Changes

October 2025 — reviewed. A literature search was conducted in September to October 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No significant changes to clinical recommendations have been made.

Update

Goals

To support primary healthcare professionals to:

• Make a diagnosis of excess and problematic earwax.
• Recognize when earwax needs to be removed.
• Remove earwax effectively and safely when indicated.
• Refer appropriately for specialist assessment and management.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE Quality standards

Hearing loss in adults

What is it?

• Earwax (or cerumen) is a normal physiological substance that is produced in the external auditory canal.
  
  • It is made up of a combination of desquamated keratin from epithelial cells, secretions from sebaceous and ceruminous glands, and various foreign substances (for example, cosmetics and dirt).
  • Earwax cleans, lubricates, and protects the lining of the ear canal, trapping dirt, dust, and hair, and repelling water. It is acidic and normally coats the walls of the ear canal, inhibiting the growth of bacteria and fungi. 
• Earwax impaction is defined as an accumulation of earwax that causes symptoms, prevents assessment of the ear, or both.
  
  • Normally, earwax is eliminated from the ear canal spontaneously through natural jaw movement. If the natural elimination mechanism is disrupted or inadequate, wax is retained in the canal and may become impacted.

[Schwartz, 2017; Horton, 2020]

What are the risk factors for earwax impaction?

• Earwax impaction is caused by one (or a combination) of the following factors [Horton, 2020]:
  
  • Overproduction — if the rate of production of earwax exceeds the rate of elimination out of the ear, impaction will occur. Some people with recurrent impaction may suffer from idiopathic earwax overproduction.
  • Obstruction — variations in the anatomy of the ear canal can lead to earwax accumulation. 
  • Inadequate epithelial migration — cerumen glands progressively atrophy and become less numerous with age, resulting in drier earwax. The drier earwax is less readily transported by the epithelial conveyor mechanism. Also, the natural process of epithelial migration may be insufficient for some earwax subtypes.
  • Cerumen phenotype — earwax can be divided into two genetically determined phenotypes: dry and wet.
    • Dry earwax is brittle and dry and can vary in colour from light to brownish-grey. It is predominant in people of Asian and Native American descent.
    • Wet earwax is often dark in colour, wet, and sticky. It is predominant in people of African and European descent.
    • It is thought that having a wet or dry earwax phenotype may promote or protect against earwax impaction and that phenotype may also affect the efficacy of different earwax removal techniques. 
• Risk factors for earwax impaction include [Schwartz, 2017] [Aaron, 2018] [Horton, 2020] [Radford, 2020]:
  
  • Age over 50 years — the prevalence of earwax impaction is higher in older people, especially those aged 50 years and older. As a person ages, the cerumen glands atrophy, causing the earwax to become drier. Also, hair in the ear canal becomes coarser with age, leading to a higher rate of impaction. 
  • Male sex — older men tend to have more hair in their ear canals. The exfoliated hair becomes incorporated in the earwax, making the wax harder and more difficult to clear naturally from the ear canal.
  • Age younger than 5 years — the prevalence of impacted cerumen is 10% in children.
  • Narrow or deformed ear canals — it is easier for earwax to occlude a narrow or deformed ear canal than a normal ear canal. Soft tissue malformations and bony growths in the ear canal (exostoses or osteomas) can also obstruct earwax migration.  
  • Down's syndrome — children and adults with Down's syndrome have narrow ear canals, predisposing them to earwax impactions. In addition, the presence of cognitive impairment might limit the person's awareness of the impaction and/or their ability to complain of the symptoms caused by the impaction. Hearing loss associated with earwax impaction may lead to further cognitive impairment.
  • Dermatological conditions — including atopic eczema and psoriasis.
  • Use of cotton buds — can push the earwax deeper into the canal.
  • Repeated insertion of hearing aids or earplugs — may result in impaction of previously unimpacted earwax, although the evidence for this is weak.
  • History of recurrent impacted wax — some people are more prone to produce excessive earwax and tend to develop impactions, which may recur. The genetic basis is not known.

How common is it?

• CKS was unable to find any recent statistics on the prevalence of earwax or earwax removal in the UK. This may be due to the fact that this condition is not necessarily reported to healthcare professionals, and because removal of earwax is carried out in many settings, not all of them NHS-based. Many sources quote that it is estimated that 2.3 million people each year in the UK have problems with earwax that are sufficient to warrant intervention, however this figure stems from a 2004 UK-based review, which made this estimation based on a 2001 study of 1507 patients in Denmark screened for adult hearing loss, along with 1994 GP figures quoted in a 2001 study from the Netherlands [Guest, 2004; Karlsmose, 2001; Eekhof, 2001].
• A 1990 survey of GPs in the Edinburgh area found that each GP saw an average of 9 patients per month with impacted earwax, and estimated that 44,000 ears were syringed each year in a population of 650,000 [Sharp, 1990].
• Prevalence of excessive or impacted earwax is higher in those who are elderly and developmentally delayed [Schwartz, 2017].
• The Royal National Institute for Deaf People (RNID) has published a report on the lack of ear wax removal services in England as part of a campaign to improve services [RNID, 2025]. It also quotes the above 2.3 million people per year figure above who need ear wax removal, and found that less than half of NHS England's Integrated Care Boards (ICBs) commission a full wax removal service, despite this being a part of National Institute for Health and Care Excellence (NICE) guidance which recommends that this service should be available in primary care when earwax is affecting hearing or causing other symptoms.

