Epidemiology

Impacted earwax is more common in:

• The elderly
• People who use hearing aids
• Those who use cotton ear buds

Presentation^[1]

• May be asymptomatic
• Hearing loss
• Blocked ears
• Ear discomfort
• Tinnitus
• Itchiness
• Vertigo (not all experts believe that wax is a cause of vertigo)
• There may be a history of exposure to water (causes expansion of the earwax and may cause complete blockage of the ear canal)

Examination

• Examine both ear canals with an auriscope.
• Assessment of conductive hearing loss may include the Rinne test and the Weber test.

Differential diagnosis

• Other causes of acute deafness, eg Eustachian tube dysfunction, foreign body
• Otitis externa

Management

Ear drops are considered first-line and often the only treatment required. Microsuction is safer than irrigation but not widely available. Complications of irrigation can be minimised by correct training and care. Impacted earwax can be treated with ear drops, irrigation, microsuction or curettage. There is little good evidence on the relative effectiveness of the various treatment options.

• Indications for removal of earwax:
  • If it is totally occluding the ear canal and causing hearing loss, earache, tinnitus or vertigo.
  • If the tympanic membrane is obscured by wax but must be viewed to establish a diagnosis.
  • If the person wears a hearing aid, wax is present and an impression needs to be taken of the ear canal for a mould, or if wax is causing the hearing aid to whistle.
• Ear drops:
  • Ear drops are often the appropriate first-line treatment.^[2] However there is little evidence on their effectiveness for the removal of symptomatic ear wax.^[3]
  • Prescribe ear drops for 3-5 days initially, to soften wax and aid removal.
  • Sodium bicarbonate, sodium chloride, olive oil or almond oil drops can be used.
  • Regular use of ear drops may be indicated for patients with recurrent earwax.
  • Do not use drops if the person has a possible perforated tympanic membrane.
• Irrigation:
  • If symptoms persist despite ear drops, consider ear irrigation, providing that there are no contra-indications (see 'Contra-indication for ear irrigation', below).
  • If irrigation is unsuccessful, consider one of the following:
  • Advise the person to use ear drops for a further 3-5 days and then return for further irrigation.
  • Instil water into the ear. After 15 minutes irrigate the ear again.
  • Refer to an Ear Nose and Throat (ENT) specialist for removal of wax.
  • Advise anyone who has had earwax removed to return if they develop otalgia, significant itching of the ear, discharge from the ear or swelling of the external auditory meatus, as this may indicate infection.
  • Seek immediate advice from an ENT specialist if severe pain, deafness, or vertigo occur during or after irrigation, or if a perforation is seen following the procedure.
• Several other mechanical removal techniques are available, but usually only in secondary care, eg ear curettes and forceps, microsuction.

Contra-indication for ear irrigation

• History of any previous problem with irrigation (pain, perforation, severe vertigo).
• Current perforation of the tympanic membrane or a history of perforation of the tympanic membrane in the previous 12 months.
• Grommets in place.
• History of any ear surgery (except extruded grommets within the last 18 months, with subsequent discharge from an ENT department).
• A mucous discharge from the ear (which may indicate an undiagnosed perforation) within the past 12 months.
• History of a middle ear infection in the previous 6 weeks.
• Cleft palate (whether repaired or not).
• Acute otitis externa with an oedematous ear canal and painful pinna.
• A foreign body, including vegetable matter, in the ear.
• Hearing only in the ear to be treated, as there is a remote chance that irrigation could cause permanent deafness.
• Confusion or agitation (may be unable to sit still).
• Inability to co-operate, eg young children and some people with learning disabilities.

Cautions with irrigation

• Vertigo (may indicate the presence of middle ear disease with perforation of the tympanic membrane).
• Recurrent otitis media (thin scars on the tympanic membrane can easily be perforated).
• Warn people with a history of recurrent otitis externa or tinnitus that ear irrigation may aggravate their symptoms.

Indications for referral^[1]

• Chronic perforation of the tympanic membrane.
• Past history of ear surgery.
• Foreign body, including vegetable matter, in their ear canal.
• Ear drops have been unsuccessful and irrigation is contra-indicated.
• Irrigation is unsuccessful.
• Refer or seek urgent advice if infection is present and the external canal needs to be cleared of wax, debris, and discharge.

Complications^[1]

• Impacted wax may cause conductive hearing loss.
• Infection may sometimes occur as a result of wax impaction.
• Problems due to earwax often recur.

Complications of irrigation

• Otitis externa.
• Perforation of the tympanic membrane.
• Damage to the external auditory meatus.
• Pain.
• Otitis media (due to water entering the middle ear when there is a previous perforation).
• Exacerbation of pre-existing tinnitus.
• Bleeding may also occur but is usually self-limiting.
• Nausea, vomiting, and vertigo.