Practice of ear candling during lockdown due to COVID-19 in the Kingdom of Saudi Arabia

ABSTRACT

Objectives:

Cerumen production is a protective process for the ear canal. Cerumen impaction causes unpleasant symptoms. There are various cerumen removal practices. These include irrigation, application of softeners/solvents, mechanical removal, and micro-suction. However, during the lockdown period of the COVID-19 pandemic, some patients opted for some procedures, such as ear candling, which are not evidence-based. This study aimed to explore the awareness of ear candling among otolaryngology doctors and record cases with complications of such practice in the Kingdom of Saudi Arabia (KSA).

Methods:

This was a cross-sectional study. A questionnaire was developed after an extensive literature search, and distributed to otolaryngology residents, fellows, and consultants of different hospitals across the country. A total of 80 respondents agreed to participate in the study.

Results:

A total of 16 doctors reported seeing cases of ear candling, of which 13 patients had different complications, of which ear pain was the most commonly reported. The majority of participants (42.5%) thought the lack of medical access during lockdown enhanced the practice of alternative medicine for ear-related complaints in society compared to 35% of participants who had a neutral response regarding this idea and 22.5% who disagreed.

Conclusions:

Although the practice of ear candling is not widely spread in KSA, different types of ear complications were recorded by the otolaryngologist. We would like to encourage the doctors to report such complications, especially after the lockdown period.

Introduction

Cerumen (earwax) production is a protective process for the ear canal, it is normal unless there is excessive cerumen accumulation causing hearing impairment, pain, or obscuring of the ear drum.[1] When it blocks the ear it might affect the quality of hearing, as well as the change in the earwax amount, which can affect the resonant properties and consequently reduce the efficiency of hearing aids.[2] Cerumen impaction is one of the most common otolaryngology (ENT) conditions, and cerumen removal is one of the most common procedures encountered in ENT practice.[3] There are various earwax removal practices, all of which are usually painless. Some effective and safe procedures performed are irrigation, application of wax softeners/solvents, irrigation following application of wax softeners, mechanical removal, and micro-suction.[2]

The process of ear candling, usually carried by alternative therapists, beauticians, or even by patients themselves, involves placing a hollow candle inside the external auditory canal. The candle is lit for around 15 min. After that, a substance believed to be a mixture of wax, bacteria, and debris comes out.[3] There is currently no scientific proof that ear candling is beneficial. In fact, it may cause more harm than good.[4] Ear candling appears to be popular recently as it is widely advertised, though the mechanism of action has not been verified, and there has been no reliable evidence of a favorable clinical effect.

The World Health Organization (Geneva) declared coronavirus disease-19 (COVID-19) as a public health emergency on March 11, 2020.[5] In Saudi Arabia, the government response to the COVID-19 pandemic was prompt, culminating in a lockdown that mandated the restriction of medical services.[6] As a response to restricted hospital access during the lockdown in 2020, patients started looking for alternative solutions for common medical conditions such as impacted cerumen. This led to some patients with cerumen impaction undergoing different types of procedures that are based on limited evidence, such as ear candling.

Thus, the current study aimed to understand the ear candling complications recorded by ENT practitioners, identify the general effect of the restricted hospital access during the lockdown period on alternative medicine, and explore ear candling awareness among ENT practitioners. To our knowledge, a study on this subject has not been reported before in our nation.

Methods

Study design and participants

This cross-sectional study was conducted in Riyadh, Saudi Arabia, from July 2021 to March 2022. A questionnaire was developed by the authors after an extensive literature search and distributed to ENT doctors at different levels including residents, registrars, fellows, and consultants from different hospitals across different regions of Saudi Arabia (Central, West, East, South, and North). The ethics committee was obtained from Imam Mohamad Ibn Saud Islamic University with project No 93-2020. Date: 10/11/2020.

