Skip to main content

Main menu

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers

User menu

  • Subscriptions
  • Alerts
  • Log in

Search

  • Advanced search
British Journal of General Practice
Intended for Healthcare Professionals
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
  • Listen to BJGP podcast
  • Subscribe BJGP on YouTube
British Journal of General Practice
Intended for Healthcare Professionals

Advanced Search

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
Clinical Practice

Ear wax management in primary care: what the busy GP needs to know

Kevin J Munro, Thomas C Giles, Christine Smith-Howell and Irwin Nazareth
British Journal of General Practice 2023; 73 (727): 90-92. DOI: https://doi.org/10.3399/bjgp23X732009
Kevin J Munro
NIHR Manchester Biomedical Research Centre, Manchester.
Roles: Professor of audiology
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Thomas C Giles
Manchester Centre for Audiology and Deafness, University of Manchester, Manchester.
Roles: Audiology researcher
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Christine Smith-Howell
Trafford Ear Care lead and national trainer, Meadway Health Centre, Manchester University NHS Foundation Trust, Manchester.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Irwin Nazareth
Research Department of Primary Care and Population Health, University College London, London.
Roles: Professor of primary care and population sciences
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info
  • eLetters
  • PDF
Loading

INTRODUCTION

Cerumen (or earwax), a self-cleaning agent, protects the outer ear. Sometimes this does not work and wax gets impacted, blocking the ear canal. This is a major reason for primary care consultation. Hearing difficulty due to untreated wax impaction can lead to social isolation and depression.1 Yet there is little quality evidence to guide practice for such a common condition. Further, people find it difficult to access NHS earwax services. This article provides new data on symptoms and severity, and reviews management options and patient preferences.

WHY DOES IT MATTER?

Earwax build-up occurs in anyone but often in older people and those using hearing aids or earbud earphones. Up to 44% of care home residents with dementia also have impacted earwax2 and about 2.3 million people/year in the UK have troublesome earwax requiring removal.3

Studies investigating earwax removal methods report how much of the tympanic membrane is visualised before and after treatment, but this does not capture the impact of the symptoms. This article reports on a symptom survey completed by 489 patients who attended the Trafford Ear Care Service, Manchester, during 2022. The most common symptom was hearing difficulty (86.5%; 423) with half of those with hearing difficulty reporting additional symptoms, including discomfort, tinnitus, or change in quality of their voice. Before wax removal, the most bothersome symptom was reported to be hearing difficulty (78.3%; 383), impacting on communication, focused listening (for example, TV), and awareness of surroundings. Predicting the effect of impacted wax on an individual is difficult as it depends on the quantity, consistency, and location of the wax within the ear canal.

Figure 1 shows that more than 90% (n = 443) found earwax at least moderately bothersome and 60% very/extremely bothersome before removal (a). After removal, more than 83% (n = 409) reported hearing difficulty to be somewhat or much better (b). In some cases, hearing difficulty may have persisted after earwax removal because most patients were older (70–79 years).

Figure 1(a).
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1(a).

How bothersome was the earwax before wax removal (n = 489); (b) immediate improvement after wax removal (n = 489). NA = not applicable.

WHY THE CURRENT CONTROVERSY?

The National Institute for Health and Care Excellence (NICE) recommends that earwax removal services should be available in primary care.1 However, earwax services are so scarce and non-existent in some locations that user groups led by the Royal National Institute for Deaf People campaign for wider access in primary care.

Controversies raised in parliament and media reports question referral to secondary care (ENT) with long delays, inappropriate use of specialist services, and the need to access private care from non-NHS ‘high street’ hearing aid dispensers. A Healthwatch Oxfordshire survey revealed that adults with earwax required 1–4 NHS visits prior to attending a dewaxing clinic, that time from symptoms to resolution was 3–30 weeks, and that microsuction required additional visits and longer waits.4

WHICH PRE-TREATMENT EARWAX SOFTENER IS BEST?

Pre-treatment drops or sprays soften the impacted wax making it easier for removal. A current concern is that earwax is often untreated with the mistaken belief that self-management with pre-treatment softeners is sufficient. Systematic reviews by both NICE1 and Cochrane5 fail to conclude which type of ear drop was more effective, or whether water or saline was better or worse than commercially available earwax softeners. NICE recommends pre-treatment softeners for up to 5 days before removal but stop short of recommending any particular product. Studies systematically comparing the benefit of different durations of ear drop use, or the administration of drops versus sprays, are limited.

