Management of Ear Wax (Cerumen) Buildup
Most people do not need routine ear wax removal, and treatment should only be pursued when cerumen causes symptoms (hearing loss, fullness, pain, itching) or prevents necessary ear examination. 1
When to Treat Ear Wax
Cerumen impaction should be diagnosed when accumulation of cerumen seen on otoscopy is associated with symptoms, prevents needed assessment of the ear, or both. 1 This is a Grade B recommendation with high confidence. 1
Common symptoms requiring treatment include: 1
- Hearing loss (returns to baseline after removal if canal was completely blocked) 1
- Sensation of fullness in the ear 1
- Itching 1
- Ear pain 1
- Discharge, odor, or cough 1
Treatment Algorithm
First-Line: Cerumenolytic Agents (Wax Softeners)
Apply cerumenolytic drops for 3-5 days as initial treatment. 2, 3, 4 All types are equally effective: 4, 5
- Water-based agents (hydrogen peroxide, sodium bicarbonate, acetic acid, sterile saline) 4
- Oil-based agents (almond oil, olive oil) 5
- Non-water/non-oil agents (carbamide peroxide) 5
No specific cerumenolytic agent has proven superiority over others; even plain saline or water is as effective as commercial preparations. 3, 5
For hydrogen peroxide (carbamide peroxide 6.5%): Tilt head sideways, place 5-10 drops into ear, keep drops in ear for several minutes by keeping head tilted or placing cotton in the ear, use twice daily for up to 4 days. 6
Second-Line: Ear Irrigation
If cerumenolytics fail after 3-5 days, proceed to irrigation using body-temperature water to avoid caloric stimulation and vertigo. 2, 3, 4
Absolute contraindications to irrigation include: 2, 3, 4
- History of tympanic membrane perforation 2, 4
- Presence of tympanostomy tubes 2, 4
- Prior ear surgery 2, 4
- Active otitis externa 2, 4
- Narrow or stenotic ear canals 2, 3
Relative contraindications requiring caution: diabetes mellitus and immunocompromised status. 2
Irrigation technique: Use gentle pressure directed at the canal wall, not directly at the tympanic membrane. 3 Potential complications include pain, ear canal injury, otitis externa, and tympanic membrane perforation (approximately 0.2% of cases). 3, 4
Third-Line: Manual Removal with Curette
When irrigation fails or is contraindicated, manual removal using curette, forceps, or suction by a clinician is appropriate. 1, 2 This takes only a few minutes and does not require anesthesia. 1
Refer to otolaryngology if multiple treatment attempts are unsuccessful or if specialized equipment/training for manual removal is lacking. 2
Critical Patient Education
Strongly counsel patients to NEVER insert cotton-tipped swabs or any foreign objects into the ear canal. 1 Cotton-tipped swabs push wax deeper into the canal, worsen impaction, and can cause trauma including skin abrasions, eardrum perforation, and ear canal injury. 1 Approximately 9% of individuals who use cotton swabs or foreign objects for ear cleaning report injuries. 1
Explicitly advise against ear candling/coning—it is completely ineffective and dangerous, with risks including burns, perforation, and hearing loss. 1, 2, 4 Studies demonstrate ear candling produces no negative pressure, removes no cerumen, and actually deposits candle wax residue into the ear canal. 1
Prevention for High-Risk Groups
Preventive measures are only necessary for specific populations: 1
- Elderly patients 1
- Hearing aid users (who have higher impaction rates due to interference with normal cleaning mechanisms) 1
- Patients with history of recurrent impaction 1
- Cognitively impaired individuals 1
For these patients, periodic use of topical cerumenolytic agents or self-irrigation with bulb syringe can prevent recurrence. 4
Expected Outcomes
Cerumenolytic treatment alone results in complete wax clearance in 22% of cases versus 5% with no treatment (NNT = 8). 5 When the ear canal is completely or almost completely blocked, removing wax restores hearing to pre-impaction levels. 1 The procedures should not cause pain. 1
Document the degree of cerumen clearance and condition of the ear canal and tympanic membrane after any cleaning procedure. 2