Ear Wax

There is NO completely safe way of removing wax from ears: ALL methods – drops / irrigation / microsuction carry with them a risk of otitis externa and tympanic membrane (TM) perforation.

Indications for wax removal, where it is occlusive, include conductive hearing loss and tinnitus.

Self- and Primary Care-Management

Sodium bicarbonate ear drops (can be bought OTC), to be used twice daily for two weeks, are the most reliable and cheapest way of dissolving wax
Oil drops are excellent at softening wax prior to irrigation or microsuction. Although they do not actually remove wax, once softened it will often just clear itself as ear canal skin grows from the drum outwards to the meatus and carries wax with it. Using cotton wool buds or other instruments in the ear often impacts this natural clearance and should be advised against.

Most ear wax can be self-managed – please see the NHS Lothian ear wax patient information leaflet, which also gives details about how patients should prepare for ear irrigation.

Primary Care Ear Irrigation

Ear irrigation for wax is a well-established procedure in primary care: please see the CTACS pages for further detail.

There is a small risk of irrigation leading to otitis externa and very rarely (1:1000 or less) of tympanic membrane perforation. Ideally the patient should apply oil to the ear twice daily for two weeks prior to the procedure.

There is no evidence that repeated ‘routine syringing’ is of benefit and should be avoided as it may also cause unnecessary harm: self-management should always be encouraged.

Long-term weekly application of sodium bicarbonate ear drops after wax clearance helps prevent recurrence and need for further irrigation or microsuction.

The ENT recommendation is that primary care ear wax removal is not needed more frequently than 6-monthly.

Irrigation should not be used where there is otitis externa, mastoid cavities or a perforated tympanic membrane.

Secondary Care Microsuction for wax

This is a well-established and generally safe procedure but requires specialist training and equipment so is expensive. Ideally the patient should apply oil to the ear twice daily for two weeks prior to the procedure for impacted wax. The service is available at Lauriston Building, East Lothian Community Hospital, St John’s Hospital and RHCYP for older children (please see the Paediatric Ear Wax page) and is provided by the Nurse Specialist and Physician Associate team. Please see below for criteria for referral.

Who to refer:

Referral for Urgent Secondary Care Microsuction

If the patient has severe otitis externa where swelling in the ear canal prohibits use of topical antibiotic/steroid drops, microsuction can be accessed as an emergency at St John’s Hospital for patients aged 16 and over by contacting the on-call ENT team via switchboard on 01506 523 000. Children should be discussed with the on-call team at RHCYP – see Paediatric Otitis Externa.

Referral for Routine Secondary Care Microsuction

Patients who have ear wax causing symptoms, where there:

have been two previous unsuccessful attempts at irrigation or microsuction in primary care
is persistent TM perforation or a mastoid cavity
is significant inflammation – otitis externa – not responding to treatment with topical antibiotic/steroid drops (see above)
has been a previous significant negative experience of irrigation.

Please note that a history of a previous perforation that has now healed is not in itself a contraindication to irrigation.

Who not to refer:

Patients who have no contraindication to wax removal by irrigation in primary require two attempts at primary care wax removal prior to referral. Please see Primary Care Management for more detail. They also need to have occlusive wax causing symptoms and have maximised self-care please see the NHS Lothian ear wax patient information leaflet.