WHAT PROCEDURES ARE RECOMMENDED FOR EARWAX REMOVAL AND WHAT DO PATIENTS PREFER?

NICE recommends electronic water irrigation and microsuction for earwax removal (or an alternative such as manual removal). Direct comparison of these two procedures in terms of safety, effectiveness, and costs is lacking. National training courses on wax removal for registered healthcare professionals (nurses, healthcare assistants) are available, with a requirement for an update every 3 years.

Manual water-filled syringes are no longer recommended in the UK because of potential damage to hearing and risk of litigation. Electronic devices that control the flow of low pressured water to flush the earwax from the ear canal are now in use. Contraindications include pre-existing otological conditions (for example, perforated eardrum, grommet, mastoid cavity, infection), presence of foreign body, or previous problems with wax removal. Specialist referrals resulting from complications of irrigation (for example, perforated eardrum) are estimated at 1/1000.6 There are anecdotal reports that drying the external ear after irrigation reduces the risk of ear infection. Irrigation is contraindicated in patients with only one functioning ear.

The alternative is to remove wax under direct visualisation using mechanical suction, the method of choice in secondary care. The cost of freestanding operating microscopes for microsuction is impractical in primary care. Lower-cost, portable hand-held video-assisted systems providing magnification and illuminated visualisation of the ear canal are a potential solution for widescale use.7 Little is known of the safety of microsuction although there are reports of discomfort and minor bleeding.

In the service evaluation mentioned above, all patients were offered both treatments and more than two-thirds had no or only a small preference for ether irrigation or microsuction (Figure 2). The proportion with direct experience of both procedures is unknown, but those expressing a preference for irrigation sometimes reported that previous microsuction was painful or noisy whereas those preferring suction report it is less messy compared with irrigation. There is currently no high-quality evidence comparing professionally administered and home-based procedures. Alternative methods of treating earwax such as ear candles are not recommended because these are ineffective.8 Also, inserting cotton buds into the ear canal has the potential to damage the ear and cause wax impaction.

Figure 2.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 2.

Preference for microsuction and water irrigation (n = 489).

A Health Technology Assessment review concluded that further research is required to improve the evidence base such as a randomised control trial (RCT) incorporating an economic evaluation to assess different pathways, different removal methods, and acceptability of the different approaches.9

WHAT PATHWAY?

Groups of practices rather than each individual practice can collaborate as primary care networks to provide a range of services, such as earwax removal. The portable nature of contemporary wax removal equipment is optimal in such a setting and for use in domiciliary visits to care homes. The cost of setting up a video-assisted mobile earwax suction service within a group of practices would involve an initial set-up and training cost-of around £1000, and any ongoing cost associated with rental of mobile equipment. However, the feasibility, clinical and cost effectiveness of this care pathway needs testing in an RCT.

TAKE-HOME MESSAGE

  • A significant number of people fail to get the care they need for earwax removal and there is an urgent need for such a service in primary care.

  • Pre-treatment softeners are recommended followed by removal using electronic water irrigation or microsuction.

  • The use of modern portable equipment within a primary care network and for use in care homes is a possible approach.

  • Further evidence on the delivery of such a service is urgently required.

Notes

Funding

Kevin J Munro is supported by the NIHR Manchester Biomedical Research Centre.

Ethical approval

Not applicable.

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

Discuss this article

Contribute and read comments about this article: bjgp.org/letters

  • Received October 16, 2022.
  • Revision requested November 10, 2022.
  • Accepted December 19, 2022.
  • © The Authors
http://creativecommons.org/licenses/by/4.0/

This article is Open Access: CC BY 4.0 licence (http://creativecommons.org/licences/by/4.0/).

