Most CTA-related injuries occurred with children themselves handling CTAs while cleaning their ears. Foreign body and tympanic membrane perforation were the most common associated diagnoses. Despite warnings against the use of CTAs in the ear canal and use of CTAs by children, these injuries continued to occur. Additional injury prevention strategies through further parent/caregiver and child education are warranted.

Between 1990 and 2010, an estimated 263 338 children aged <18 years were treated for CTA-related ear injuries in US hospital EDs. There was a nonsignificant increase in the annual number of injuries from 1990 through 2001 (78.2%) and a significant decrease from 2001 through 2010 (26.0%). Younger children sustained the highest rate of injury (32.2 per 100 000 for age 0-3 years). Ear cleaning was the most frequently documented circumstance at the time of injury (73.2%), and patients themselves were most commonly handling the CTA (76.9%). Foreign body sensation (39.2%) and bleeding (34.8%) were commonly documented reasons for visiting the ED. The presence of a foreign body (29.7%) and tympanic membrane perforation (25.3%) were common diagnoses.

Data on CTA-related ear injuries among children presenting to US emergency departments (EDs) from 1990 through 2010 were obtained from the National Electronic Injury Surveillance System.

In 1923, Leo Gerstenzang invented the cotton-tip applicator (CTA) after watching his wife use cotton on toothpicks to clean their baby's ears.The first medical concerns regarding the risk associated with CTA use were published in 1972, citing reports of tympanic membrane perforation (TMP), otitis externa, and cerumen impaction.Despite manufacturers' warning labels and clinicians' advice to avoid using CTAs inside the ear canal, CTA use remains the most common cause of accidental penetrating ear injury in children.

Although CTAs have many uses, they are most commonly used for ear hygiene, principally to remove cerumen.Numerous studies have found an association between the use of CTAs for ear hygiene and the presence of cerumen impaction,TMP,foreign body,and otitis externa.According to a UK study, the majority of mothers who use CTAs to care for their children also use the same CTAs for themselves.Common reasons cited for using CTAs were believing it was a good idea, saw them advertised, and saw others use them.

This study used the National Electronic Injury Surveillance System (NEISS), a nationally representative database, to describe the epidemiology and trends associated with pediatric ear trauma related to CTA use in the US. The findings from this study can be used to generate measures to help prevent future ear injury among the pediatric population.

Statistical analysis was conducted using SPSS version 21 (IBM, Armonk, New York) and SAS version 9.3 (SAS Institute, Cary, North Carolina). PROC SURVEYFREQ and PROC SURVEYMEANS procedures in SAS 9.3, which accounted for the NEISS sampling design and sample weights, were used to calculate national estimates for CTA-related ear injuries and the mean and median age of patients. Injury rates per 100 000 US residents aged <18 years were calculated using US Census Bureau population estimates.Trends were analyzed using weighted linear regression, with weights equal to the inverse of the variance of the estimated statistic. If the slope of the regression line was significantly different from 0, then the overall percentage of increase/decrease was reported as significant. If the slope was not significantly different from 0, then the overall percentage of increase/decrease was reported as not significant. Additional statistical analyses included Roa-Scott's χanalysis and relative risk calculation with 95% CIs. Statistical significance was established at α = 0.05. National estimates reported in this article are stable estimates unless stated otherwise. As estimate is potentially unstable at a sample size <20 cases, an estimate <1200, or a coefficient of variation >30%. Unknown values for specific variables are given in the table but are excluded from the analysis. This study was approved by the Institutional Review Board of the Research Institute at Nationwide Children's Hospital.

Intercensal estimates of the resident population by single year of age, sex, race, and hispanic origin for the United States: April 1, 2000 to July 1, 2010.

The NEISS diagnosis codes and case narratives were used to reclassify the diagnosis into the following ear-specific injuries: TMP (NEISS narrative containing TMP or NEISS diagnosis coded as puncture), foreign body, soft tissue injury (including NEISS categories of abrasion/contusion and hematoma), laceration, hemorrhage, and other (including NEISS categories of avulsion and other). Note that because TMP is considered one of the most severe ear injuries, the NEISS narratives were used to initially identify these cases.

