Earwax

What is earwax?¹

Earwax is a build-up of cerumen, sebum, dead cells, sweat, hair and foreign material - eg, dust. Cerumen has antibacterial and antifungal properties.² Earwax is a normal physiological substance that protects the ear canal. Earwax produced varies greatly between individuals. Earwax may be either wet or dry. Wet wax is either soft (more common in children) or hard (more common in the elderly and more likely to become impacted and thereby cause symptoms). Dry wax is dry, flaky and golden yellow and is common in people from Asia.

How common is impacted earwax?

Being a physiological process, earwax is a universal phenomenon. Impacted earwax is more common in:

• The elderly.³

• People who use hearing aids.

• Those who use cotton ear buds.

It has been estimated that up to two million ear irrigations are performed in England and Wales each year.⁴ Reported prevalence rates from varying populations range from 7-34%.⁵

One study reported a high incidence of earwax in people with schizophrenia; this was linked to reduced functioning and social isolation.⁶ .

Earwax symptoms

• Hearing loss (most common symptom).

• 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).

Examination

• Examine both ear canals with an auriscope.

• Assessment of conductive hearing loss may include Rinne's test and the Weber's test.

Differential diagnosis⁷

• Other causes of acute deafness - eg, Eustachian tube dysfunction, foreign body.

• Otitis externa.

Earwax treatment and management^{8 9 10}

Impacted earwax can be treated with ear drops, irrigation, microsuction or curettage. Ear drops are considered first-line and often the only treatment required. Microsuction is safer than irrigation but not widely available. Complications of irrigation can be minimised by correct training and care. There is little good evidence on the relative effectiveness of the various treatment options.¹¹

Indications for removal of earwax

Earwax only needs removal if it is causing symptoms or interfering with a view of the eardrum or ear canal. Earwax removal may be indicated if:

• Earwax is totally occluding the ear canal and causing hearing loss, earache, tinnitus or vertigo.

• The tympanic membrane is obscured by wax but must be viewed to establish a diagnosis.

• 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.

Ear drops

Ear drops are often the appropriate first-line treatment. However, there is no high-quality evidence to allow a firm conclusion whether one type of cerumenolytic is more effective than another, no evidence of a difference in efficacy between oil-based and water-based active treatments, and no evidence to show that using saline or water alone is better or worse than commercially produced cerumenolytics.¹²

The British National Formulary (BNF) recommends olive oil or almond oil be used, as sodium bicarbonate drops may cause dryness of the ear canal, and docusate sodium or urea hydrogen peroxide, which are ingredients in a number of proprietary preparations for softening earwax can irritate the external meatus.¹³ Do not advise almond oil drops if the person has an allergy to almonds.

Prescribe ear drops for 3-5 days initially, to soften wax and aid removal. Regular use of ear drops may be indicated for patients with recurrent earwax problems.

Do not use drops if the person has a possible perforated tympanic membrane.

Irrigation

• If symptoms persist despite ear drops, consider ear irrigation, providing that there are no contra-indications (see 'Contra-indication for ear irrigation', below).

• The use of softening ear drops (such as olive oil) is advised for 3-5 days prior to irrigation. This is partly as irrigation may not then be required and partly because it may help reduce the potential for trauma to the ear canal.¹

• Self-irrigation using a bulb syringe has been advocated for people who require regular irrigation, thus reducing the demand on primary care.¹⁴

• Seek immediate advice from an ENT specialist if severe pain, deafness, or vertigo occurs during or after irrigation, or if a perforation is seen following the procedure.

• Advise anyone who has had earwax removed to return if they develop otalgia, significant itching of the ear, discharge from the ear or swelling of the external auditory meatus, as this may indicate infection.

If irrigation is unsuccessful, consider one of the following:

• Advise the person to use ear drops for a further 3-5 days and then return for further irrigation.

• Instil water into the ear. After 15 minutes irrigate the ear again.

• Refer to an ENT specialist for removal of wax.

• Several other mechanical removal techniques are available but usually only in secondary care - eg, ear curettes and forceps, microsuction.

Contra-indication for ear irrigation¹

• Signs or symptoms of current infection: otitis externa or otitis media.

• Current perforation of the tympanic membrane or a history of perforation of the tympanic membrane in the previous 12 months. (Some experts would include any history of perforation ever.) A mucous discharge from the ear within the previous 12 months is also a contra-indication, as it may indicate an undiagnosed perforation.

• History of any previous problem with irrigation (pain, perforation, severe vertigo).

• Grommets in place.

• History of any ear surgery (except extruded grommets with subsequent discharge from an ENT department).

• History of a middle ear infection in the previous six weeks.

• History of recurrent otitis externa or tinnitus.

• Cleft palate (whether repaired or not).

• A foreign body containing vegetable matter, in the ear. (The water may cause it to swell.)

• Hearing only in the ear to be treated (due to the small possibility of irrigation causing permanent deafness).

• Confusion or agitation (may be unable to sit still).

• Inability to co-operate - eg, young children and some people with learning disabilities.

Cautions with irrigation

• Vertigo (may indicate the presence of middle ear disease with perforation of the tympanic membrane).

• Recurrent otitis media (thin scars on the tympanic membrane can easily be perforated).

• Those with immunocompromise or at increased risk of infection.

Indications for referral¹

• Chronic perforation of the tympanic membrane.

• Past history of ear surgery.

• Foreign body, including vegetable matter, in their ear canal.

• Ear drops have been unsuccessful and irrigation is contra-indicated.

• Irrigation is unsuccessful.

Refer or seek urgent advice if infection is present and the external canal needs to be cleared of wax, debris and discharge. Also as stated above, seek immediate advice from an ENT specialist if severe pain, deafness, or vertigo occurs during or after irrigation, or if a perforation is seen following the procedure.

Earwax complications¹

• Impacted earwax may cause conductive hearing loss.

• Infection may sometimes occur as a result of earwax impaction.

• Recurrence is common.

Complications of irrigation

• Otitis externa.

• Perforation of the tympanic membrane.

• Damage to the external auditory meatus.

• Pain.

• Otitis media (due to water entering the middle ear when there is a previous perforation).

• Exacerbation of pre-existing tinnitus.

• Bleeding may also occur but is usually self-limiting.

• Nausea, vomiting and vertigo.

• Facial nerve palsy has been reported.¹⁵