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This summary has been developed for use by community pharmacists under our Guidelines for Pharmacy title and therefore only covers the information relevant to this setting. Areas covered include: diagnosis, management, and referral. Please refer to the full guideline for the complete set of recommendations.

How do I diagnose impacted earwax?

  • Many people will have made the diagnosis themselves, particularly if they have had a history of recurrent earwax problems
  • Although some people are asymptomatic, the most common symptom from impacted earwax is hearing loss. People may also complain of:
    • blocked ears
    • ear discomfort
    • feeling of fullness in the ear
    • earache
    • tinnitus (noises in the ear)
    • itchiness
    • vertigo (not all experts believe that wax is a cause of vertigo)
    • cough (rare and due to stimulation of the auricular branch of the vagus nerve by pressure from impacted earwax)
  • There may be a history of exposure to water as this causes expansion of the earwax and may cause complete blockage of the ear canal
  • Children may present with yellow, waxy discharge, this is less common is adults
  • Ask about previous removal of impacted earwax, previous tympanic membrane perforation, recurrent or chronic ear problems, hearing aid use and other co-morbidities

What else could it be?

  • Otitis externa (inflammation of the auricle or external ear canal due to allergy, infection, or eczematous conditions)
  • Foreign bodies (particularly suspect in children)
  • Keratosis obturans is rare and of unknown aetiology, and is characterized by increased keratin production. A pearly white plug made up of densely compressed keratin squames fills the external ear canal, causing erosion of the bony canal. It presents with otalgia, hearing loss, and otorrhoea, usually with bilateral involvement in younger people. The external meatus may become markedly enlarged leading to severe wax accumulation
  • Polyp of the ear canal
  • Osteoma of the ear canal

What are the complications?

  • Impacted wax may cause conductive hearing loss
  • If wax is in contact with the tympanic membrane it may cause discomfort and, occasionally, vertigo
  • Hearing loss due to impacted wax may cause frustration, stress, social isolation, paranoia, and depression
  • Infection may sometimes occur as a result of wax impaction

Management

From age 6 months onwards.

When should earwax be removed?

  • If earwax is totally occluding the ear canal and any of the following are present:
    • hearing loss
    • earache
    • tinnitus
    • vertigo
    • cough suspected to be due to earwax
  • If the tympanic membrane is obscured by wax but needs to 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

How should earwax be removed?

  • Explain that removal of earwax may not necessarily relieve the symptoms (for example hearing loss may be a sensorineural loss and not due to impacted wax)
  • Prescribe ear drops for 3–5 days initially, to soften wax and aid removal
    • olive oil, or almond oil drops can be used 3–4 times daily for 3–5 days (do not prescribe almond oil ear drops to anyone who is allergic to almonds)
    • sodium bicarbonate 5%, sodium chloride 0.9%
      • sodium chloride 0.9% is not available as a proprietary ear drop product. However, sodium chloride 0.9% nasal drops can be prescribed for use in the ear (off-label use)
    • do not prescribe drops if you suspect the person has a perforated tympanic membrane
    • warn the person that instilling ear drops may cause transient hearing loss, discomfort, dizziness and irritation of the skin
  • If symptoms persist, consider ear irrigation, providing that there are no contraindications
  • If irrigation is unsuccessful, there are three options:
    • advise the person to use ear drops for a further 3–5 days and then return for further irrigation
    • instill water into the ear. After 15 minutes irrigate the ear again
    • refer to an ear nose and throat specialist for removal of wax
  • Advise anyone who has had earwax removed to return if they develop otalgia, or significant itching of the ear, discharge from the ear (otorrhoea), or swelling of the external auditory meatus, as this may indicate infection
  • Advise people against inserting anything in the ear. Cotton buds, matchsticks, and hair pins can:
    • damage the wall of the canal and increase the likelihood of otitis externa
    • cause the wax to become impacted by pushing it further into the canal
    • perforate the tympanic membrane
  • Advise that the use of ear candles has no benefit in the management of earwax removal and may result in serious injury
    • ear candling should never be used: a hollow candle is burned with one end in the ear canal. The intention is to create a negative pressure which draws the earwax out of the ear canal

When should I refer a person with earwax?

  • Refer before irrigation if:
    • the person has (or is suspected to have) a chronic perforation of the tympanic membrane
    • there is a past history of ear surgery
    • there is a foreign body, including vegetable matter, in the ear canal
    • there is a visible tympanic membrane perforation
    • ear drops have been unsuccessful and irrigation is contraindicated
  • Refer after irrigation if irrigation is unsuccessful
  • Seek immediate advice from an ear nose and throat specialist if severe pain, deafness, or vertigo occur during or after irrigation
  • Refer or seek urgent advice if infection is present and the external canal needs to be cleared of wax, debris, and discharge
  • If the person continues to experience hearing loss after wax removal arrange an audiogram

How should I manage recurrent wax?

  • Decide on the most appropriate treatment taking into account the person’s wishes, previous successful treatment, and any contraindications
  • Treatment options include: ear drops, irrigation, or referral for manual removal of earwax
  • To prevent wax becoming impacted, advise that regular use of ear drops may be helpful
    • explain that there is no evidence to suggest the best type of ear drops or how frequently they should be used
    • experts suggest using either sodium bicarbonate, sodium chloride, olive or almond oil ear drops. The suggested frequency of use varied from daily to once a fortnight
    • it is not known if such treatment is effective and the person may need to return for repeat wax removal

© NICE 2016. NICE CKS on earwax. Available from: cks.nice.org.uk/earwax. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

Last updated: July 2016.