The case narratives were used to code additional information regarding the person handling the CTA at the time of injury, circumstances of the injury, and reason for the ED visit. The person handling the CTA was classified as self, parent, sibling, or other (eg, other relative, friend). Circumstances surrounding the injury were classified as cleaning, playing, fell/tripped/slipped/ran into, bumped/pushed/hit by someone, or other (eg, laid down/rolled over, removing water, scratching/itching, imitating someone). The reason for the ED visit was coded as foreign body sensation, bleeding, ear pain, ear pain and bleeding, or other (eg, discharge, hearing loss, dizziness, ear pain and bleeding).

The NEISS variables for age, sex, location of incident, and ED disposition were recategorized for analyses. Patient ages was divided into 3 groups: 0-3 years, 4-7 years, and 8-17 years. These age groups were created based on children's ability to provide overall self-care, which typically transitions from complete dependence to partial dependence to independence from parent/caregiver. Location of the incident was classified as home (including NEISS categories of home, apartment/condominium, and manufactured/mobile home) or other (including school, sports facility, and recreational area). ED disposition was classified as treated and released, admitted (included NEISS categories of treated and transferred to another hospital, treated and admitted for hospitalization, and held for observation), or left against medical advice.

Because there is no specific NEISS product code for CTAs, all pediatric ear injury cases were first queried from the NEISS using the NEISS body part injured code 94 for ear or if the case narrative contained the word “ear.” From these cases, a case was identified as CTA-related if the case narrative contained any of the following alternative terms for CTA: “Q-tip,” “cotton bud,” “cotton swab,” and “cotton-tipped swab.” Note that “Q-tip” is a trademarked name commonly used term to refer to CTAs of any brand (including Q-tips). The CTA-related ear injury cases thus identified were further reviewed to select only cases involving ear trauma or ear injury. Cases involving impaction or infection, such as otitis media and otitis externa, were excluded, given the difficulty in ascertaining whether they were present before CTA insertion or developed immediately after its use.

Data on ear injuries in children aged <18 years treated in hospital emergency departments (EDs) in the US and its territories between 1990 and 2010 were obtained from the NEISS database. More recent data were not available because the NEISS stopped coding for CTA-related injuries after 2010. The NEISS is organized by the US Consumer Product Safety Commission to monitor consumer product-, sports-, and recreational activity-related injuries. The NEISS collects data from a sample of approximately 100 hospitals, which represents a stratified probability sample of more than 5300 hospitals located in the US and its territories with a 24-hour ED and at least 6 beds.The NEISS database includes information about patient demographics, body part injured, product(s) involved, injury diagnosis, and a brief case narrative.

A diagnosis was documented in 99.8% of the CTA-related ear injuries. Foreign body (29.7%) was the most common diagnosis, followed by TMP (25.3%) and then soft tissue injury (23.1%) ( Table II ). Lacerations accounted for only 5% of the injuries. Foreign body was the most common diagnosis in the children aged 8-17 years (52.3%), whereas TMP was the most common diagnosis in those aged <8 years ( Table II ). Children aged 8-17 years were 2.8 times (95% CI, 2.42-3.25 times) more likely to be diagnosed with foreign body, whereas children aged <8 years were 1.67 times (95% CI, 1.46-1.91 times) more likely to be diagnosed with TMP. Among the CTA-related injuries associated with ear cleaning, soft tissue injuries (26.3%), foreign body sensation (25.0%), and TMP (21.7%) together accounted for almost three-quarters of the injuries ( Table III ).

Among the 99.8% of CTA-related ear injuries with documented disposition from an ED, almost all of the patients (99.2%) were treated and released. The reason for the ED visit was documented for 56.1% of the injuries. The most common reason for an ED visit was foreign body sensation (39.2%), followed by bleeding (34.8%) and ear pain (17.1%) ( Table I ). The most frequent reason for an ED visit was ear bleeding (58.3%) in children aged 0-3 years and foreign body sensation (61.0%) in children aged 8-17 years ( Table II ).

