Ear wax impaction
Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.
Clinical features
- Hearing loss
- Other symptoms include: discomfort, pain, tinnitus, itchiness, dizziness, cough
- Otitis externa and otitis media are discussed under separate headings
Referral criteria
- Suspected or known perforation of the tympanic membrane
- History of ear surgery
- Suspected foreign body
- OTC ear drops unsuccessful despite use for the recommended timeframe (or other measures that have been tried)
- Severe pain or deafness, signs of vertigo or infection
- Uncertain whether it is due to lack of ability to perform an aural examination in the community pharmacy setting
Time frame to resolution
- Seek medical advice if symptoms are troublesome or OTC eardrops have not helped after a few days' use
Management strategy
Non-pharmacological advice
- Wax provides a protective film and need only be removed if it is causing problems such as hearing loss or when an impression of the ear canal is needed (for example, when fitting a hearing aid)
- A build-up of ear wax should not be removed with fingers, a cotton bud or any other object (this can cause damage and cause greater impaction)
- Water in the ear(s) can cause expansion of ear wax and can lead to blockage of the ear canal
Pharmacological advice
- Simple remedies appear to be equally effective as branded ear wax products for softening wax. This is reiterated in BNF where olive oil, almond oil and sodium bicarbonate are discussed but the proprietary products are deemed 'less suitable for prescribing'. A recent Cochrane Systematic Review concluded that using ear drops when you have a partially or completely blocked ear canal may help to remove the ear wax in your ear. However, it is not clear whether one type of drop is any better than another, or whether drops containing active ingredients are any better than plain or salty water
- Do not recommend ear wax drops if the person has a perforated (or suspected to be) tympanic membrane. Check product information in case a previous perforation precludes use as well. Warn the person that side-effects of the ear drops may include temporary hearing loss, discomfort, dizziness and irritation of the skin. Be careful to establish allergy status as some products contain peanut oil/soya
- How to insert ear drops. Several reference sources recommend use for 3-5 days, but remember to check the manufacturer's instructions otherwise you could be acting out of licence
- If patients develop symptoms such as otalgia, significant itching of the ear, discharge from the ear or swelling of the external auditory meatus after wax removal, they should seek medical attention as this may indicate infection
- Ear wax may also be removed by irrigation with water or micro-suction techniques (these methods need to be done by an expert and are not suitable for everyone)
- Pregnancy: not typically managed OTC but check individual products prior to sale as some simple remedies such as olive oil may be okay