/266071
| Introduction|| |
Cotton buds, also known as Q-tips, are small plastic rods with cotton-covered tips. They have been in use since they were first invented in 1923 for ear cleaning purposes. The ideal method of using cotton buds is to clean the auricle – the externally visible part of the ear – only. However, the use of cotton buds for inner ear cleaning is now a very common practice around the world, ranging from an alarmingly high rate of 53% up to 100%.,,, The public uses cotton buds mainly to remove ear wax (cerumen) and water and relieve itchiness, among other reasons.,, Certainly, there is a widespread belief that it is necessary to remove excess cerumen to maintain a good standard of ear hygiene.
It is well-known among physicians that the external auditory canal (EAC) has a perfectly sufficient self-cleaning mechanism  and that a cotton bud can work in opposition to this mechanism by pushing the cerumen further back into the EAC, resulting in wax impaction. The continuous application of cotton buds also causes other devastating complications that are well-documented in the literature, such as traumatic injury to the EAC, otitis externa, cotton bud retention, deafness, and a perforated eardrum.,,, The widespread prevalence of their use and the frequently encountered cotton bud-related injuries have made them a common reason for attending an ear, nose, and throat (ENT) clinic nowadays.
Due to the scarcity of research in this field, there is a dire need to study the correlation between sociodemographic factors and the prevalence of ear cleaning with cotton buds and its related complications. It is important that we identify this association so that we can determine appropriate preventative measures to combat any potential injury to the ear. Moreover, assessing the local community's awareness of the dangers of this potentially risky habit is an important first step in helping to guide people toward a viable solution to the problem. To achieve this solution, this study aims to determine the frequency of cotton bud usage and assess the attitude of people toward cotton bud use, along with its associated complications.
| Methodology|| |
This cross-sectional observational study was conducted at King Abdulaziz University Hospital, on a calculated, convenient sample of patients attending the ENT outpatient clinics between January and March 2018. It was approved by an Institutional Review Board in King Saud University in 2018 with the approval number E-18-2818.
Data collection was done by distributing self-administered, semi-structured, paper-based questionnaires, including an informed consent form that assured participants of the confidentiality of their responses; the participants' personal information (names, identity numbers, and addresses) were not collected.
The questionnaire assessed the participants' sociodemographic data, the frequency of cotton bud use, and the participants' knowledge of and attitude toward the complications related to inappropriate cotton bud use. The attitude section was partly designed using a questionnaire by Hobson and Lavy  and was scored with a five-point Likert scale – strongly disagree, disagree, not sure/neutral, agree, and strongly agree. A pilot study was performed on 10 outpatients using an Arabic version of the questionnaire. It was done to assess the feasibility of, understanding of, and time needed to complete the questionnaire.
The collected data were entered into an Excel spreadsheet and then imported and analyzed using the Statistical Package for the Social Sciences, version 21.0 (SPSS 21; IBM Corp., USA). We performed a t-test and a one-way ANOVA to compare the patients' demographic data, and their frequency of cotton bud use to examine any statistical differences in their attitudes toward cotton bud use. A Bonferroni correction was performed to adjust the post hoc pairwise comparison between age groups and patients' mean attitudes toward cotton bud use. The results are presented as frequency (percentage) and mean (standard deviation [SD]).
| Results|| |
A total of 378 patients completed the survey; male patients represented 54.5% of the sample. The mean age of the participants was 36.8 ± 13.9 years (13–75 years old). Moreover, more than nine-tenths of the participants (93.4%) were Saudis, and half of the samples possessed a university or higher education degree; only 4.5% of the respondents were illiterate. Regarding employment status, approximately 43.7% were employed, and 11% specified that they were retired [Table 1].
Most of the participants (69.6%) responded that they had used cotton buds, as shown in [Table 2]. Approximately 30.4% had never used cotton buds to clear their ears, and about 19% responded that they had used cotton buds to clear their ears at least once, or more than once daily.
|Table 2: Cotton bud usage and associated practices and side effects (n=378)|
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We found that only 18% of the respondents had previous ear canal complications associated with cotton bud use, even though, up to 63.2% of the respondents stated that they had attended at least one educational session warning them against cotton bud use.
[Figure 1] shows that the most frequent reason for using cotton buds was for clearing ear wax (n = 107, 34.2%), followed by the need to clear dirt or debris (n = 93, 29.7%), and the need to find relief from ear itchiness (n = 58, 18.5%). Only a small proportion of the participants (n = 3, 1%) stated other reasons using cotton buds, including the presence of psoriasis and other ear problems.
|Figure 1: Frequency of reasons why patients used cotton tips for ear cleaning (n = 263)|
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Based on the 68 participants, who reported having had at least one or more complication attributable to cotton bud use, the results suggest that cerumen impaction was the most commonly reported complication (n = 28, 41.2%), followed by ear pain (n = 27, 39.7%), ear itchiness (n = 18, 26.5%), and otitis externa (n = 16, 23.5%) [Table 3].
