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Earwax - Management
How should earwax be removed?

  • Explain that removal of earwax may not necessarily relieve the symptoms (e.g. 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.
    • Do not prescribe drops if you suspect the person has a perforated tympanic membrane.
  • If symptoms persist, consider ear irrigation, providing there are no contraindications and you are still confident that symptoms are due to earwax.
  • 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.
  • Refer to secondary care anyone in whom the above treatment is contraindicated or is unsuccessful.
  • Advise anyone who has had earwax removed to return if they develop earache, or significant itching of the ear, or discharge from the ear (otorrhoea), or swelling of the external auditory meatus, as these symptoms may indicate infection.
Basis for recommendation
  • These recommendations are based on published expert opinion [Sharp et al, 1990; Zivic and King, 1993; Bird, 2003; Clarke et al, 2004; NHS Quality Improvement Scotland, 2006].
  • Older people with a sensorineural hearing loss may request removal of ear wax in the mistaken belief that it will restore their hearing [Sharp et al, 1990].
  • Although there is consensus that ear irrigation is effective at removing wax, BMJ Clinical Evidence found no randomized controlled trials comparing ear irrigation alone to no treatment [Browning, 2006]. A more recent systematic review and economic evaluation of different methods of earwax removal found the evidence on the effectiveness of different methods of irrigation or mechanical removal was equivocal [Clegg et al, 2010].
  • There is limited evidence that ear irrigation improves hearing and symptoms [Memel et al, 2002].
  • Although irrigation may be performed without the prior use of ear drops, CKS recommends using drops for 3–5 days as first-line management, with the aim of avoiding irrigation whenever possible [Eekhof et al, 2001].
  • There is evidence from a randomized study that the instillation of tap water (at body temperature) for 15 minutes into an ear in which irrigation did not remove all of the wax may disperse the wax sufficiently for a further attempt at irrigation to be successful.
  • We have not recommended irrigation without prior use of a softening agent because expert opinion stated that extra force may be needed which is more likely to cause trauma.

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