The circumstances associated with CTA-related ear injuries were documented in 31.3% of the injuries; among these cases, 73.2% were associated with cleaning, 9.7% were associated with playing, and 9.3% were associated with fell/tripped/slipped/ran into ( Table I ). Of the 60.4% of the injuries where the person handling the CTA was identified, patients themselves handling the CTA accounted for 76.9% of injuries, followed by a parent (15.8%) and a sibling (6.2%) ( Table II ). Children aged 0-3 years were 4.68 times (95% CI, 3.13-7.00 times) more likely than children aged 4-17 years to have incurred an ear injury while playing. The likelihood of a parent handling the CTA associated with a cleaning injury decreased with the child's increasing age ( Table III ). The person handling the CTA was documented in 85.2% of the ear cleaning-related injuries. A parent handled the CTA in 79.1% of the cleaning injuries among children aged <4 years but only in 10.3% of the injuries among children aged 8-17 years. Patients aged 0-7 years were 6.30 times (95% CI, 4.73-8.39 times) more likely than children aged 8-17 years to be injured during ear cleaning by their parents.

Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

† Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

† Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

† Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

† Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

Percentages for available and unknown/missing data are of the actual number of cases.

* Percentages for available and unknown/missing data are of the actual number of cases.

Among the 61.7% of the injuries for which the location of the injury was documented, 99.4% occurred at home ( Table I ). The mean ± SD age of patients treated for CTA-related ear injuries was 6.32 ± 0.13 years, and the median age was 4.09 years (IQR, 1.98-9.09 years). The number and rate of injuries peaked at age 2 years and then declined through adolescence ( Figure , B). Patients aged 0-3 years accounted for 40.2% of the injuries, and patients aged <8 years accounted for 67.4%. Patients aged 0-3 years had the highest injury rate per 100 000 children (32.2; 95% CI, 25.5-38.9), followed by those aged 4-7 years (21.7; 95% CI, 16.8-26.5) and those aged 8-17 years (10.3; 95% CI, 7.6-12.9). Males accounted for 55.6% of the injuries ( Table II ). The majority of the CTA-related ear injuries among children aged 0-3 years (61.3%) and children aged 4-7 years (56.9%) occurred in males, whereas females account for the majority of the CTA-related ear injuries in children aged 8-17 years (52.5%).

Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

† Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

† Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

† Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

† Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

Percentages for available and unknown/missing data are of the actual number of cases.

* Percentages for available and unknown/missing data are of the actual number of cases.

Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

† Percentages of weighted available data, which might not sum to 100.0% owing to rounding error.

Percentages for available and unknown/missing data are of the actual number of cases.

* Percentages for available and unknown/missing data are of the actual number of cases.

Between 1990 and 2010, an estimated 263 338 (95% CI, 204 871-321 804) children aged <18 years were treated in US hospital EDs for CTA-related ear injuries, for an annual average of 12 540 injuries (95% CI, 9756-15 324), or 17.6 injuries (95% CI, 13.7-21.5) per 100 000 children. There was a nonsignificant 78.2% increase (m = 322.6; P = .059) in the annual number of CTA-related ear injuries, from 9794 injuries (95% CI, 6722-12 866) in 1990 to 17 449 injuries (95% CI, 9107-25 790) in 2001, followed by a decrease to 12 911 injuries (95% CI, 9621-16 202) in 2010, a significant decrease of 26.0% (m = −442.5; P = .007) ( Figure , A). This corresponded to a nonsignificant 57.4% (m = 0.29; P = .231) increase in the annual injury rate per 100 000 children aged <18 years from 1990 (15.3; 95% CI, 10.5-20.0) through 2001 (24.0; 95% CI, 12.5-35.5) and then a significant decrease by 27.5% (m = −0.64; P = .006) from 2001 (24.0; 95% CI, 12.5-35.5) through 2010 (17.4; 95% CI, 13.0-21.8) ( Figure , A).

NEISS 1990-2010. A, Estimated annual number and rate of injuries associated with CTA use. B, Estimated number and rate of injuries associated with CTA use, by age.

Figure NEISS 1990-2010. A, Estimated annual number and rate of injuries associated with CTA use. B, Estimated number and rate of injuries associated with CTA use, by age.

Discussion

Over the study period, an estimated >260 000 children aged <18 years were treated for CTA-related ear injuries in US EDs. This injury rate varied during the study period, but what may have led to the changes at those specific time points is unclear. Otolaryngologists do not recommend using CTAs in the ear canal because of the risk of injury. Several commercially available brands of CTAs state on their packaging that they are not to be used in the ear or by children.