[Figure 2] demonstrates that at least 235 participants reported having acquired some education from various resources regarding the use of cotton buds. Media channels were the most common source of information warning against the dangers of cotton buds (n = 92, 39.1%), followed by family and friends (n = 68, 28.9%). Only a quarter (24.3%) of the participants reported that they had received this information from ENT physicians.
|Figure 2: Patients' sources of information regarding ear cotton bud use (n = 235)|
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As depicted in [Table 4], the mean overall rating of the attitude of the patients toward cotton bud usage resulted in a score of 12 out of a maximum agreement score of 20, thereby denoting that these participants were only slightly inclined to use cotton buds. An equivalency of attitude equal to 12/20 × 100 = 60% out of a maximum 100% believe in the usefulness, benefits, and recommendation of cotton buds. Nonetheless, the ENT patients' overall agreement with the statement, “cotton buds should be used to clean the ears” was rated with a score of 3.2 points out of a maximum of five, denoting that they were “unsure” as to whether cotton buds should be used to clear ear canals. In terms of the statement “Cotton buds are good at removing ear wax” this, too, was rated with a score of 3.2 agreement points out of a maximum of five points, thereby denoting that they were “unsure” whether cotton buds were good or not good for clearing their ear canals. However, the patients' collective agreement as to whether “It is best not to clean the ears with the aid of cotton buds” was rated with 3.6 points out of a maximum of five points, which showed a general agreement with the fact that no attempt should be made to clean the ear canals with a cleaning aid regardless of the perceived benefits. Finally, the patients' agreement level with the statement, “Cotton buds can cause lots of complications, for example, bleeding, infections, and wax impaction” was rated 3.4 points out of a potential five. This score indicated that these patients were somewhat unsure as to whether cotton buds can cause further ear canal complications.
|Table 4: Patients' attitudes toward the use of cotton buds for ear cleaning (n=378)|
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As demonstrated in [Table 5], ENT patients who reported having used cotton buds had a significantly greater attitude score regarding cotton bud usefulness (mean, 13.4; SD, 2.8) than those who reported not using them (mean = 10.6, SD = 2.7, P < 0.001). However, several ENT patients reported that they had previously received a warning against the use of cotton buds for ear canal cleaning. These patients were significantly less likely to use cotton buds for ear cleaning (mean, 11.9; SD, 2.9) than those who had received no previous warning regarding their use (mean, 13.7; SD, 3.1) (P < 0.001).
|Table 5: Relationship between patients' attitudes toward cotton swab use and their habits and demographic characteristics (n=378)|
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A one-way ANOVA test showed significant differences between patient age groups and their mean attitudes toward cotton bud usage (P = 0.016). Further analysis showed that people in the 20–30 years of age group were significantly more likely to use cotton buds for ear cleaning (mean, 12.9; SD, 3.2) than those aged ≥50 years (mean, 11.3; SD, 3.1) (95% confidence interval = 0.22: 3, P= 0.012). The other age groups did not necessarily differ significantly in view of the pairwise comparison. In addition, there were statistically significant differences in relation to the mean attitudes toward cotton bud usage and the frequency of clearing the ear canals (P < 0.001). Post hoc Bonferroni-adjusted pairwise comparisons indicated that only patients who used cotton buds once per month or less frequently (i.e., at a rate of “almost never”) had significantly lower attitude scores regarding cotton bud use (mean, 12.2; SD, 2.8) than those who used them one to six times per week (mean, 14.1; SD, 2.3) (P = 0.001) and those who used them several times daily (mean = 13.8, SD = 3.2, P= 0.038). Furthermore, as the frequency of cotton bud use reportedly increased from “never” to “several times per day,” the attitudes of the participants toward cotton bud usage tended to improve as well. Those who reported never having used cotton buds in the past were significantly less likely to use them than those who had used them.
We found no significant differences between participants' mean attitude toward cotton bud use, irrespective of the participants' gender, nationality, educational level, or employment status. Incidentally, a relatively low proportion of patients reported previous complications associated with cotton bud usage. In short, it appeared as though the patients' ages and their cotton bud practices, frequency of cotton bud usage, and exposure to previous education might help us understand the differences between people's attitudes toward cotton bud use. Accordingly, we decided to take the analysis, a step further using a multivariate linear regression analysis, as shown in [Table 6], help us assess the individual and combined effects of these patients' characteristics on their overall attitudes toward cotton bud use. The model showed that at least one or more of the variables had a significant multivariate association with the ENT patients' attitudes toward cotton bud use.
|Table 6: Multivariate linear regression model explaining the association between the patients' demographic data and their ear cleaning practices as well as their attitudes toward cotton bud use (n=378)|
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| Discussion|| |
The proper aim of using cotton buds in the ears is limited to cleaning the auricle only. Yet, the widespread practice of their improper use has led to a different variety of complications in the ears. The current hospital-based cross-sectional observational study (questionnaire-based survey) is, thus, aimed at understanding the knowledge, attitudes toward, and prevalence of cotton bud use among the visitors of our tertiary care center. Assessments were performed across various age groups, educational levels, and employment status.
