Otic Drops for Earwax Impaction
For earwax impaction, you can order carbamide peroxide (Debrox), hydrogen peroxide, saline solution, or sodium bicarbonate solution—all are equally effective, with no evidence that one is superior to another. 1, 2
First-Line Cerumenolytic Options
Water-Based Preparations (Preferred)
Water-based agents have the lowest risk of local skin reactions and are recommended as first-line options: 1, 2
- Carbamide peroxide (Debrox): 5-10 drops twice daily for up to 4 days in adults and children over 12 years 3, 4
- Hydrogen peroxide solution: 5-10 drops twice daily for up to 4 days in adults and children over 12 years 1, 5
- Sodium bicarbonate solution: Most effective for wax disintegration in vitro studies 2
- Sterile saline solution: As effective as commercial products with minimal adverse effects 2, 6
- Acetic acid solution: Another water-based option 1, 2
- Docusate sodium (Colace): Water-based preparation 1
Oil-Based Preparations (Alternative)
These lubricate and soften cerumen without disintegrating it: 1, 2
Important note: Plain water is as effective as specially formulated commercial products, making saline or tap water reasonable cost-effective alternatives. 1, 2
Administration Protocol
Standard dosing for adults and children over 12 years: 5, 3
- Tilt head sideways
- Place 5-10 drops into ear
- Keep drops in ear for several minutes by keeping head tilted or placing cotton in ear
- Use twice daily for up to 4 days
- After treatment, flush ear with warm water using soft rubber bulb syringe if needed
For children under 12 years: Consult a physician before use 5, 3
Absolute Contraindications
Do not use cerumenolytic drops if the patient has: 2, 6, 7
- Perforated tympanic membrane (nonintact eardrum)
- History of ear surgery (unless cleared by ENT)
- Tympanostomy tubes in place
- Active otitis externa or ear infection
- Ear canal stenosis or exostoses
Modifying Factors Requiring Caution
Assess for these conditions that may affect management approach: 1, 2
- Anticoagulant therapy
- Immunocompromised state
- Diabetes mellitus
- Prior radiation therapy to head and neck
Treatment Algorithm
- Apply cerumenolytic drops for 3-5 days 6
- If impaction persists: Proceed to irrigation with body-temperature water (can be done at home with bulb syringe or by provider) 2, 6
- If irrigation fails: Manual removal by healthcare provider with specialized instruments 1, 6
- If multiple attempts unsuccessful: Refer to otolaryngology 2, 6
Most cost-effective approach: Cerumenolytic followed by self-irrigation at home 1, 2
Expected Outcomes and Follow-Up
- Hearing improvement: Average 5-10 dB improvement after successful removal 7
- Document resolution: Assess at conclusion of treatment and document whether impaction resolved 1, 6
- If symptoms persist despite clearance: Evaluate for alternative diagnoses 1, 6
Adverse Effects
Potential side effects are generally mild: 2
- Transient discomfort or irritation
- Temporary hearing changes
- Dizziness (especially if water temperature differs from body temperature)
- Tinnitus (rare)
- Tympanic membrane perforation (approximately 0.2% with irrigation) 6
What NOT to Recommend
Absolutely contraindicated interventions: 2, 6
- Ear candling/coning: No evidence of efficacy and can cause serious injury including burns and tympanic membrane perforation
- Cotton-tipped swabs: Push wax deeper and can cause canal laceration, TM perforation, or ossicular dislocation
- Home oral jet irrigators: Lack safety and efficacy research
Key Clinical Pearls
- No specific cerumenolytic is superior to plain water or saline based on Cochrane review evidence 2, 8
- Water should be at body temperature during irrigation to avoid caloric effects causing dizziness 6, 7
- Only treat symptomatic impaction or when ear examination is needed—do not routinely treat asymptomatic cerumen 1
- Procedure should not take more than 30 minutes including preparation 7