In the present study, the characteristics of CTA-related ear injuries varied by children's age, with more than two-thirds of the injuries occurring in children aged <8 years. Children aged 8-17 years were more likely to be diagnosed with foreign body, and those aged 0-7 years were more likely to be diagnosed with TMP. The diagnosis of foreign body may be related to part of the CTA remaining in the ear canal or to clinical suspicion of another foreign object. The most common reason for ED visits was bleeding in children aged 0-3 years and foreign body sensation in children aged 8-17 years. Although bleeding might not be coded as the primary diagnosis in the NEISS, it is possible that blood may be present from an injury to the canal or from TMP, with limited visualization of the tympanic membrane in the acute setting complicating the diagnosis. Even though it can be indicative of a more severe complication, the documented symptom of dizziness was uncommon.

2 Smith M.

Darrat I.

Seidman M. Otologic complications of cotton swab use: one institution's experience. , 20 Neuenschwander M.C.

Deutsch E.S.

Cornetta A.

Willcox T.O. Penetrating middle ear trauma: a report of 2 cases. 2 Smith M.

Darrat I.

Seidman M. Otologic complications of cotton swab use: one institution's experience. 21 Chiang T.

Merz M. Cerebellar abscess resulting from multiple foreign body-induced otitis in a pediatric patient. , 22 Goldman S.A.

Ankerstjerne J.K.

Welker K.B.

Chen D.A. Fatal meningitis and brain abscess resulting from foreign body-induced otomastoiditis. 2 Smith M.

Darrat I.

Seidman M. Otologic complications of cotton swab use: one institution's experience. Nearly all of the patients with CTA-related ear injuries were treated and released, but this does not imply that some of the injuries were not serious. Previous studies have documented delayed treatment for severe CTA injuries, such as TMP, ossicular dislocation (joints between malleus-incus-stapes, or stapes footplate subluxation), hearing loss (conductive, sensorineural, or mixed), perilymphatic fistula, and facial nerve paralysis.Smith et al reported a 7.4% rate of delayed surgical tympanic membrane repair after CTA injury.In that study, TMP was seen in nearly 25% of cases, and foreign body sensation was the most common reason for ED visits. Typically, a retained foreign body in the ear canal causes no complications if removed in a timely manner, but when not removed, the presence of a CTA as a chronic ear foreign body has been linked to intracranial complications, including brain abscess and fatal meningitis.Perilymphatic fistula can present with symptoms of dizziness, vertigo, balance disturbances, and sudden or fluctuating sensorineural hearing loss. Clinical suspicion of perilymphatic fistula or the presence of facial nerve paralysis warrants immediate otolaryngology consultation for surgical evaluation.

2 Smith M.

Darrat I.

Seidman M. Otologic complications of cotton swab use: one institution's experience. , 10 Kravitz H.

Neyhus A.I.

Dale D.O.

Laker H.I.

Gomberg R.M.

Korach A. The cotton-tipped swab: a major cause of ear injury and hearing loss. , 12 Mick P.

Moxham P.

Ludemann J. Penetrating and blast ear trauma: 7-year review of two pediatric practices. , 13 Marin J.R.

Trainor J.L. Foreign body removal from the external auditory canal in a pediatric emergency department. , 14 Tiago R.S.

Salgado D.C.

Corrêa J.P.

Pio M.R.

Lambert E.E. Foreign body in ear, nose and oropharynx: experience from a tertiary hospital. , 15 Svider P.F.

Vong A.

Sheyn A.

Bojrab 2nd, D.I.

Hong R.S.

Eloy J.A.

et al. What are we putting in our ears? A consumer product analysis of aural foreign bodies. 5 Nagala S.

Singh P.

Tostevin P. Extent of cotton-bud use in ears. 2 Smith M.

Darrat I.

Seidman M. Otologic complications of cotton swab use: one institution's experience. , 3 Hobson J.C.

Lavy J.A. Use and abuse of cotton buds. , 5 Nagala S.

Singh P.

Tostevin P. Extent of cotton-bud use in ears. 5 Nagala S.

Singh P.

Tostevin P. Extent of cotton-bud use in ears. , 9 Hanger H.C.

Mulley G.P. Cerumen: its fascination and clinical importance: a review. 8 Baxter P. Association between use of cotton tipped swabs and cerumen plugs. , 9 Hanger H.C.

Mulley G.P. Cerumen: its fascination and clinical importance: a review. , 10 Kravitz H.