What are the complications?

• An accumulation of earwax in the ear canal can [Schwartz, 2017; NICE, 2023]: 
  • Cause symptoms, such as hearing loss and earache. 
  • Contribute to infections.
  • Exacerbate stress, social isolation, and depression.
  • Diminish cognitive function, particularly in the elderly or those with developmental delay.
  • Prevent adequate clinical examination of the ear, delaying investigations and management.
• Complications of earwax removal are uncommon, with specialist referrals for complications being estimated at 1 in 1000 procedures[Schwartz, 2017]. Potential complications include [Schwartz, 2017; Horton, 2020]:
  • Eardrum perforation.
  • Injury to the ear canal.
  • Infection.
  • Bleeding.
  • Hearing loss.

What is the prognosis?

• If not treated, build-up and impaction of earwax may lead to symptoms such as hearing loss which may contribute to other complications [NICE, 2023].
• A study in 2023 found that of 489 patients having earwax removal in a Manchester ear care service in 2022, 86.5% had hearing difficulty, and 83% reported hearing difficulty to be somewhat or much improved following the procedure [Munro, 2023].
• There are limited studies observing the natural course of impacted earwax, but some small studies have demonstrated that in many cases it may clear without intervention [Schwartz, 2017].
• Some people may have recurrent earwax impaction, due to having risk factors for the condition or due to an idiopathic overproduction of cerumen [Schwartz, 2017; Horton, 2020].

How should I diagnose earwax impaction?

• Take a history.
  • Ask about symptoms of impacted earwax, including:
    • Hearing loss (most common symptom).
    • A feeling of fullness in the ears.
    • Ear discomfort or pain.
    • Tinnitus.
    • Itchiness.
    • Dizziness or a sense of imbalance.
    • Ear infections (impacted earwax may increase the risk of otitis externa).
    • Cough (rare and due to stimulation of the auricular branch of the vagus nerve by pressure from impacted earwax).
  • Identify factors that may complicate/modify earwax removal, for example, previous ear surgery, anticoagulant therapy, immunocompromise, or diabetes. See the section on Contraindications and cautions for more information.
  • Ask about previous removal of impacted earwax.
• Examine both ear canals with an otoscope to ensure the tympanic membrane is intact, without perforation or tympanostomy tubes, and to assess for any abnormalities. 
  • Note whether wax is present and whether it appears to be impacted. 
  • Note that:
    • It may not be possible to view the tympanic membrane if wax is present. 
    • Earwax can be dry or wet in type, can be soft or hard, and can vary in colour.
• Exclude differential diagnoses, such as otitis externa. 
• Diagnose earwax impaction when an accumulation of earwax is associated with symptoms, prevents needed assessment of the ear, or both.

What else could it be?

• Differential diagnoses of earwax include:
  • Otitis externa — inflammation of the auricle or external ear canal due to allergy, infection, or eczematous conditions. See the CKS topic on Otitis externa for more information. 
  • Foreign body in the ear canal (particularly suspect in children).
  • Polyp of the ear canal — visualization of a polyp covered by skin or granulation tissue partially or totally occluding the ear canal. There may be signs of infection and purulent otorrhoea. 
  • Osteoma of the ear canal — bony-hard, skin-covered mass(es) that protrude into the lumen of the ear canal, causing partial or total obstruction of the ear canal. 
  • Keratosis obturans — a rare condition characterized by increased keratin production. A pearly white plug made up of densely compressed keratin squames fills the external ear canal, causing erosion of the bony canal. It presents with otalgia, hearing loss, and otorrhoea, usually with bilateral involvement in younger people. The external meatus may become markedly enlarged, leading to severe wax accumulation.
  • Cholesteatoma — eroding epithelial tissue in the middle ear and mastoid, with discharge in the ear canal.

Scenario: Management

From age 6 months onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on the primary care management of earwax.

Search dates

February 2021 - October 2025

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• cerumen/
• cerumenolytic agents/
• Ear Canal / pathology*
• Ear Diseases / diagnosis*
• cerumen.ti,ab.
• earwax.ti,ab.
• ear wax.ti,ab.
• ear syring*.ti,ab
• aural canal syring*.ti,ab.
• cerumenolytic*.ti,ab
• ear care.ti,ab.
• aural care.ti,ab.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.