PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 30 no. 2 July – december 2015

LETTER TO THE EDITOR

56 PhiliPPine Journal of otolaryngology-head and neck Surgery

Philipp J Otolaryngol Head Neck Surg 2015; 30 (2): 56-58 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.

Dear Editor,

The tympanic membrane and the ossicular chain contribute roughly 28 dB in hearing gain. In
chronic suppurative otitis media, loss of tympanic membrane and lysis of the ossicular chain are
significant causes of hearing loss.1 Through the years, hearing impairment has been augmented
using various devices such as ear trumpets, carbon hearing aids, vacuum tube and transistor
hearing aids, bone anchored hearing aids and cochlear implants.2 This case report describes how
a cotton wick was used to amplify sound.

Case RepoRt
A 65-year-old man consulted for hearing loss. He had a childhood history of recurrent ear

discharge and hearing loss and was diagnosed with chronic suppurative otitis media. At age 55, he
underwent tympanomastoidectomy of the left ear. While surgery stopped the left ear discharge,
there was complete hearing loss in this ear. For this reason, he opted not to have surgery on the
right ear. There was subsequent recurrent ear disease of the right ear. He would clean his ear
with a cotton wick and apply antibiotic drops during bouts of ear discharge. He observed that
leaving the ear wick with a few drops of topical otic preparations (polymyxin-neomycin-steroid
or ofloxacin) would lessen the frequency of ear discharge and improve his hearing. He found
that morning application and positioning of the cotton wick in his right ear using tweezers and a
toothpick allowed him to hear adequately to conduct his daily activities as an architect. (Figure 1,
2) The fear of hearing loss from another surgery, cost of a commercial hearing aid and great utility
of a simple cotton wick made him continue his practice for these ten years.

Examination of the right middle ear without the cotton wick showed thickened mucosa,
absent malleus and incus structures, a patent Eustachian tube and a near – total tympanic
membrane perforation. There was no keratinous material or foul smelling discharge. (Figure 3)
Pure tone audiometry confirmed that with the cotton wick, the right air-bone gap decreased at
500 hz, 1kHz, 2Kh and 4KHz by 30db, 40dB, 35dB and 25dB, respectively. (Table 1)

a Cotton Wick Improves Hearing in a patient
with profound Hearing Loss

Ryner Jose D. Carrillo, MD, MSc1,2

Precious Eunice R. Grullo, MD, MPH1

Maria Luz M. San Agustin, RN, MClinAudio1,3

1Department of Otorhinolaryngology
Philippine General Hospital, University of the Philippines
Manila

2Department of Anatomy
College of Medicine, University of the Philippines Manila

3Philippine National Ear Institute
National Institutes of Health, University of the Philippines
Manila

Correspondence: Dr. Ryner Jose D. Carrillo
Department of Otorhinolaryngology
Ward 10 Philippine General Hospital
Taft Avenue, Ermita, Manila 1000
Philippines
Phone: (632) 554 8467
Email: ryner_c@yahoo.com
Reprints will not be available from the authors.

The authors declare that this represents original material that
is not being considered for publication elsewhere in full or in
part, in print or electronic media; that the manuscript has been
read and approved by all the authors, that the requirements
for authorship have been met by each authors, and that each
author believes that the manuscript represents honest work.

Disclosures: The authors signed disclosures that there are no
financial or other (including personal) relationships, intellectual
passion, political or religious beliefs, and institutional affiliations
that might lead to a conflict of interest

PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 30 no. 2 July – december 2015

PhiliPPine Journal of otolaryngology-head and neck Surgery 57

LETTER TO THE EDITOR

Figure 1. Cotton wick is shaped using a toothpick and tweezers applied in the
ear canal and repositioned using the same tools while performing a valsalva
maneuver.

Figure 2. Cotton wick positioned in right ear canal. Figure 3. Right middle ear with absent malleus-incus ossicles, thickened middle
ear mucosa and patent Eustachian tube.

