CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.
Earwax - Management
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].
© NHS Institute for Innovation and Improvement