Recommended Ear Wax Removal Liquids
For ear wax removal, use water-based cerumenolytic agents such as carbamide peroxide (e.g., Debrox), hydrogen peroxide, saline solution, or sodium bicarbonate—no specific agent has proven superiority over any other, including plain water. 1, 2
First-Line Water-Based Options
The American Academy of Otolaryngology-Head and Neck Surgery recommends water-based preparations as preferred first-line treatments due to their lower risk of local skin reactions compared to oil-based products: 3, 1
- Carbamide peroxide (e.g., Debrox) 1, 2
- Hydrogen peroxide solution 1, 2, 4
- Saline solution (equally effective as commercial products with minimal adverse effects) 1, 2
- Sodium bicarbonate 10% solution (most effective for wax disintegration in laboratory studies) 1, 2
- Docusate sodium 1, 2
- Acetic acid solution 1
Plain water is as effective as specially formulated commercial products, making it a reasonable and cost-effective option. 1, 5
Alternative Oil-Based Options
If water-based agents are not tolerated, oil-based preparations can be used, though they work by lubricating and softening cerumen rather than disintegrating it: 1, 2
A Cochrane review found no evidence that oil-based preparations are superior to water-based agents or plain water. 1, 5
Proper Administration Technique
For hydrogen peroxide (adults and children over 12 years): 4
- Tilt head sideways and place 5-10 drops into ear
- Tip of applicator should not enter ear canal
- 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 if needed
General technique for all cerumenolytics: 2
- Have patient lie with affected ear upward
- Fill ear canal with drops along the side of the canal
- Use gentle to-and-fro movement of the pinna and tragal pumping
- Patient remains in position for 3-5 minutes
- Leave canal open to dry after application
Treatment Algorithm
The most cost-effective approach is cerumenolytic drops followed by self-irrigation at home (£24,433 per QALY versus £32,130 per QALY for professional irrigation). 1, 2, 6
- Apply cerumenolytic drops for 3-5 days 1, 2
- If impaction persists, irrigate with body-temperature water (close to 37°C/98.6°F to avoid caloric effects causing dizziness) 1, 2
- If irrigation fails, refer for manual removal by healthcare provider 1, 2
Critical Safety Contraindications
Do NOT use cerumenolytic drops if the patient has: 1, 2
- 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
Exercise special consideration in patients with: 1, 2
- Anticoagulant therapy
- Immunocompromised state
- Diabetes mellitus (avoid tap water irrigation to prevent malignant otitis externa)
- Prior radiation therapy to head and neck
What NOT to Use
- Ear candling/coning (no evidence of efficacy; can cause burns, ear canal occlusion, and tympanic membrane perforation)
- Cotton-tipped swabs (push wax deeper; can cause canal laceration, tympanic membrane perforation, and ossicular dislocation)
- Home oral jet irrigators (lack safety and efficacy research)
- Foreign objects (pens, paper clips, bobby pins)
Expected Adverse Effects
Cerumenolytic agents can cause mild, transient effects: 1, 2
- Transient hearing loss
- Dizziness
- Discomfort or irritation
- Local skin reactions (rare with water-based preparations)
Serious adverse effects are extremely rare, with tympanic membrane perforation occurring in approximately 0.2% of irrigations and only 1 in 1000 cases requiring specialist referral. 1, 7
Age Restrictions
Children under 12 years should consult a physician before using hydrogen peroxide drops. 4 Children under 3 years should not use cerumenolytics without medical supervision. 1
When to Refer
Refer to otolaryngology if: 1, 2
- Multiple treatment attempts fail
- Symptoms persist despite appropriate management
- Specialized equipment or manual removal is needed
- Hearing loss persists after addressing obvious causes