dear anthony

as you know ,the bile is conjucated bilirobin which produces in hepatocyte and excreted in bile tree into intestine. and the reason of the taste of earwax is not billirobin

You know, Anthony. I think you are right. We noted some years back in our research that there bile secretes in the concha of the human pinna, and just never analyzed for it in the cerumen. While bile, as Habibollah ably pointed out, secretes mainly into the duodenum and upper intestinal tract--then, most of it recaptured in the transverse colon to be sent back to the liver, excessive bile is sometimes also secreted into the exosystem's gatekeeper and largest organ of the body, the skin itself. So, if we find it on the back of hands and in bowls of ears, why not in cerumen? 

"You know, Anthony. I think you are right"

Well, I never expected this -- it really was a bit of a wild guess!   However, if true, it is really interesting as it indicates an unrecognised (though not by Hippocrates?) but important anatomical pathway from the bottom to the top of the body, transporting such things as cancers (rhabdomyosarcoma), viruses (herpes zoster), fluid (otitis externa), etc.  

   Is there any chance you could publish your findings?

During the early days of working with video otoscopy (1991-1994) I was asked by Starkey Labs to explore with a couple others some of the potential uses and practical implications of the technology. Doing so, we bumped into a lot of new things that could be viewed by trained practitioners through this new means of magnification and lighting into the EAC.

Comparing our findings with Johnson and Hawke (variously 1966-1978), we noted tissue desquamation pathways, differentiation of keratin (ie, corneum stratum), a better way for explaining several EAC Reflexes that were incited by earmold insertion (via mechanoreceptor interaction with the Arnold's Brand of Vagus, Trigmeminal, Facial, Tensor Tympani, and 4th Cervical at the Tympanic Plexus), epithelial differentiation, etc. We noted secretions of bile and various lipids in the concha, but did not look for it in the EAC. But I've no doubt some makes it way there as it does in many areas of the body--probably, one of the most important outcomes of our work was observing and getting a better understanding of the Septic Keratosis Obturans, what I call "the ingrown toe nail of the ear". I'm attaching a short monograph on that in case you and or someone could use it. Since then, we've also refined our behavioral models and published a few items on it, including my Video Otoscopy: A Quantitative View (a study in book form  not available online, but available through purchase at DigiCare Behavioral Research should you want a copy. As far as I am concerned, the more we study the ear the more we find there is to know, and have a long way to go in understanding the genetics and some very complex immunological cascades arising from the head and neck region. But I thought your question about bile in cerumen was an interesting one, and will probably mention it in my lecture to Mid America Conference (Cincinnati, OH) tomorrow when I present on Advanced Video Otoscopy if you don't mind. Thanks again, Anthony!

"We noted secretions of bile and various lipids in the concha, but did not look for it in the EAC. But I've no doubt some makes it way there as it does in many areas of the body--probably"

This purported anatomical route from the bottom to top of the body must not just exteriorise at the EAM.  I asked about earwax as there is a discrete and testable product.  In vicarious menstruation, for example, blood can exit from ear, nose, eyes, etc.

"one of the most important outcomes of our work was observing and getting a better understanding of the Septic Keratosis Obturans, what I call "the ingrown toe nail of the ear".

I know nothing about SKO, but wonder if you have not hit the nail on the head!   See this extract from the best.gout.remedies website:

"And sometimes it goes for both at once, or one after the other, switching its attack within 24 hours. Tophi are more likely to develop here than in other gouty areas, albeit in a much smaller way. Unlike other places, there are no juicy joints in the external ears to attract a gout attack, and gout doesn’t go for the area where the visible ear connects to the head, but what probably promotes gout MSU crystal deposition in the ears - which over time leads to tophaceous gout, (tophi) - are the same factors as those for the big toes. Except that the big toes have joints which have pressure put on them, which isn’t put on the ears. So why does gout go for the ears?"

Answer:  because the proposed route goes from head to toe, and once crystals get into it, they can end up anywhere along it.   The switching I think is a real clue to the underlying hydrodynamic mechanism.   Does otitis externa alternate between ears?

If there is no head-to-toe fluid route, how on earth to explain these bizarre cases:

Hogg FR Notes on menstruation Med Times Gaz 1871;2:555.

These 7 cases came from personal enquiries of his 2000 patients.

 Extraordinary cases need extraordinary explanations.

