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Earwax - Management
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Overview of management

  • Indications for removal of earwax include:
    • Totally occlusive wax.
    • Symptoms presumed to be due to wax.
    • Diagnostic purposes, to gain an unimpeded view of the tympanic membrane.
    • If the person wears a hearing aid and there is wax 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.
  • Explain that removal of earwax may not necessarily relieve the symptoms.
  • Prescribe ear drops for 3–5 days initially, to soften wax and aid removal (unless 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 secondary care for removal of wax.
  • Refer to secondary care anyone in whom the above treatment is contraindicated or is unsuccessful.
  • Seek immediate advice from an Ear Nose and Throat specialist if severe pain, deafness, or vertigo occurs during or after irrigation, or if a perforation is seen following the procedure.

When should earwax be removed?

  • Consider removing earwax 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
    • The tympanic membrane is obscured by wax but must be viewed to establish a diagnosis.
    • The person wears a hearing aid and needs a mould or the wax is causing the hearing aid to whistle.
Basis for recommendation
  • There is no evidence to suggest when earwax should be removed, and the basis for this recommendation is expert opinion [Sharp et al, 1990; Browning, 1994; Aung and Mulley, 2002; Guest et al, 2004; NHS Quality Improvement Scotland, 2006; Action on ENT Steering Board, 2007].
  • If there is hearing loss and the tympanic membrane cannot be seen, then the wax should be removed as the majority of causes of conductive deafness are diagnosed by examining the tympanic membrane [Browning, 1994].
  • Once the wax has been removed if hearing does not improve then alternative causes should be considered [Browning, 1994]. Visualisation of the tympanic membrane may identify causes of conductive deafness.
  • Wax may need to be removed in order to take an impression of the ear canal, for people who wear hearing aids. Excess wax may cause the hearing aid to whistle.

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.

Which ear drops should I prescribe?

  • CKS recommends use of sodium bicarbonate 5% ear drops, sodium chloride 0.9%, olive oil, or almond oil.
  • Choice of ear drops may be influenced by what the person has already tried, and what has worked in the past.
  • 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 almond oil ear drops to anyone who is allergic to almonds.
Basis for recommendation
  • Evidence is very limited regarding the choice of ear drops to treat earwax.
    • Two systematic reviews have concluded that using ear drops of any kind to remove impacted earwax is better than no treatment. However, there is no evidence to provide a preference of one particular wax softener to another.
    • This has been supported by a more recent systematic review and economic evaluation of different methods of earwax removal, which found that although softeners are effective, which specific softeners are most effective remains uncertain [Clegg et al, 2010].
    • CKS therefore recommends the use of either sodium bicarbonate 5%, sodium chloride 0.9%, olive oil, or almond oil.
  • Many proprietary preparations contain organic solvents (e.g. Cerumol®). These preparations are not recommended because they may cause irritation and inflammation of the external ear canal, and do not offer any clear advantages over other products [Somerville, 2002].
  • Ear drops soften wax and aid removal. There are two kinds of earwax solvents: oil based and water based [Burton and Doree, 2003].
    • Oil-based ear drops are thought to work by dissolving earwax.
    • Water-based ear drops improve water miscibility.

Ear irrigation

What are the contraindications, cautions and warnings for ear irrigation?

  • Do not use ear irrigation to remove wax for people with:
    • A history of any previous problem with irrigation (pain, perforation, severe vertigo).
    • Current perforation of the tympanic membrane.
    • A history of perforation of the tympanic membrane in the last 12 months. Not all experts would agree with this: some experts would advise that any history of a perforation at any time, even one that has been surgically repaired, is a contraindication to irrigation because a healed perforation may have a thin area which would be more prone to re-perforation.
    • Grommets in place.
    • A history of any ear surgery (except extruded grommets within the last 18 months, and the person has been discharged from the Ear Nose and Throat department).
    • A mucus discharge from the ear (which may indicate an undiagnosed perforation) within the past 12 months.
    • A history of a middle ear infection in the previous 6 weeks.
    • Cleft palate, whether repaired or not.
    • Acute otitis externa with an oedematous ear canal and painful pinna.
    • Presence of a foreign body, including vegetable matter, in the ear.
    • Hearing ear in only one ear if it is the ear to be treated, as there is a remote chance that irrigation could cause permanent deafness.
    • Confusion or agitation, as they may be unable to sit still.
    • Inability to co-operate e.g. young children and some people with learning disabilities.
  • Use ear irrigation with caution in people with:
  • Warn people with a history of recurrent otitis externa or tinnitus that ear irrigation may aggravate their symptoms [Burton and Doree, 2003].

How should I irrigate an ear?

