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Ear wax

GP Dr Alex Watson and ENT surgeon Mr Peter Robb on wax softeners and which patients should not have their ears syringed

GP Dr Alex Watson and ENT surgeon Mr Peter Robb on wax softeners and which patients should not have their ears syringed

Ear wax (cerumen) is a normal secretion produced by the ceruminous glands in the outer one-third of the ear canal mixed with desquamated skin and hair.

While many people obsess about having wax-free ears, ear wax does provide protection to the surrounding skin. It acts as a water repellent and – being slightly acidic – discourages bacterial and fungal growth.

As the ear canal epithelium migrates outwards the wax should move out too, until it reaches the opening of the ear canal and sloughs off, thus providing a natural cleaning system.

When does it cause problems?

Some people produce unusually large amounts of wax which can prove difficult to clear naturally, resulting in a ‘blocked' ear canal. More commonly, impacted wax is the result of patients trying to clean their own ears. Cotton wool buds are the main culprit – they are inserted into the external ear canal pushing any debris deeper into the meatus.

While some people are asymptomatic, impacted wax remains a common presentation to GPs. Patients may complain of hearing loss – usually mild unless the meatus is totally obstructed – and occasionally of local irritation, discomfort, tinnitus or dizziness. Water may also get trapped behind the wax, predisposing to an otitis externa.

Structural changes – for example exostoses or otitis externa – may interfere with the normal migratory process and those people with very narrow ears may also develop problems as the meatus blocks more easily.

In the longer term hearing impairment due to wax impaction can lead to stress, particularly in older people, leading to social isolation and depression.

Management of impacted wax

A careful history and examination is vital before deciding on any further action. In particular, you should ask about any ear discharge, previous ear infections and perforations. Beware stubborn attic ‘wax' which may be concealing an underlying cholesteatoma, since wax is not made in the deep external auditory canal.

Wax softeners
If on inspection the wax looks hard then a softener such as warm olive oil or sodium bicarbonate can be used for a couple of weeks, facilitating its normal migration out of the ear canal. The patients should be advised to lie with the affected ear uppermost for a few minutes after a generous amount of the softening agent has been introduced.

There are several other proprietary preparations containing mixtures of organic solvents – such as urea, glycerol and hydrogen peroxide – but they can irritate the skin of the external ear, are more expensive and usually no more effective than simpler solutions.

For some people a wax softener may be all that is required to aid its natural removal. This is a particularly useful method in young children who would not tolerate any further interference. In those with recurrent collections of excessive ear wax, olive oil drops can be helpful on a more regular basis.

Many patients require further assistance and the type of method used will depend on the equipment and expertise available. In general practice syringing is still the most popular choice, increasingly carried out by practice nurses.

It is essential that this skill is learnt well as there are significant risks to the patient.

It should be avoided if there is a recent history of eardrum perforation, otitis externa, the presence of a mastoid cavity, recent trauma, a history of ear surgery and in people who have good hearing in one ear only.

Certain groups – young children for example – may not tolerate this procedure.

Key points

• Ear wax is a normal protective secretion that should be left alone unless causing problems

• Discourage patients from cleaning their ears with cotton buds

• Wax softeners can aid its natural removal and should be used if the wax is hard before syringing

• Syringing should only be carried out by a skilled practitioner with appropriate expertise and equipment

• Beware attic wax that could be concealing an underlying cholesteatoma

Frequently asked questions

• How can I prevent impacted ear wax from recurring?
Advise patients to avoid using ear buds and use a drop of olive or almond oil in each ear weekly.
• Is one ear softener better than another?
Plain olive/almond/arachis oils are good for prevention though arachis oil is peanut based so avoid in patients with allergies. Proprietary wax dissolving drops are good for impaction. Some ENT specialists avoid sodium bicarbonate as it is water-based and may lead to an otitis externa.
• How frequently and for how long should ear drops be used before considering syringing or microsuction?
Ideally each night for a week – the ear may of course become more blocked during this time.
•What are the risks of not using wax softeners before clearance?
If the wax is hard and adherent to the skin, it may prove difficult to successfully remove the wax. Also the skin may lift and cause discomfort and bleeding.
• Why is wax impaction more of a problem in older people?Not sure – but perhaps epithelial migration with age prevents the wax being carried out the outer ear.
• What about mastoid cavities?
Need referral for microsuction – avoid syringing.
How often can you syringe the same person's ears?
As often as required – typically once every few years.

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