REFERENCES

  1. 1.↵
    1. National Institute for Health and Care Excellence
    (2018) Hearing loss in adults: assessment and management NG98 (NICE, London) www.nice.org.uk/guidance/ng98 (accessed 3 Jan 2023).
  2. 2.↵
    1. Cross H,
    2. Dawes P,
    3. Hooper E,
    4. et al.
    (2022) Effectiveness of hearing rehabilitation for care home residents with dementia: a systematic review. J Am Med Dir Assoc 23, 3, 450–460.
    OpenUrl
  3. 3.↵
    1. Radford JC
    (2020) Treatment of impacted ear wax: a case for increased community-based microsuction. BJGP Open doi:10.3399/bjgpopen20X101064.
    OpenUrlCrossRef
  4. 4.↵
    (2021) Healthwatch Oxfordshire. What people have told us about getting treatment for earwax and hearing problems, https://healthwatchoxfordshire.co.uk/report/what-people-have-told-us-about-getting-treatment-for-earwax-and-hearing-problems-in-oxfordshire-september-2021/ (accessed 3 Jan 2023).
  5. 5.↵
    1. Aaron K,
    2. Cooper TE,
    3. Warner L,
    4. Burton MJ
    (2018) Ear drops for the removal of ear wax. Cochrane Database Syst Rev 7, 7, CD12171, doi:10.1002/14651858.CD12171.pub2.
    OpenUrlCrossRef
  6. 6.↵
    1. Sharp JF,
    2. Wilson JA,
    3. Ross L,
    4. Barr-Hamilton RM
    (1990) Ear wax removal: a survey of current practice. BMJ 301, 6763, 1251–1253, doi:10.1136/bmj.301.6763.1251.
    OpenUrlAbstract/FREE Full Text
  7. 7.↵
    1. Forde CT,
    2. Dimitrov L,
    3. Doal S,
    4. et al.
    (2022) Delivery of remote otology care: a UK pilot feasibility study. BMJ Open Qual 11, 1, e001444, doi:10.1136/bmjopenq-2021-001444.
    OpenUrlAbstract/FREE Full Text
  8. 8.↵
    1. Schwartz SR,
    2. Magit AE,
    3. Rosenfeld RM,
    4. et al.
    (2017) Clinical practice guideline (update): earwax (cerumen impaction). Otology Head Neck Surg 156, 1_suppl, S1–S29, doi:10.1177/0194599816671491.
    OpenUrlCrossRef
  9. 9.↵
    1. Clegg AJ,
    2. Loveman E,
    3. Gospodarevskaya E,
    4. et al.
    (2010) The safety and effectiveness of different methods of earwax removal: a systematic review and economic evaluation. Health Technol Assess 14, 28, 1–192.
    OpenUrlCrossRefPubMed
Back to top
Previous ArticleNext Article

In this issue

British Journal of General Practice: 73 (727)
British Journal of General Practice
Vol. 73, Issue 727
February 2023
  • Table of Contents
  • Index by author
Download PDF
Download PowerPoint
Email Article

Thank you for recommending British Journal of General Practice.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Ear wax management in primary care: what the busy GP needs to know
(Your Name) has forwarded a page to you from British Journal of General Practice
(Your Name) thought you would like to see this page from British Journal of General Practice.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Ear wax management in primary care: what the busy GP needs to know
Kevin J Munro, Thomas C Giles, Christine Smith-Howell, Irwin Nazareth
British Journal of General Practice 2023; 73 (727): 90-92. DOI: 10.3399/bjgp23X732009

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Ear wax management in primary care: what the busy GP needs to know
Kevin J Munro, Thomas C Giles, Christine Smith-Howell, Irwin Nazareth
British Journal of General Practice 2023; 73 (727): 90-92. DOI: 10.3399/bjgp23X732009
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • INTRODUCTION
    • WHY DOES IT MATTER?
    • WHY THE CURRENT CONTROVERSY?
    • WHICH PRE-TREATMENT EARWAX SOFTENER IS BEST?
    • WHAT PROCEDURES ARE RECOMMENDED FOR EARWAX REMOVAL AND WHAT DO PATIENTS PREFER?
    • WHAT PATHWAY?
    • TAKE-HOME MESSAGE
    • Notes
    • REFERENCES
  • Figures & Data
  • Info
  • eLetters
  • PDF

More in this TOC Section

  • Withdrawing from SSRI antidepressants: advice for primary care
  • Safeguarding and children’s oral health: what to look out for in primary care
  • Ketamine misuse: an update for primary care
Show more Clinical Practice

Related Articles

Cited By...

Intended for Healthcare Professionals

BJGP Life

BJGP Open

 

@BJGPjournal's Likes on Twitter

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Current Issue
  • All Issues
  • Online First
  • Authors & reviewers

RCGP

  • BJGP for RCGP members
  • BJGP Open
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers

MY ACCOUNT

  • RCGP members' login
  • Subscriber login
  • Activate subscription
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP: research
  • Writing for BJGP: other sections
  • BJGP editorial process & policies
  • BJGP ethical guidelines
  • Peer review for BJGP

CUSTOMER SERVICES

  • Advertising
  • Contact subscription agent
  • Copyright
  • Librarian information

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7400
Email: journal@rcgp.org.uk

British Journal of General Practice is an editorially-independent publication of the Royal College of General Practitioners
© 2023 British Journal of General Practice

Print ISSN: 0960-1643
Online ISSN: 1478-5242