Ear Wax

Earwax is a build up of cerumen, sebum, dead cells, sweat, hair and foreign material, e.g. dust.¹ Earwax is a normal physiological substance that protects the ear canal. The quantity produced varies greatly between individuals.

Impacted earwax is more common in:

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

• Other causes of acute deafness, e.g. eustachian tube dysfunction, foreign body
• Otitis externa

• Earwax needs to be removed only if it is causing symptoms or if a clearer view of the eardrum is required. The use of cotton buds to clear the ear canal should be discouraged as wax is likely to become more impacted.
• Impacted earwax can be treated with ear drops, irrigation, microsuction or curettage. 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. There is little good evidence on the relative effectiveness of the various treatment options.
• Ear drops to soften wax:
  • Are often the appropriate first-line treatment²
  • There is little evidence on their effectiveness for the removal of symptomatic ear wax³
  • Water and sodium chloride 0.9% seem to be as effective as any proprietary agent³
  • Olive oil and almond oil are also recommended
  • Sodium bicarbonate ear drops are also effective but may cause dryness of the ear canal
  • Docusate sodium and urea hydrogen peroxide are the active ingredients in a number of preparations for softening ear wax²
• Ear irrigation
  • Is indicated if impacted wax causes loss of hearing, discomfort or tinnitus
  • Avoid ear irrigation if there is any past or present history of perforation of the tympanic membrane, or a grommet in situ. Irrigation should only be used if absolutely necessary and with great caution in patients with previous middle ear or mastoid surgery, or recurrent otitis externa or chronic middle ear disease.
  • Drops to soften the wax should ideally have been used before irrigation is attempted
  • An electronic irrigator is safer than a syringe
  • The water should be warmed to body temperature
  • Direct the water flow backwards and along the roof of the ear canal
  • Complications of syringing occur in about 1 in 1000 ears syringed.⁴ These include:⁵
    • Bleeding (which is usually self-limited)
    • Perforation
    • Otitis externa
    • Disturbance in balance with nausea and vomiting
    • Deafness and balance difficulties (rare)
• Several other mechanical removal techniques are available, but usually only available in secondary care:
  • Ear curettes and forceps
  • Microsuction

• Depression and social isolation in the elderly
• Complications of ear wax without any other ear problem are uncommon in children, but may include deafness leading to impaired speech and language development and school difficulties.