Index

NICE guideline [NG98] Hearing loss in adults: assessment and management. Last updated: Oct 2023. NICE CKS Earwax. Last revised: Mar 2025.

Background Information

Ear wax (cerumen): normal physiological substance produced in the external auditory canal

Component: combination of desquamated keratin from epithelial cells + secretions from sebaceous and ceruminous glands + foreign substances (e.g. dirt and cosmetixa)

Earwax impaction: accumulation of earwax that causes symptoms and/or prevent assessment of the ear (often tympanic membrane not visualised)

Diagnosis is made by otoscopic examination:

Impaction: cerumen is seen completely obstructing the external auditory canal, preventing visualisation of the tympanic membrane

Ear wax causing hearing loss or other symptoms
Typmanic membrane obscured by wax but needs to be viewed to establish a diagnosis

Methods of removal:

1st line: wax softeners (sodium bicarbonate 5% ear drops, olive / almond oil drops, sodium chloride 0.9% nasal drops)
2nd line: ear irrigation with electronic irrigator with pre-treatment wax softeners (up to 5 days before)
- If unsuccessful: repeat use of wax softners, or instil water into the ear canal 15 min before repeating ear irrigation
3rd line: microsuction / manual removal with a probe

Increased risk of infection / trauma / haemorrhage
- Perforated tympanic membrane
- Active infection / dermatitis of the ear canal
- Abnormalities of the ear canal (e.g. exostoses and ear canal stenosis)
Acute otitis externa with oedematous ear canal and painful pinna
Grommets in situ
History of
- Any ear surgery (except extruded grommets within the last 18 months and discharged by ENT)
- Middle ear infection in the previous 6 weeks
- Any previous problems with ear irrigation
Cleft palate (even if repaired)
Foreign body in the ear

Mucus discharge from the ear within the past 12 months (may indicate undiagnosed perforation)
Hearing in only one ear if it is the ear to be treated
Confusion or agitation
Inability to cooperate (e.g. young children and some people with learning difficulties)

NICE CKS Earwax

Author: Adams Lau
Reviewer:
Last edited: 13/07/25