The prevalence of cotton bud use in this study was 69.6%, with both genders using cotton buds in approximately equal proportions (53% in males vs. 47% in females). The most prevalent users of cotton buds were adults in the 21–30-year-old age group. The prevalence rate of cotton bud use in our study is lower than those reported in two studies conducted at the Aminu Kano Hospital  and Sokoto metropolis, which reported rates of 76.3% and 91.2%, respectively. In addition, a higher prevalence of cotton bud usage was reported in females in Nigeria than in this study.
One reason for these high proportions compared to our study could be the widespread habit of using cotton buds in Nigeria. Another reason that may explain the high prevalence of cotton bud use in our study may be the socio-religious habits of the participants. Most of our participants were Muslims, who are known to perform ablution (i.e., the ritual washing of specified body parts before the performance of prayer) five times a day as a religious ritual. By doing so, they effectively cleanse their ears from all dirt with every ablution. This ritual might lead them to believe that they do not require the use of cotton buds to further clean their ears. Therefore, this may explain why there is a lower prevalence of cotton bud use in the Saudi population.
Most of the participants in this study cleaned their ears with cotton buds on a weekly or monthly basis, while another study reported that the majority of cotton bud users cleaned their ears daily.
Interestingly, a study conducted at Corps Camp in Nigeria showed a high prevalence of cotton bud usage (93.4%) and a high perception that ear cleaning was beneficial (97.1%). Conversely, in our study, most of the participants were only slightly in the agreement of the usefulness of cotton bud use for ear cleaning. When comparing the motives behind cotton bud use, our respondents' main reasons for using cotton buds were to clean dirt (34.2%) and remove wax (29.7%). Another study reported a similar reason for the use of cotton buds, with 54.7% of the respondents admitting to using cotton buds to clear their ears. On the contrary, the study conducted in the Corps camp in Nigeria revealed that cotton buds were mainly used to relieve itching (50%).
About 18% of the respondents in our survey reported complications from the use of cotton buds. Interestingly, only 9.3% did so in a study conducted at Jos University Teaching Hospital. The most common complications reported in our survey were wax impaction (41.2%) and ear pain (39.7%). The study in Aminu Kano Hospital in Nigeria revealed that foreign body invasion (40.7%) and trauma to the ear canal (24.6%) were the most common adverse events related to cotton bud use. Another complication was otitis externa, which was found to be highly prevalent in our study (23.5%) when compared to another study that reported only one case. This result may be explained by the fact that our participants were all regular attendees of the ENT clinic and were not from the general public. In addition, Nussinovitch et al. reported that otitis externa due to cotton bud usage was reported by 70.1% of their sample; this finding is in line with our results, which showed that otitis externa is not an uncommon complication.
The main source of information regarding the ill-effects of cotton bud usage was found to be media channels, whereas the source which provided the least information was found to be general practitioners (GPs). Moreover, when participants were asked about their perception of the complications, they were unsure of the adverse effects (3.4/5). Patients visit GP offices regularly, so more education is needed to correct the harmful practices that arise as a result of cotton bud misuse. Furthermore, health education programs should be implemented in the community to raise awareness of the issue.
To the best of our knowledge, similar studies to this one (with an emphasis on the prevalence of use and attitudes toward using cotton buds) have not been performed in Saudi Arabia. However, this study has limitations that cannot be overlooked. First, our study has all the limitations inherent to cross-sectional surveys. In addition, the relatively small sample size and the sampling method preclude generalization of our results. In fact, our selection of patients visiting the ENT outpatient clinic may have introduced a bias in our results. Nevertheless, our study serves as a basis for future investigations, which, we believe, should include a larger sample to improve the accuracy of the results and be used to modify this common behavior among the public. In addition, this study offers a plausible explanation regarding the common problems suffered by ENT patients due to the improper use of cotton buds.
| Conclusion|| |
Patients attending the ENT clinic at our tertiary care center seem to have relatively insufficient knowledge and rather lax attitudes toward cotton bud usage and the related complications. Hence, we recommend conducting larger studies and that Saudi health officials organize more educational and awareness programs to address the improper use of cotton buds in the ear.
The authors would like to thank Mayar Alsaqr, Sarah Alangari, Abdulaziz Alanazi, and Fatimah Alangari for their help in collecting the data for this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]