Study tool and method

A self-administered online survey form with three sections was created with Google forms. The first section was dedicated to gathering demographic information. The second section had specific questions on the knowledge of otolaryngology doctors about the practice of ear candling. Those who had been exposed to patients with a history of ear candling usage were asked certain questions regarding the practice and complications. The last section had questions on ear care during the lockdown period.

The questionnaire, which was written in English, was reviewed by a panel of specialized doctors to get validation and feedback on different items of the survey. After modifying the questionnaire based on their suggestions, the questionnaire was distributed. The methods of distribution included emails to all members of the Saudi Society of Otolaryngology, accounts on social media, and a WhatsApp group for otolaryngology doctors.

Statistical analysis

All statistical analyses were performed using (IBM) SPSS version 19. Descriptive statistics were used to outline the characteristics of respondents using frequencies and percentages for categorical variables.

Results

Demographic characteristics

A total of 80 respondents (men, 45 [56.3%]; women, 35 [43.8%]) agreed to participate in the survey. The majority of participants were between 25 and 35 years of age (n = 50, 62.6%), 18 participants (22.5%) were between 35 and 40 years of age, and 12 participants (15%) were above 40 years of age. Of the total, 92.5% of the respondents were of Saudi nationality. Approximately half of the participants were consultants (n = 38, 47.5%), meanwhile, residents and registrars represented 27.5% and 13.8% of the participants, respectively. The years of experience in ENT practice were less than 5 years in 30% of participants, 6 to 10 years in 41.3%, 11 to 15 in 20%, and more than 15 in 8.8%. Almost two-thirds (70%) of the participants worked in governmental hospitals, 5 participants (6.3%) worked in private hospitals, and 19 participants (23.8%) worked in both governmental and private hospitals. Approximately 56.3% of participants worked in the central region of the Kingdom of Saudi Arabia (KSA) and 23.8% in the western region.

Knowledge of ear candling among otolaryngology doctors

Regarding ear candling awareness, 51 participants (63.8%) had heard about ear candling before. The equal agreement, disagreement, and neutral response percentages were noticed for the question: “the practice of ear candling based on clear mechanism of action (vacuum and heat effect)”.

However, 66 participants (82.6%) reported that they would not recommend using ear candling.

When asked about their opinions about possible indications for ear candling, the participants reported that aural fullness was possibly the most common indication for ear candling (n = 31, 38.75%), followed by ear itching (n = 11, 13.75%), and otalgia (n = 10, 12.5%). They also reported that ear candling may be used for relieving flu-like symptoms, tinnitus, and excessive ear wax [Figure 1].

Figure 1.

Indications of the use of ear candling

Popularity and safety of ear candling

Regarding ear candling awareness, 64 participants (80%) reported that they were not aware of any patients in their practice using ear candles.

Regarding the safety and efficacy of ear candling, 69 participants (86.3%) reported that they were not aware of any patients in their practice using ear candles. Eleven participants (13.7%) reported that they had encountered patients who had previously used ear candling. From those who had encountered patients who had resulting complications from ear candling, 13 cases were reported (two participants reported two such cases) [Table 1].

Table 1.

Awareness of ear candling and its complications

Item	Number of respondents	%
Are you aware of any patients in your practice who use ear candles?
Yes	16	20.0
No	64	80.0
Have you seen any complications resulting from the use of ear candles?
Yes	11	13.7
No	69	86.3

Several complications of ear candling were reported, including ear pain (n = 13, 16.3%), burning of the pinna or external auditory canal (n = 9, 11.3%), burning of hair or scalp (n = 6, 7.5%), ear blockage (n = 5, 6.3%), ear discharge (n = 5, 6.3%), and tympanic membrane perforation (n = 4, 5%). The presence of a foreign body (the tip of the candle) in the external canal was reported by one participant. However, none of them reported serious complications that required long-term treatment [Figure 2].

Figure 2.

