Ear Syringing / Wax Management

About cerumen (earwax)

Cerumen production is normal. It moisturises the canal skin and protects it from infection, giving a barrier against water, foreign bodies, and even insects. Normal jaw movement expels it spontaneously, so most people never need active removal.

Roughly 60% of cerumen’s mass is keratin from shed skin cells, the rest lipids and peptides from the sebaceous and ceruminous glands of the outer third of the canal.

Impaction happens when that self-clearing mechanism fails. It occurs in up to 6% of the general population, 10% of children, and over 30% of older and cognitively impaired people. Hearing aids, earplugs, exostoses and canal anomalies all predispose.

Frequent insertion of cotton swabs, hearing aids or earbuds accelerates cerumen production and can change its composition. Using cotton swabs for an itchy ear increases wax production and makes the itch worse.

When to remove it

Treat when the patient has hearing loss, ear fullness, pruritus, dizziness, tinnitus or otalgia. Also remove it when it blocks otoscopy of a symptomatic ear, or prevents audiometry or tympanometry.

Do not remove asymptomatic wax reflexively. Explain that cerumen is bactericidal, protective and emollient, and offer observation instead.

Exceptions where treating asymptomatic wax is reasonable: young children, frail older people, and cognitively impaired patients who may not be able to report symptoms.

After removal, do not stop there if symptoms persist. Otalgia, tinnitus, dizziness, hearing loss, aural fullness and itch are non-specific. Look for Eustachian tube dysfunction, otitis media, otosclerosis, sensorineural hearing loss, TMJ syndrome and upper respiratory infection before attributing symptoms to the wax that was removed.

Methods

Three methods are recommended: cerumenolytic drops, irrigation, and manual removal.

Cerumenolytics. Water-based (hydrogen peroxide, docusate sodium, acetic acid, sodium bicarbonate) or oil-based (olive, almond, peanut oil). Waxsol, Ear Clear and hydrogen peroxide are the common Australian options. Typically up to 5 drops per dose, once or twice daily for 3–7 days. Docusate sodium looks the most effective, particularly as pre-treatment before irrigation.

Irrigation. Only after the tympanic membrane has been visualised to exclude perforation. Warm water, or a 50/50 water and hydrogen peroxide mix, delivered by syringe with a basin underneath.

Use water close to body temperature. Fluid that is too warm or too cool sets up a convection current in the semicircular canals and causes vertigo — the same mechanism as caloric vestibular testing.

Manual removal under direct vision with a curette, loop, spoon or alligator forceps. Its advantage is a lower infection risk because the canal is never wetted. It needs more skill and more patient cooperation, and still carries a small risk of perforation and local trauma.

Irrigation appears less effective than manual removal under visualisation in patients over 70.

Contraindications and cautions

There are no absolute contraindications to cerumen removal as such — the restrictions attach to the method chosen.

Do not irrigate if the tympanic membrane cannot be visualised, or where there is current otitis media or externa, past or present perforation, previous ear surgery, or an uncooperative patient. If hearing is impaired, do not syringe the better-hearing ear.

Cerumenolytics are contraindicated by a perforated tympanic membrane or previous ear surgery including grommets. Local irritation and rash are the usual reactions; superinfection can occur with prolonged use.

Take extra care with:

• Immunosuppression (HIV, diabetes, transplant) — higher infection risk after even minor trauma, and higher risk of malignant otitis externa, which can mimic impaction.
• Diabetes specifically — cerumen pH is higher, so superimposed bacterial infection is commoner.
• Chronic anticoagulation — higher risk of haemorrhage or haematoma.
• Anatomical anomalies narrowing the canal.
• Recurrent otitis externa or tinnitus, which syringing may aggravate.

Complications and procedural side effects

• Tympanic membrane perforation, and external auditory canal trauma.
• Otitis externa or media — water retained behind incompletely removed wax raises this risk.
• Pain and bleeding. Canal sensitivity increases towards the drum, which is very sensitive to minimal contact.
• Coughing or gagging from stimulation of Arnold’s nerve, the vagal branch supplying the canal. Warn the patient, and be ready to withdraw the instrument quickly.

Perforation from syringing usually heals without intervention; if infected, use ciprofloxacin-based topical drops.

Advise patients against two things they can buy themselves. Cotton swabs worsen impaction and can perforate the drum. Ear candling is ineffective and carries a real injury risk — the US FDA recommends strongly against it.

Preventing recurrence

• Mineral oil to the external canal for 10–20 minutes weekly, for anyone impacting more than once a year.
• Hearing aid users should leave the aids out for 8 hours a day to reduce wax buildup.

How well do drops actually work?

A Cochrane review of 10 trials (623 participants) found the evidence thin.

• A single study found ear drops for five days cleared more ears than no treatment: 22% versus 5%.
• No evidence that an active cerumenolytic beats plain water or saline.
• No evidence that water or saline beats no treatment at all.
• No evidence that oil-based drops differ from water-based ones, or that any one active agent is superior to another.
• Adverse effects were uncommon and mild — slight irritation, pain, unpleasant smell. None were serious.

Practically: drops are cheap, safe and reasonable before irrigation, but do not promise a particular brand will work better than warm water.