No “cotton wick”
500 Hz 500 Hz1kHz 1kHz2KHz 2KHz4KHz 4KHz

With “cotton wick”

Air
conduction AD

Pure tone
average

Bone
conduction AD

Air bone gap

ABG gain

ABG average dB

107.5

56.25

120

110

120

NR at 65

23.75

NR at 65

Table 1. Pure tone audiometry without and with the “cotton wick”

PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 30 no. 2 July – december 2015

LETTER TO THE EDITOR

58 PhiliPPine Journal of otolaryngology-head and neck Surgery

ReFeReNCes
1. Chien W, Lee D. Physiology of the auditory system. In: Flint P, Haughey B, Lund V, Niparko J,

Robbins T, Thomas R, Lesperance M, editors. Cummings otolaryngology head and neck surgery.
6th ed. Canada: Saunders; 2015. p1995.

2. Hearing aid museum.com [homepage in the internet]. Philadelphia: Center for Hearing; c2006-
2015. [cited 2015 Aug 10]. Available from: http://www.hearingaidmuseum.com/gallery.htm

3. Schlauch R, Nelson P. Basic test and procedures. In: Katz J editor. Handbook of clinical audiology,
7th ed. Philadelphia: Wolters Kluwer Health; 2015. p30.

4. Carrillo RJC, Yang NW, Abes GT. Relationship of Pure Tone Audiometry and Ossicular
Discontinuity in Chronic Suppurative Otitis Media. Philipp J Otolaryngol Head Neck Surg. 2006;
21(1-2):5-10.

5. Triana R. Revision tympanoplasty. In: Carrasco V and Pillsbury H. Revision otologic surgery. New
York: Thieme Medical Publishing; 1997. p.81-82.

DIsCUssIoN
At different anatomic levels, mechanical sound energy is amplified

and transmitted to the functional parts of the ear. The tympanic
membrane and oval window ratio of 21:1 and malleus-incus lever
mechanism ratio of 1.3:1 provide a 28 dB amplification of conductive
hearing.1 This gain is reflected by frequency specific air-bone gaps
which can range between 25-40 dB. With the contribution from the
external ear, the overall conductive gain is 60 dB.1,3 Damage to the
auditory system often results in a loss of hearing sensitivity that is
frequency – specific. The presence of a frequency – specific wide air-
bone gap suggests ossicular chain discontinuity among patients with
chronic otitis media.4 Narrowing of the air-bone gap which in this case
was provided by insertion of the cotton wick may lead to at least partial
restoration of ossicular coupling.

The ability of the cotton wick to improve hearing may be attributed
to its possession of characteristics for sound conduction and acoustic
impedance such as stiffness, resistance and mass. The effectiveness of
the cotton wick was reported to be dependent on its positioning in the
ear; the patient would have to insert the wick down to the level of the
promontory or oval window occasionally blow his nose or reposition
the cotton wick to achieve an acceptable hearing level. However, for a
patient with completely deaf contralateral ear, a 32.5 dB gain in hearing
is very pronounced and significant.

The hearing gain produced by the cotton wick only amplified the air

conductive component of hearing but not bone conduction. While it
afforded amplification of sound and a route of medicine administration,
it may also have contributed to sensorineural hearing loss brought
about by ototoxicity of medications and thickening of the oval and
round window from chronic irritation. For this reason, utmost caution
must be advised before considering use of a “cotton wick” to amplify
hearing in this manner-- a practice we do not endorse.

The cotton wick may have served as a vibrating piston on top of
the oval window which amplified hearing. Such a mechanism may
conceivably prognosticate potential gain from a contemplated
tympanoplasty in the same way that the “paper patch test”5 predicts
simple myringoplasty outcomes. Having said that, the diagnostic utility
of such a cotton wick requires further investigation before potential
clinical applications such as prognostication of tympanoplasty are
theorized. Could future studies show that a preoperative cotton wick
(or equivalent device) may approximate potential gains from a good
tympanoplasty with ossiculoplasty in a patient with total tympanic
perforation and ossicular chain loss?

Sincerely,
Ryner Jose D. Carrillo, MD, MSc
Precious Eunice R. Grullo, MD, MPH
Maria Luz M. San Agustin, RN, MClinAudio