Very interesting and thought-provoking, Anthony. There are many routes of communication in the human body, probably the most ubiquitious is via immunology throughout the body. Immunology and neurology trump vascularization any day and move immensely faster, to boot. Proinflammatory cytokines can travel so far and fast ahead of the blood the courses throughout the body that almost instantaneously when one feels the stub of a toe an immunological cascade of adult stem cells, bone cells, macrophage cells, thymus cells, the list is huge are on the spot before the blood from the heart can reach the feet. No part of the body is truly isolated from another part of the body. When it is, it is called neuropathy or gangrene or cancer. I know you know or at least suspect this, but in my lectures on the neurophysiology of the human ear I regularly point out that what happens in the ear region affects the entire body and what happens in other parts of the body affects the ears. Rarely is an earache an earache; more often than not it is actually referred pain along the trigeminal, facial, etc. nerves from the teeth, jaw, sinuses, neck, and mastoid region. Thanks again for a great question! 

"There are many routes of communication in the human body, probably the most ubiquitious is via immunology throughout the body.....before the blood from the heart can reach the feet"

One thing that be quickly ruled out is that this head-to-toe route is anything to do with the blood vascular system.   The sheer variety of substances that occasionally end up in the ear canal precludes this (menstrual blood, urine, breastmilk, gout, etc).  The consistent unilaterality (see,eg, my post 3 days ago on vicarious menstruation) excludes the blood vascular system.   I have still not worked out the anatomy of this route, but it must be closely linked with the lymphatic system.  Perineural and perivascular lymphatic pathways may be involved, or it may simply be a route through connective tissue.  I was watching a TV programme last night and was intrigued to see a simple skin sensor being used to track alcohol concentrations, a non-invasive alternative to blood alcohol measures.  My prediction is that the sweat alcohol levels lead the blood levels since the sweat derives from lymph not blood, and alcohol from the stomach goes first into lymph.

If there is any route! so in kliker nadjar disease which conduction of bilirubin is impaired so we should expect the content and taste of ear wax changs.

Yes, and through the blood system bile does travel to all parts of the body head to toe, especially in cases of jaundice. We tend to see excessive bile collect in certain parts of the body more often than others, such as on back of hands (left more than right, usually), in skin cells in the concha, etc. It only makes sense that bile can appear into the EAC as much most other places. Most of the bile should be collected (resorbed) in the transverse colon, but about 20-30% ends up elsewhere, even in the stools of the individual.

A very striking feature of cases where substances from lower in the body end up in the ear canal is the extreme pain involved.  I do not know much about endometriosis other than it is very painful and mysterious, but I wondered if womb tissue made use of this non-vascular head-to-toe pathway.  So I Googled Endometriosis Otitis Externa.  Not only are these connected, there is actually a Mobile Support Group for those with both conditions!

"Yes, and through the blood system bile does travel to all parts of the body head to toe, especially in cases of jaundice"

The whole body turns yellow in such cases.   The localised or asymmetrical distribution of bile, or indeed of vicarious menstruation, cannot possibly be from the blood vascular system..  

Yes, Anthony, the effects can be all over the body from diverse and seemingly unrelated areas of the body. One of the roles of pro-inflammatory cytokine secretions is to isolate a site of lesion from other areas, albeit usually poorly over the long term. A good example is the presence of localized sepsis that, even though it has not entered the bloodstream for more ubiquitous distribution, can be detected in any other sensitive area of the body via immunological messengers. You mentioned the yellow tinge of jaundice being ubiquitous, and yes that would, if exposed to the underlying tissues of the ceruminous and sebacious glands, yield evidence of bile in the earwax.   

And how does Hep B virus end up in earwax?  Not through the blood surely?   Aural sex??           (J Laryngol Otol 2013; 127:1065):

   Thirty patients with chronic Hep B  were positive for hepatitis B surface antigen and negative for hepatitis B surface antibodies.  Hep B virus DNA was detected in the cerumen of two cases.

"..it indicates an unrecognised (though not by Hippocrates?) but important anatomical pathway from the bottom to the top of the body, transporting such things as cancers (rhabdomyosarcoma), viruses (herpes zoster), fluid (otitis externa), etc.

.. and homogentistic acid?  (ENT manifestations of alkaptonuria..  J Laryngol Otol 2015;129: 1004).

   It seems much more likely that the black earwax arrives upwardly from deep inside the body than directly from the bloodstream.

"Earwax sampling could measure stress hormone | UCL News ...

www.ucl.ac.uk › news › nov › earwax-sampling-could-...

3 Nov 2020 — Lead researcher Dr Andres Herane-Vives (UCL Institute of Cognitive Neuroscience and Institute of Psychiatry, Psychology & Neuroscience, ..."