Troublesome Ear Wax

 

This guideline applies to adults aged 18 years and over.

 

Introduction

 

Ear wax may be wet or dry and is a normal physiological substance that protects the ear canal. It has several functions; it cleans, lubricates, and protects the lining of the ear canal, trapping dirt and repelling water. It also provides a sticky barrier to dirt and debris, stopping them from proceeding deeper into the ear canal.

In the vast majority of people, persistent use of ear wax softeners will be sufficient enough to resolve any issues they experience with ear wax.

Although wax can obscure the view of the tympanic membrane (TM), it does not cause permanent hearing impairment.

 

 

Key Features of Assessment

 

Hearing loss is the most common symptom, but can cause feeling of fullness, otalgia, itch or tinnitus.

Has the patient had ear surgery in the past?

On examination:

• look for differential diagnoses – including foreign body or cholesteatoma (recurrent or chronically discharging ear)
• identify/exclude active infection, eczema / dermatitis, TM perforation

 

 

Primary Care Management

Routine Ear Wax:
 

1. Provide reassurance – most ear wax will not require treatment.
   
   
2. Provide an Earwax information sheet
   
   
3. Advise to keep ears dry:
   • Detergents in soap, shampoos, and conditioners can irritate the ear skin and increase the amount of wax produced.
   • Use precautions to prevent water ingress when swimming, bathing, showering, etc.
   • Advise using silicone swim plugs (available from pharmacies), a ball of cotton wool soaked in petroleum jelly or adhesive putty positioned in the outer bowl of the ear (and not pushed into the canal).
      
4. Avoid cotton buds or any other implement to try and take the wax out. This causes the wax to be pushed deeper down the ear canal, often against the ear drum, and can cause trauma to the ear.
    
5. Offer local treatment:

*Contraindications (CI) to sodium bicarbonate drops include:

• Known TM perforation
• Active ear infection
• Eczema / dermatitis of ear canal and/or external ear

 

Troublesome Ear Wax:

 

Troublesome ear wax that has not responded to ear wax softeners should be managed by irrigation if this is available in primary care unless it is contraindicated.

 

Contraindications to ear irrigation:

• Active ear infection
• Active ear disease, including eczema / dermatitis of ear canal and/or external ear
• Tympanic membrane (TM) perforation
• Past history of ear surgery
• Abnormalities of ear canal
• Grommets
• Foreign body
• Hearing in only one ear
• Uncooperative patient

 

Patients may wish to consider consulting a private ear wax removal service provider if:

• irrigation is contraindicated or not available
   
• do not meet criteria for secondary care referral
   
• have routine wax and it is important to have it removed

 

 

Referral

 

NHS Kernow has a strict commissioning policy for removal of ear wax in secondary care.

 

Provider:

Referrals should be directed via RMS to the Aural Care Service.

 

Inclusion criteria:

Exclusion criteria:

• Referral for hearing test
   
• Removal of wax:
  • not meeting inclusion criteria
  • for audiology purposes
  • due to unsuccessful private removal attempt, or lack of affordability

 

Minimum required information:

• Patient symptoms and examination findings
   
• Confirmation that:
  • the full course of recommended drops has been completed
  • contraindications to irrigation
• Results of any relevant investigations
   
• Whether patient is known to ENT services

 

 

Individual Funding Request (IFR):

If the referral criteria are not met and you think the patient has an exceptional or unique clinical need then you may wish to consider an IFR

 

Advice and guidance

 

To discuss a patient please email rcht.auralcareservice@nhs.net. There is no formal A&G service.

 

Supporting Information

 

For professionals:

Nice CKS - Ear Wax

 

For patients:

NHS Cornwall ICB - Ear Wax Information Sheet

 

 

 

References

NHS Cornwall ICB Treatment Policies

 

 

Page Review Information

 

Review date	08 February 2024
Next review date	08 February 2026
Specialty Lead GP	Dr Laura Vines
Contributors	Commissioning Manager for ENT & Audiology Jenefer Feenan, former Aural Care Specialist Nurse