What are the best eardrops to prescribe for cerumen (earwax) impaction?

Best Eardrops for Earwax Impaction

Water-based cerumenolytic agents—including plain water, saline solution, sodium bicarbonate, hydrogen peroxide, or carbamide peroxide—are equally effective first-line options for earwax impaction, with no evidence that any commercial preparation is superior to simple saline or water. 1, 2, 3

First-Line Treatment Options

The American Academy of Otolaryngology-Head and Neck Surgery recommends any of the following water-based preparations as equally effective 1, 2:

• Plain water or sterile saline (lowest cost, lowest risk of skin reactions) 1, 2
• Carbamide peroxide (Debrox) - FDA-approved for 5-10 drops twice daily for up to 4 days 4
• Hydrogen peroxide solution - FDA-approved for 5-10 drops twice daily for up to 4 days 5
• Sodium bicarbonate solution (most effective for wax disintegration in laboratory studies) 2
• Docusate sodium (Colace) 1, 2
• Acetic acid solution 1, 2

A 2018 Cochrane review found no evidence that commercial cerumenolytic products are more effective than plain water or saline, making expensive preparations unnecessary in most cases. 3 A 2004 randomized controlled trial specifically demonstrated that both Cerumenex and Murine were no more effective than saline placebo. 6

Treatment Algorithm

Follow this stepwise approach 2, 7:

1. Apply cerumenolytic drops twice daily for 3-5 days 2, 7, 5, 4

   • Tilt head sideways, instill 5-10 drops, keep head tilted for several minutes 5, 4
   • Tip of applicator should not enter ear canal 5, 4

2. If impaction persists after 3-5 days, proceed to irrigation with body-temperature water 2, 7

   • Can be performed by clinician or as self-irrigation at home with bulb syringe 7
   • Water must be at body temperature to avoid caloric effects (dizziness) 2, 7

3. If irrigation fails, refer for manual removal with instrumentation 2, 7

The most cost-effective protocol is cerumenolytic followed by self-irrigation at home. 2

Oil-Based Alternatives (Second-Line)

If water-based agents cause irritation or are not tolerated, oil-based preparations may be used 1, 2:

• Olive oil
• Almond oil
• Mineral oil/liquid petrolatum

However, oil-based preparations only lubricate and soften cerumen without disintegrating it, and evidence shows they are not superior to water-based agents. 2, 3, 8

Absolute Contraindications

Do NOT use cerumenolytic drops or irrigation if the patient has 2, 7:

• Perforated tympanic membrane
• 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 2, 7:

• Anticoagulant therapy
• Immunocompromised state
• Diabetes mellitus
• Prior radiation therapy to head and neck

Common Pitfalls to Avoid

Never recommend ear candling—it has no evidence of efficacy and can cause serious injury including burns, ear canal occlusion, and tympanic membrane perforation. 1, 2, 7 The FDA has issued warnings against this practice. 1

Advise against cotton-tipped swabs—they push wax deeper into the canal and can cause canal laceration, tympanic membrane perforation, or ossicular dislocation. 1, 2, 7

Expected Adverse Effects

Cerumenolytic agents may cause 2:

• Transient hearing loss
• Dizziness
• Mild discomfort or irritation
• Local skin reactions (rare with water-based preparations)

All reported adverse effects across studies were mild, with no serious complications documented. 1, 3

Follow-Up and Referral

Document resolution of impaction after treatment. 2 If impaction persists despite multiple treatment attempts, refer to otolaryngology for specialized equipment and manual removal. 2, 7 If symptoms persist despite clearance of wax, evaluate for alternative diagnoses. 2