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.

Impaction 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

• 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)

• People with a learning disability or Down syndrome

Three steps:

• Confirm the wax is genuinely occlusive and is the cause on otoscopy

• Exclude red flags – never attribute new sudden hearing loss to wax, because idiopathic sudden sensorineural hearing loss is a 24-hour emergency

• 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