Earwax

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Earwax is a build-up of cerumen, sebum, dead cells, sweat, hair and foreign material - eg, dust.[1] Cerumen has antibacterial and antifungal properties.[2] Earwax is a normal physiological substance that protects the ear canal. The quantity produced varies greatly between individuals. Earwax may be either wet or dry. Wet wax is either soft (more common in children) or hard (more common in the elderly). Dry wax is dry, flaky and golden yellow and is common in people from Asia.[1]

Being a physiological process, earwax is a universal phenomenon. Impacted earwax is more common in:

  • The elderly[3] 
  • People who use hearing aids
  • Those who use cotton ear buds

It has been estimated that up to two million ear irrigations are performed in England and Wales each year.[4] Reported prevalence rates from varying populations range from 7-34%.[5]

One study reported a high incidence of earwax in people with schizophrenia; this was linked to reduced functioning and social isolation.[6] 

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  • May be asymptomatic
  • Hearing loss[7] 
  • 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 (this 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 Rinne's test and the Weber's test.

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.[9] 

  • 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.[10] However, there is little evidence on their effectiveness for the removal of symptomatic ear wax.[9]
    • 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.
    • Docusate sodium or urea hydrogen peroxide are ingredients in a number of proprietary preparations for softening earwax but the British National Formulary warns that these organic solvents can irritate the external meatus.[10] 
    • 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).
    • Self-irrigation using a bulb syringe has been advocated for people who require regular irrigation, thus reducing the demand on primary care.[11] 
  • 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 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 occurs 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.
  • 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 previous 18 months, with subsequent discharge from an ENT department).
  • A mucous discharge from the ear (which may indicate an undiagnosed perforation) within the previous 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.
  • 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
  • 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
  • Facial nerve palsy has been reported[13] 

Further reading & references

  1. Earwax; NICE CKS, May 2012
  2. Lum CL, Jeyanthi S, Prepageran N, et al; Antibacterial and antifungal properties of human cerumen. J Laryngol Otol. 2009 Apr;123(4):375-8. doi: 10.1017/S0022215108003307. Epub 2008 Aug 11.
  3. Oron Y, Zwecker-Lazar I, Levy D, et al; Cerumen removal: comparison of cerumenolytic agents and effect on cognition among the elderly. Arch Gerontol Geriatr. 2011 Mar-Apr;52(2):228-32. doi: 10.1016/j.archger.2010.03.025. Epub 2010 Apr 24.
  4. Loveman E, Gospodarevskaya E, Clegg A, et al; Ear wax removal interventions: a systematic review and economic evaluation. Br J Gen Pract. 2011 Oct;61(591):e680-3. doi: 10.3399/bjgp11X601497.
  5. Browning GG; Ear wax. Clin Evid (Online). 2008 Jan 25;2008. pii: 0504.
  6. Saana E, Eila S, Kaisla J, et al; Cerumen impaction in patients with schizophrenia. Clin Schizophr Relat Psychoses. 2013 Feb 27:1-10.
  7. Adobamen PR, Ogisi FO; Hearing loss due to wax impaction. Nig Q J Hosp Med. 2012 Apr-Jun;22(2):117-20.
  8. Clegg AJ, Loveman E, Gospodarevskaya E, et al; The safety and effectiveness of different methods of earwax removal: a systematic review and economic evaluation. Health Technol Assess. 2010 Jun;14(28):1-192. doi: 10.3310/hta14280.
  9. Burton MJ, Doree C; Ear drops for the removal of ear wax. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD004326.
  10. British National Formulary
  11. Coppin R, Wicke D, Little P; Randomized trial of bulb syringes for earwax: impact on health service utilization. Ann Fam Med. 2011 Mar-Apr;9(2):110-4. doi: 10.1370/afm.1229.
  12. Brearley G; Guidelines for Ear Irrigation Using the Propulse Electronic Ear Irrigator, NHS, 2010
  13. Thomas AM, Poojary B, Badaridatta HC; Facial nerve palsy as a complication of ear syringing. J Laryngol Otol. 2012 Jul;126(7):714-6. doi: 10.1017/S0022215112000886. Epub 2012 May 29.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Colin Tidy
Current Version:
Peer Reviewer:
Dr Helen Huins
Document ID:
537 (v5)
Last Checked:
07/06/2013
Next Review:
06/06/2018