Neyhus A.I.

Dale D.O.

Laker H.I.

Gomberg R.M.

Korach A. The cotton-tipped swab: a major cause of ear injury and hearing loss. , 11 Macknin M.L.

Talo H.

Medendrop S.V. Effect of cotton-tipped swab use on ear-wax occlusion. 23 McCarter D.F.

Courtney A.U.

Pollart S.M. Cerumen impaction. Cleaning was the most commonly documented circumstance surrounding the ear injuries, accounting for an estimated 73.2% of the injuries. Injuries associated with cleaning were often diagnosed as soft tissue injuries, foreign body, and TMP, consistent with other studies.According to a UK study, 68% of people surveyed used CTAs in their ear and 96% of them used CTAs primarily to remove cerumen.There is a misconception among the general public that the ear canal requires regular cleaning and that CTAs are good products for that purpose.Contrary to public belief, cerumen is beneficial for the ear, and the ear has a natural mechanism for self-cleaning.Previous studies have shown an association between routine use of CTAs in ear canal and cerumen impaction.If cerumen removal is needed, safer methods that do not involve CTAs should be used. These methods include gentle irrigation, cerumenolytics, or consultation with an otolaryngologist for microscopic removal with an instrument.

5 Nagala S.

Singh P.

Tostevin P. Extent of cotton-bud use in ears. , 8 Baxter P. Association between use of cotton tipped swabs and cerumen plugs. 10 Kravitz H.

Neyhus A.I.

Dale D.O.

Laker H.I.

Gomberg R.M.

Korach A. The cotton-tipped swab: a major cause of ear injury and hearing loss. Although the number and rate of injuries has declined by >25% from 2001 through 2010, still >12 000 children were treated for CTA-related ear injuries in 2010. The key to eliminating the risk of ear injury associated with CTA use is to promote awareness of the potential complications associated with cleaning the ears with CTAs and to educate the public on proper ways to care for their ears without the use of CTAs. Several potential avenues to increase public awareness include distributing or posting flyers at primary care centers, airing public service announcements on television or radio, and providing more effective product warning labels.Many CTA manufacturers include warning labels on their packages; however, to our knowledge, this is not a mandatory warning, and it is insufficient to prevent injuries. A stronger warning label including an easily visible pictogram of an ear with a red circle and line across it may be more effective than words alone. In the present study, a parent handled the CTA in almost 80% of the ear cleaning-related injuries in children aged <4 years. Thus, another consideration is to instruct new mothers to avoid using CTAs in their newborn's ears at the time of discharge after birth.In addition, proper storage in the home setting, such as keeping CTAs out of children's reach and storing them in a child-resistant container, may help prevent CTA injuries associated with exploratory behavior.

This study has several limitations. The biggest limitation is that NEISS case narratives sometimes lack complete details pertaining to the event of the injury because health care professionals may not always document the specific details that led to the injury. Therefore, variables created from the narratives, such as injury circumstances, person handling the CTA, and reason for the ED visit, contained high percentages of missing values and thus might not be representative of all CTA-related ear injuries. For example, ear pain was not specified in many cases, but it can be presumed that the child had pain if the injury was sufficiently serious to prompt an ED visit. The number of children with CTA-related ear injuries in this study is an underestimate of the total number, because NEISS data do not include children presenting to healthcare settings other than an ED or those with injuries who did not receive professional medical attention. Because NEISS data are obtained from EDs, injury diagnoses after specialist evaluation may be more severe. Owing to a lack of CTA exposure data, population-based injury rates using US census data were calculated as an alternative. Finally, because the NEISS stopped coding for CTA injuries after 2010, we were unable to provide any morerecent data trends or further analysis; however, this is ascomprehensive a study as can be performed using available data on documented ear injuries in an ED setting.

In this study, the use of CTAs to clean children's ears accounted for an estimated 73.2% of the injuries with a documented circumstance. Despite the decline in the number of CTA-related ear injuries during the last half of the study period, and despite the presence of warning labels on CTA packages, the prevalence of these injuries remains relatively high. Potential measures to help reduce these injuries include increasing awareness to dispel the notion that the ears need to be manually cleaned in the home setting, and providing more effective warning labels on product packages. CTA-related ear injuries can be prevented through improved consumer education.