Primary care

Removal of ear wax

T Aung, specialist registrar ^a, G P Mulley, professor ^b. 

^a Department of Medicine for the Elderly, Hull Royal Infirmary, Hull HU3 2JZ, ^b Elderly Services, St James's University Hospital, Beckett Street, Leeds LS9 7TF

Correspondence to: G Mulley Graham.Mulley{at}leedsth.nhs.uk

An elderly man says he cannot hear properly and the problem has been worsening for a few months. He now has difficulty conversing and watches television at high volume. Normally, he is a sociable man, so he is frustrated and depressed. You find that both external ear canals are occluded with hard wax, which you offer to remove.

	What issues you should cover

Top What issues you should... What you should do

PrevalenceExplain that impacted ear wax is common; just under a third of older people experience the problem. In the United Kingdom thousands of people every week have ear wax removed. The chances of wax accumulating are increased by use of hearing aids and cotton buds.

Removing waxExplain that ear wax can be removed in several ways. Wax softeners for five days can be tried first and are often effective. Mechanical methods are the next step. The traditional way is with irrigation, after softening, with a metal hand held syringe. A safer method is an electric oral jet irrigator (with special ear irrigator tip), which provides better water pressure control and more precise water jet direction. Some people need further intervention, with wax removed under direct vision using suction, probes, or forceps.

Effects of impacted waxThough some people are asymptomatic, others may have (in addition to some hearing loss) earache, itchiness in the ear, reflex cough, dizziness, vertigo, or tinnitus. Hearing impairment can cause frustration, stress, social isolation, paranoia, and depression.

Contraindications to syringingPerforation (past or present) of the ear drum, ear infection, presence of a grommet, history of ear surgery, and young children who are uncooperative are contraindications to ear syringing.

Complications of syringingAdverse effects are common. Perforation of the ear drum, otitis externa, damage to the external canal, pain, deafness, vertigo, and tinnitus are all possible complications.

	What you should do

Top What issues you should... What you should do

• Always take a full history, asking specifically about ear discharge, previous perforation of the ear drum, or ear infection.
• Carefully examine the ear canal.
• Suggest wax softeners (such as sodium bicarbonate ear drops) as first line treatment.
• If wax softeners are ineffective, consider ear syringing and explain the possible risks to the patient.
• The person doing ear irrigation must be fully trained.
• If syringing, aim the jet at the superoposterior part of the ear canal. If the nozzle of the syringe is not properly secured, it can be detached during the procedure. If the ear canal is occluded by the instrument tip, the pressure can rise to a dangerous level. It is important to use the correct techniquepulling the pinna outwards and backwards to avoid occlusion and using the correct equipment.
• If a metal syringe is used, it should not be pressed too forcibly, as excess pressure can damage the ear drum.
• Water used in ear syringing should be at body temperature (37°C)if it is too cold or too hot, it will cause dizziness or vertigo.
• Keep a detailed medical record of the procedure
• Advise patient on ear hygiene and to avoid using cotton buds
• Look for signs and symptoms of complicationsfor example, severe pain during syringing, deafness, or vertigoand refer immediately to an ear, nose, and throat specialist if problems occur during or after the procedure or if deafness persists.

	Footnotes

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