EAR WAX

Alternative names: Cerumen impaction

Written by Oh Chunghyeon

Background Information

Definitions of levels of care (in this guideline)

● Level 1: Community healthcare worker/non-doctor
● Level 2: Medical doctor
● Level 3: ENT Surgeon

Cerumen, or ‘wax’ as it is commonly known, is a normal secretion of the ceruminous and sebaceous
glands mixed with dead skin tissues in the external auditory canal. It is generally thought to be protective
to the ear. It is slightly acidic, contains lysozymes and immunoglobulins associated with the bactericidal
qualities1. It is also the primary reason why the external auditory canal (EAC) can become obstructed.
While often harmless, blockage of the EAC by cerumen can lead to a host of symptoms: ear fullness,
hearing loss, tinnitus, itching, otalgia, discharge, foul odour and cough2. Normally, cerumen is eliminated
or expelled by a self-cleaning mechanism, which causes it to migrate out of the EAC assisted by jaw
movement3.

Diagnosis
History/Predisposing factors:
● Self-ear cleaning
● Using cotton buds
● Old age
● Developmentally delayed
● Ear plugs, hearing aid users
● Otological surgery
● Anatomical ear canal abnormalities (narrow canal, exostoses and osteoma)
● Local radiation therapy (osteoradionecrosis)

Symptoms:
Main symptoms
● Ear fullness
● The main complaint is ear blockage following a shower or swimming.
● Hearing impairment
● Tinnitus
Possible symptoms
● Itching
● Otalgia
● Discharge
● Foul odour
● Cough
Physical Examination
● Black/dark brown/yellow /dark orange chunky materials obstructing the EAC partially or totally.

Examination

General:
● The EAC examination should be performed to
diagnose cerumen impaction.
● Gently pull the pinna backward and upward in
order to examine the EAC with a light source
(see Figure 1.2).

Level 1:
● Ask the patient to gently pull the tragus
anteriorly with finger to open the EAC and at
the same time the examiner should pull the
pinna backward and upward.
● You may use any light source to examine the
EAC (e.g.; torch light, pen light, cellular phone
light, lantern or sunlight).

Level 2:
● Otoscopy should be performed with an otoscope to diagnose cerumen impaction.

Level 3:
● Oto-microscopy or oto-endoscopy should be performed.
● In case of recurrent cerumen impaction, please check possible predisposing factors (see
diagnosis section).

Management

General:
● Understand cerumen (earwax) is normal. If earwax is not causing symptoms the ear should be
left alone.
● Prior to examination of the EAC it is essential to talk to the patient and / or their caretaker to
obtain a detailed history and provide explanation of any procedure(s) performed. The patient as
well as the caregiver should be fully informed of possible complications of the procedure and
effects of ear irrigation, to ensure that the patient understands and gives consent2.
● Medical personnel should explain proper ear hygiene to prevent cerumen impaction.
● Don’t use cotton buds for ear cleaning in the EAC.

● Don’t put anything in the EAC except prescribed/recommended ear drops by a physician when
needed.
● Interventions that are not appropriate for cerumen removal include home use of oral jet
irrigators and cotton-tipped swabs.
 ● The most popular alternative practice for cerumen removal is ear candling, also known as “ear
coning” or “thermo-auricular therapy.” This is ineffective and potentially dangerous and should
not be used to make practitioners and patients aware of the ineffectiveness and risks associated
with ear candling/coning for cerumen removal4.

Level 1:
● Following patients’ ears assessment and examination, if impacted wax is the problem advice
needs to be given to the patient/ and or care giver regarding wax softening prior to further
procedures being carried out. This is to promote patient safety by reducing risk of procedures,
and increasing likelihood of successful wax removal2.
● There is no evidence to confirm that any one wax softening agent is superior to another. Even
normal saline has similar effects for wax softening5.
● Advise patient/ care giver on the use of wax softener. Instil in the EAC: 2-3 drops, pump the
tragus (repeatedly push it in and out) to spread the wax softener in the ear canal, 2-3 times/day,
for a minimum of 5-7 days1.
● Advise patient to lie on the unaffected side, if possible, while wax softener is inserted, and to
remain on their side for 5 minutes1.
● Advise patient not to put cotton wool into the EAC following instillation of wax softener, as the
cotton wool absorbs the drops which could lead to ineffective treatment1.
● The patient should be re-assessed, and ears re-examined after 5-7 days, and consider if any
further intervention is required.
● If you can’t remove the impacted cerumen, you should refer to another clinician who can treat
cerumen impaction when identified.

