Background Information

Definition

Ear wax (cerumen): normal physiological substance produced in the external auditory canal

• Component: combination of desquamated keratin from epithelial cells + secretions from sebaceous and ceruminous glands + foreign substances (e.g. dirt and cosmetica)

Earwax impaction: accumulation of earwax that causes symptoms and/or prevents assessment of the ear (often tympanic membrane not visualised)

Guidelines

Investigation and Diagnosis

Diagnosis is made by otoscopic examination:

• Impaction: cerumen is seen completely obstructing the external auditory canal, preventing visualisation of the tympanic membrane

Management

Indications For Removal

• Earwax causing hearing loss or other symptoms
• Typmanic membrane obscured by wax but needs to be viewed to establish a diagnosis (e.g. tympanic membrane perforation, otitis media)

Ear Wax Removal

Methods of removal:

• 1st line: wax softeners (sodium bicarbonate 5% ear drops, olive / almond oil drops, sodium chloride 0.9% nasal drops)
• 2nd line: ear irrigation with electronic irrigator with pre-treatment wax softeners (up to 5 days before)
  • If unsuccessful: repeat use of wax softeners, or instil water into the ear canal 15 min before repeating ear irrigation
• 3rd line: microsuction / manual removal with a probe

Contraindications of Ear Irrigation

• Increased risk of infection / trauma / haemorrhage
  • Perforated tympanic membrane
  • Active infection / dermatitis of the ear canal
  • Abnormalities of the ear canal (e.g. exostoses and ear canal stenosis)
• Acute otitis externa with oedematous ear canal and painful pinna
• Grommets in situ
• History of
  • Any ear surgery (except extruded grommets within the last 18 months and discharged by ENT)
  • Middle ear infection in the previous 6 weeks
  • Any previous problems with ear irrigation
• Cleft palate (even if repaired)
• Foreign body in the ear 

• Mucus discharge from the ear within the past 12 months (may indicate undiagnosed perforation)
• Hearing in only one ear if it is the ear to be treated
• Confusion or agitation 
• Inability to cooperate (e.g. young children and some people with learning difficulties)

Possible Complications of Earwax Removal

• Otitis externa and media
• Tympanic membrane perforation
• Pain
• Veritgo
• Exacerbation of pre-existing tinnitus

References

Original Guideline