Earwax

🧭 When to suspect

Earwax (cerumen) is a normal, protective secretion that keeps the external auditory canal clean and moist. Impaction is an accumulation that occludes the canal and produces symptoms or prevents examination – it is one of the commonest ear presentations in primary care, with an estimated 2.3 million people a year in the UK needing intervention. Suspect it in a patient with conductive hearing loss (usually gradual, but it can feel sudden when water enters and the wax swells), a sensation of fullness or blockage, mild discomfort or itch, tinnitus, occasionally dizziness, or a reflex cough (vagal/Arnold reflex from wax against the drum).

Risk is higher with hearing aid, earplug, earbud or cotton-bud use, narrow, hairy or tortuous canals, bony canal swellings (exostoses/osteomata), increasing age, dermatological conditions (eczema, seborrhoeic dermatitis, psoriasis), and in people with a learning disability or Down syndrome.

The key clinical skill is threefold: confirm the wax is genuinely occlusive and is the cause on otoscopy; exclude red flags – crucially, never attribute new sudden hearing loss to wax, because idiopathic sudden sensorineural hearing loss is a 24-hour emergency; and soften first, remove only if symptomatic, knowing the contraindications to irrigation. NICE advises excluding impacted wax and acute infection before attributing a hearing difficulty or arranging audiology.

Source: NICE NG98 · NICE QS185