Level 2:
● See level 1
● Ear irrigation is a widely practised form of cerumen removal and can be performed with a
syringe. There is general consensus that ear irrigation is effective in removing cerumen2.
● Ear irrigation should not be performed in individuals who have a perforated tympanic membrane
or those who have had ear surgery, since the tympanic membrane may be thinned or atrophic
and vulnerable to perforation6.
● Also, ear irrigation should be avoided in individuals with anatomic abnormalities of the canal
(congenital malformations, osteomas, exostoses, scar tissue, etc) that might trap saline in the
external auditory canal following irrigation7,8. Manual removal under guidance (level 3) is
recommended for those with anatomic abnormalities.
● Following cerumen removal with ear irrigation, the ear canal and ear drum should be
re-evaluated with an otoscope whether any damage of ear drum or another pathology of the
ear.
● The main complications reported after ear irrigation are pain, injury to the skin of the ear canal
with or without haemorrhage, and acute otitis externa. Commonly reported significant
complications are tympanic membrane perforation (0.2%) and vertigo (0.2%)9.
● Symptoms of complications include sudden pain, tinnitus, hearing loss, bleeding, dizziness or
water coming out of the patient’s nose. If a patient experiences any of these symptoms, the
provider should immediately stop10.

Level 3:
● Clinicians should assess the patient with cerumen impaction by history and/or physical
examination for factors that modify management such as one or more of the following:
 non-intact tympanic membrane, ear canal stenosis, exostoses, diabetes mellitus,
immunocompromised state, or anticoagulant therapy2.
● Clinicians should remove the impacted cerumen with one or several combinations of
cerumenolytic agents, ear irrigation and manual removal with specialised instruments.
● If the patient has a perforated tympanic membrane, active otitis externa, history of ear surgery,
narrowed ear canal or osteoradionecrosis, clinicians should consider suctioning of the cerumen
rather than ear irrigation.

Further reading

1. Lyons, M. Ear Care Guidelines SH CP 196. (2016).

2. Schwartz, S. R. et al. Clinical Practice Guideline (Update): Earwax (Cerumen Impaction). Otolaryngol
Head Neck Surg 156, S1–S29 (2017).
3. Alberti, P. W. EPITHELIAL MIGRATION ON THE TYMPANIC MEMBRANE. J Laryngol Otol 78, 808–830
(1964).
4. Seely, D. R., Quigley, S. M. & Langman, A. W. Ear candles--efficacy and safety. Laryngoscope 106,
1226–1229 (1996).
5. Burton, M. J. & Doree, C. Ear drops for the removal of ear wax. Cochrane Database Syst Rev
CD004326 (2009) doi:10.1002/14651858.CD004326.pub2.
6. Rubin, J., Yu, V. L., Kamerer, D. B. & Wagener, M. Aural irrigation with water: a potential pathogenic
mechanism for inducing malignant external otitis? Ann Otol Rhinol Laryngol 99, 117–119 (1990).
7. Ford, G. R. & Courteney-Harris, R. G. Another hazard of ear syringing: malignant external otitis. J
Laryngol Otol 104, 709–710 (1990).
8. Driscoll, P. V., Ramachandrula, A., Drezner, D. A., Hicks, T. A. & Schaffer, S. R. Characteristics of
cerumen in diabetic patients: a key to understanding malignant external otitis? Otolaryngol Head
Neck Surg 109, 676–679 (1993).
9. Pavlidis, C. & Pickering, J. A. Water as a fast acting wax softening agent before ear syringing. Aust
Fam Physician 34, 303–304 (2005).
10. World Health Organization. Primary ear and hearing care training resource.
https://apps.who.int/iris/handle/10665/43333 (2006).