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ENT (Ear, Nose, Throat Conditions)

Wax in the Ear (Cerumen Impaction)

Accumulation of earwax (cerumen) in the external auditory canal, potentially forming a plug that causes symptoms.

Also known as: Ear Wax Blockage, Impacted Cerumen

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Referral and warning signs

When to refer

Refer if: Syringing is contraindicated (perforation, infection). Syringing fails after softening. Manual removal required. Complications occur during removal.

Red flags

  • Sudden hearing loss (consider other causes).
  • Severe pain (suggests infection or trauma).
  • Vertigo associated with wax or removal attempts.
  • Bleeding from the ear canal.
  • Facial weakness.

Signs and symptoms

  • Feeling of blockage or fullness in the ear.
  • Hearing loss (conductive type).
  • Tinnitus (buzzing or ringing sound).
  • Mild ear pain or discomfort (sometimes).
  • Dizziness (less common).
  • Cough (rare, due to vagal nerve stimulation).

Risk factors

  • Overproduction of wax.
  • Narrow or tortuous ear canals.
  • Hairy ear canals.
  • Improper use of cotton buds (pushing wax deeper).
  • Use of hearing aids or earplugs.
  • Older age (wax tends to become drier).

Diagnosis

Clinical assessment

History of symptoms. Visualization of impacted wax occluding the ear canal using otoscopy.

Investigations

  • Otoscopy.

Diagnostic criteria

Visualization of impacted cerumen causing symptoms or preventing examination of the tympanic membrane.

Management

Non-pharmacological management

  • Wax Softening: Instill drops of vegetable oil (e.g., olive oil), Glycerine, or Sodium bicarbonate 5% solution into the ear canal BID-TID for 3-5 days. This may allow wax to migrate out naturally or make removal easier. (LOC: HC2)
  • Ear Syringing (Irrigation): After softening, gently irrigate the ear canal with clean, lukewarm (body temperature) water using an appropriate ear syringe. Direct water flow along canal wall, not directly at tympanic membrane. (LOC: HC2/3)
  • - Contraindications to Syringing: Known/suspected tympanic membrane perforation, history of ear surgery, current ear infection (otitis externa/media), presence of grommets, foreign body (especially vegetable matter).
  • Manual Removal (Instrumentation): Use of curettes or hooks by trained personnel under direct vision (otoscope or microscope). Often preferred if syringing contraindicated or fails. (LOC: HC3/Specialist)

Pharmacological treatment

  • Cerumenolytic drops (Sodium bicarbonate, Glycerine, Oil) for softening.

Monitoring

Assess for symptom resolution and clearance of canal after procedure.

Complications

  • Usually minimal if managed correctly.
  • Complications of syringing/removal: Ear canal trauma, Otitis externa, Tympanic membrane perforation, Vertigo (if water too cold/hot), Tinnitus, Pain, Bleeding.

Prevention

  • Avoid inserting objects (cotton buds, keys, etc.) into the ear canal.
  • Regular use of softening drops (e.g., weekly olive oil) ONLY if prone to recurrent impaction (controversial).
  • Address underlying skin conditions if contributing.

Patient education

  • Explanation that wax is normal and protective.
  • How to use softening drops correctly.
  • Advice against using cotton buds or other objects.
  • Explanation of syringing or manual removal procedure if performed.
  • When to seek help for recurrence.

Uganda-specific notes

Impacted wax is very common. Softening with oil/glycerine/soda bicarbonate followed by syringing is standard practice at HC2/3. Ensure water is clean and body temperature for syringing. Refer if perforation suspected or removal difficult.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 21, Section 21.1.2

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