• 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 must 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.

In depth

• Prescribe ear drops for 3–5 days initially, to soften wax and aid removal.
• Sodium bicarbonate 5%, sodium chloride 0.9%, olive oil, or almond oil drops can be used.
• 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.
• 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.

In depth

• 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.

In depth

• 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.