Complications due to ear candling

Alternative medicine during the lockdown period of COVID-19

When asked about the effect of the lockdown period, only 33 participants (41.25%) agreed that the fear of COVID-19 infection during the pandemic period enhanced the practice of alternative medicine among society members for ear-related complaints.

The majority of participants (n = 34, 42.5%) agreed that the lack of medical access during lockdown enhanced the practice of alternative medicine in the society for ear-related complaints compared to 35% of participants who had a neutral response regarding this idea and 22.5% who disagreed. Moreover, 34 participants (42.5%) reported that they had not encountered more patients with complications from using alternative medicine for ear-related complaints during the lockdown period compared to 31 participants (38.8%) who had a neutral response and 15 participants (18.7%) who agreed on that the number of cases with such complications increased during lockdown [Table 2].

Table 2.

Popularity of alternative medicines during the lockdown due to COVID-19

Item	Agree	Strongly agree	Neutral	Disagree	Strongly disagree
Popularity of alternative medicines during the lockdown period of COVID-19
I think the fear of COVID-19 infection during the pandemic period enhanced the practice of alternative medicines among society members for ear-related complaints	26 (32.5%)	7 (8.8%)	27 (33.8%)	9 (11.3%)	11 (13.8%)
I think the lack of medical access during lockdown enhanced the practice of alternative medicines among society members for ear-related complaints	26 (32.5%)	8 (10%)	28 (35%)	11 (13.8%)	7 (8.8%)
I have seen more patients with complications of using alternative medicines for ear-related complaints after the lockdown period	13 (16.3%)	2 (2.5%)	31 (38.8%)	23 (28.8%)	11 (13.8%)

Discussion

The lockdown period resulted in a noticeable change in patients’ behavior resulting in a significant reduction in hospital visits and admissions.[7,8]

We assumed that ear candling practice might be one of the alternative methods that had increased in popularity. Some patients often try it to alleviate various ear complaints before visiting the ENT clinic.

The data in this report demonstrate the general effect of the lockdown period on ear candling usage in addition to exploring ear candling awareness among otolaryngologists. With regard to the awareness of ear candling in Saudi Arabia, approximately half of the participants were aware of ear candling. However, most of them had no exposure to any patient who used ear candling in their practice. Therefore, ear candling is not as common in KSA and is not frequently encountered in clinics when compared to the frequency of encountering the practice reported in studies conducted in other countries.[9,10] In 1996, Seely et al.[11] conducted an epidemiological survey about ear candling on the members of the North West Academy of Otolaryngology. He reported that 40 physicians (32.7%) were aware of ear candling, and 14 had treated patients with different complications.

During the lockdown period of COVID-19, some practitioners reported an increase in alternative medicine cases when compared to the period before lockdown because the COVID-19 pandemic reduced the accessibility to medical services. We believe that ear candling could represent one of the alternative medicines used during that period.

Reportedly, there were some complications that occur because of ear candle usage, which shows that ear candling can be hazardous. These include ear pain, burning of the pinna or external auditory canal, burning of the hair or the scalp, ear blockage, ear discharge, and tympanic membrane perforation.[3,11] Another report indicates hearing loss and the sensation of a plugged ear in a woman who used ear candling.[12]

According to some reports, ear candling appears to be popular around the world and is widely advertised.[3,10] However, based on our local study, more than half of the doctors were aware of ear candling but the majority of them had not encountered any patient in their practice who had used ear candles. This might be because not all ear candling users seek medical service unless they have consequent complications.

The majority of the participants agreed that the fear of COVID-19 infection during the lockdown period enhanced the practice of alternative medicine in society for ear-related complaints. Evidence on the increasing use of ear candling can be better obtained if ENT doctors can be encouraged to report and conduct a retrospective review of such cases.

This is the first study that highlighted the ear candling practice in KSA with diverse geographic distribution. However, there are some limitations including the response bias to the questionnaire. Further studies on the general community are warranted to understand the long-term effect of lockdown on the use of alternative medicines including ear candling.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.