  • Use an electronic ear irrigator. This should have a variable pressure control so that irrigation can begin at the minimum pressure.
  • Prepare equipment as per local guidelines and manufacturer's instructions. This will include a fresh speculum and disposable jet tip for each person. Protect the person's clothing with a disposable towel or waterproof covering. Ask the person to hold the water receiver under their affected ear.
  • Ensure that the person is sitting comfortably and that you are sitting at the same level. Use a good light source, preferably with a head lamp or head mirror, throughout the procedure.
  • Ensure that the temperature of water used for irrigation is around body temperature.
  • Pull the pinna upwards and outwards (downwards and backwards in children) to straighten the ear canal.
  • Angle the jet tip so that the flow of the water is along the top of the posterior wall. Compare the perimeter of the canal to a clock face: for the left ear direct the fluid towards 1 o'clock, and for the right ear direct the fluid towards 11 o'clock.
  • Inspect the ear canal periodically with the auriscope and monitor the solution running into the receiver to determine whether wax is coming out.
  • If the person complains of dizziness or pain, stop the procedure.
  • In general, use no more than 500 mL of water per ear in any one irrigating procedure.
  • Following irrigation, examine the ear with an auriscope to check that the wax has been removed and the tympanic membrane is intact. Look for old healed perforations. Inspect the canal for otitis externa. Follow local protocols regarding dry mopping.
  • Seek immediate advice from an Ear Nose and Throat specialist if severe pain, deafness, or vertigo occur during or after irrigation, or if a perforation is seen following the procedure.
Basis for recommendation
  • These recommendations are based on published expert opinion [Zivic and King, 1993; Clarke et al, 2004; NHS Quality Improvement Scotland, 2006; Action on ENT Steering Board, 2007].
  • The use of a metal syringe for the irrigation of the ear canal is not recommended as there is a risk of causing damage to the ear, including the tympanic membrane and the oval and round windows. The design of the syringe, combined with the inability to control water pressure, increases the risk of ear damage. It is also difficult to disinfect after use [NHS Quality Improvement Scotland, 2006].
  • Some practitioners recommend dry mopping to remove excess water. Dry mopping is usually done using cotton wool on a Jobson–Horne probe. The research base on dry mopping the ear following ear irrigation is still evolving: it may reduce the risk of infection from the water left in the ear, or it may encourage infection. A working group has therefore recommended that staff follow local protocols [NHS Quality Improvement Scotland, 2006].
  • Urgent assessment by an Ear Nose and Throat specialist is recommended as a perforated tympanic membrane, a perilymph fistula, or disarticulation of the ossicles caused by excessive irrigation pressure may need to be corrected surgically [Grossan, 2000].

What are the complications of ear irrigation?

  • The following have been reported [Sharp et al, 1990]:
    • Failure of wax removal
    • Otitis externa
    • Perforation of the tympanic membrane
    • Damage to the external auditory meatus
    • Pain [Clegg et al, 2010]
    • Irritation and itching of the ear [Clegg et al, 2010]
    • Vertigo
    • Otitis media due to water entering the middle ear when there is a previous perforation.
    • Exacerbation of pre-existing tinnitus [Burton and Doree, 2003].
  • Bleeding may also occur but is usually self limiting [Grossan, 2000].
  • Nausea, vomiting, and vertigo may result from temperature variations of the irrigating fluid [Zivic and King, 1993].
  • There is evidence that rarely (approximately 1 in every 1000 ears syringed) serious complications may occur.

When should I refer?

  • Refer 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.
    • Ear drops have been unsuccessful and irrigation is contraindicated.
    • Irrigation is unsuccessful.
  • Seek immediate advice from an Ear Nose and Throat specialist if severe pain, deafness, or vertigo occur during or after irrigation, or if a perforation is seen following the procedure.
  • Refer or seek urgent advice if infection is present and the external canal needs to be cleared of wax, debris, and discharge.
Basis for recommendation
  • The basis for this recommendation is expert opinion [Aung and Mulley, 2002] and pragmatic advice.
  • If a person has not responded to ear drops and irrigation, or these are contraindicated, further treatment options require specialist training. Such procedures include:
    • Microsuction (i.e. the use of suction under the microscope): a gentle level of suction is used to remove the wax from the ear. This procedure is noisy and may be uncomfortable [NHS Quality Improvement Scotland, 2006].
    • Aural toilet: a Jobson–Horne probe is used to remove the wax under direct vision.
  • Although there are no systematic reviews or randomized controlled trials on mechanical methods of removing earwax (other than irrigation), most Ear Nose and Throat specialists consider microsuction to be a standard treatment to enable the tympanic membrane to be seen [Browning, 2006].
  • Urgent assessment by an Ear Nose and Throat specialist is recommended as a perforated tympanic membrane, perilymph fistula, or disarticulation of the ossicles caused by excessive irrigation pressure may need to be corrected surgically [Grossan, 2000].
  • Wax may contribute towards infection and need removal [Keane et al, 1995].
  • An ear canal with a suspected vegetable foreign body should not be irrigated or drops instilled as this may cause the vegetable matter to swell [Samuel, Personal Communication, 2007].

What methods of earwax removal are not recommended?

  • 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.
Clarification / Additional information
  • 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.
Basis for recommendation
  • The basis for these recommendations is expert advice [Clarke et al, 2004].
  • A small study aimed to evaluate the efficacy and safety of the use of ear candles found the following [Seely et al, 1996]:
    • It is claimed that ear candling works by creating a vacuum which draws earwax from the ear. To investigate this two different sorts of candles were burnt in 20 ears. Tympanometric measurements in the ear canal demonstrated that ear candling did not produce a negative pressure at any time during the trial.
    • A small trial (n = 8 ears, 4 with no wax and 4 with impacted wax) did not show that any earwax was removed from the canals of the ears with impacted wax. Instead candle wax was deposited into the ear canal in some of the participants.
    • A survey of 122 otolaryngologists identified 21 injuries resulting from the use of ear candles: 13 burns of the auricle and external auditory canal, seven partial or complete occlusions of the ear canal with candle wax, and one perforation of the tympanic membrane.

How do I manage someone with recurrent earwax?

  • 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. See How to remove earwax.
  • To prevent wax becoming impacted advise the person 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.
Basis for recommendation
  • The basis for this recommendation is pragmatic advice.
  • CKS found no evidence or guidelines for preventing ear wax impaction and there was no consensus of opinion amongst expert reviewers. Advice from expert reviewers ranged from instilling ear drops (sodium bicarbonate, sodium chloride, olive or almond oil) every day to once every two weeks.

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