Earwax
Exam Tips
- In OSCEs, diagnose impaction only when wax is symptomatic or blocks needed examination; visible wax alone is not always disease.
- Always ask about contraindication modifiers before removal: previous ear surgery, perforation history, active infection/dermatitis, anticoagulants, diabetes, immunocompromise.
- State clearly that adults should not have manual syringe irrigation; use electronic irrigation or microsuction/manual instrumentation by trained staff.
- After irrigation, re-check and document tympanic membrane integrity and canal condition.
- If severe pain, deafness, or vertigo occurs during/after irrigation, stop and seek urgent ENT input.
Definition
Earwax (cerumen) impaction is a clinical condition where retained cerumen in the external auditory canal causes symptoms, obstructs examination of the ear, or both. Cerumen itself is normally protective and self-clearing, but impaction occurs when production exceeds clearance or canal anatomy/epithelial migration prevents normal extrusion.
Pathophysiology
Cerumen is formed from desquamated keratin mixed with sebaceous and ceruminous gland secretions, then transported outward by epithelial migration assisted by jaw movement. Impaction develops when this conveyor mechanism fails (for example with ageing-related gland atrophy causing drier wax, canal narrowing, or instrumentation pushing wax medially), producing a plug that mechanically blocks sound conduction and can trap moisture/debris, predisposing to otitis externa. Cerumen phenotype (dry vs wet) is genetically determined and may influence both impaction tendency and response to removal techniques. See standard otoscopy diagrams of the external auditory canal and tympanic membrane orientation in ENT teaching atlases (commonly used in UK undergraduate ENT modules).
Risk Factors
- Age over 50 years (drier wax, coarser canal hair, reduced epithelial migration)
- Age under 5 years
- Narrow, deformed, or obstructed ear canal (including exostoses/osteomas)
- Down syndrome (narrow canals and possible reduced symptom reporting)
- Dermatological disease affecting canal skin (for example eczema, psoriasis)
- Cotton bud use or other self-cleaning attempts that push wax deeper
- Repeated hearing-aid or earplug insertion
- Male sex in older age groups (hair-related retention)
- History of recurrent impacted wax or possible idiopathic overproduction
- Developmental delay/cognitive impairment
Clinical Features
Symptoms
- Conductive hearing loss (most common)
- Aural fullness
- Ear discomfort or otalgia
- Itch in ear canal
- Tinnitus
- Dizziness or imbalance
- Cough (rare; auricular branch of vagus stimulation)
- Recurrent otitis externa symptoms
Signs
- Visible cerumen occluding or partially occluding external canal on otoscopy
- Tympanic membrane not fully visualised because of wax
- Wax may be dry/brittle or wet/sticky, variable colour
- Sometimes associated canal skin irritation or otitis externa features
- Apparent conductive hearing reduction on bedside assessment
Investigations
Management
Lifestyle Modifications
- Explain that earwax is usually protective and should not be routinely removed if asymptomatic
- Avoid cotton buds, ear candling, and self-instrumentation of the canal
- Offer removal when symptomatic, when tympanic membrane inspection is required, or before ear-mould impressions
- Safety-net: urgent ENT advice if severe pain, sudden hearing loss, vertigo, or bleeding during/after removal
Pharmacological Treatment
Cerumenolytics / softening drops
- Sodium bicarbonate 5% ear drops: instil 3-4 times daily for 3-5 days
- Olive oil ear drops: instil 3-4 times daily for 3-5 days
- Almond oil ear drops: instil 3-4 times daily for 3-5 days
- Sodium chloride 0.9% drops (nasal drops used off-label in ear): instil 3-4 times daily for 3-5 days
Can also be used immediately before irrigation if needed. Warn about transient worsening hearing, local discomfort, dizziness, and skin irritation. Avoid if suspected tympanic membrane perforation, active otitis externa/infection, or active ear-canal dermatitis. Avoid almond oil in nut allergy.
Surgical / Interventional
- Electronic ear irrigation (not manual syringing in adults), with prior softening drops and trained operator
- Microsuction in appropriate settings by trained practitioners
- Manual removal with curette/probe under direct vision in suitable patients
- If irrigation fails after two attempts, refer to specialist ear care/ENT service
Complications
- Persistent conductive hearing loss and communication difficulty
- Otitis externa
- Delayed diagnosis due to inability to inspect tympanic membrane
- Stress, social isolation, and low mood linked to hearing impairment
- Reduced cognitive performance in vulnerable older adults/developmental delay
- Procedure-related complications (uncommon): canal trauma, bleeding, infection, tympanic membrane perforation, vertigo, iatrogenic hearing loss
Prognosis
Overall prognosis is good: most patients improve after appropriate wax removal, and service data suggest hearing symptoms frequently improve substantially. Some cases resolve spontaneously, but recurrence is common in people with predisposing anatomy, age-related changes, or high cerumen production, so repeat episodes are expected in primary care.
Sources & References
💊BNF Drug References(2)
- Almond oil[management.pharmacological]
- Olive oil[management.pharmacological]
✅NICE Guidelines(1)
- Earwax[overview]