• Hearing loss
• Feeling of fullness or blockage
• Earache
• Tinnitus
• Vertigo
• Itchiness

• Check for presence of wax and whether it appears impacted
• Ensure the tympanic membrane is intact if possible
• Check for the presence of grommets

• Check the patient is not using cotton buds

Advise the use of ear drops to soften wax and aid removal*:

• Consider self-syringing at home using an ear bulb syringe**

* unless you suspect a perforation or there is active dermatitis or infection

** studies have shown these to be safe and effective; around half of patients who use it are successfully treated

• Try electronic ear irrigation twice unless contraindicated, after using wax softeners for at least 5 days
• Contraindications to irrigation include:
  • Recent perforation of the tympanic membrane (within 12 months)
  • Suspected current perforation of the tympanic membrane
  • Recently (within the last 6 weeks) active acute or chronic otitis media
  • Acute otitis externa with an oedematous ear canal and painful pinna
  • Active skin complaint such as dermatitis, eczema or psoriasis of the ear canal
  • Presence of a mastoid cavity
  • Abnormality of the ear canal such as exostoses or stenosis that makes irrigation not possible
  • Presence of grommets (ears can be irrigated if previous grommets have been inserted, provided they have extruded, and drum has healed)
  • Presence of a foreign body in the ear, including vegetable matter which could swell and / or cause infection
  • Inability to cooperate, for example young children and some people with learning difficulties.

Note: Prior to attending Audiology for a hearing test the ears must be completely clear of wax. If long delay before audiology appointment, consider asking the patient to return to check ears clear of wax before appointment.

Ear wax should be removed in the community in most circumstances.

Referral Criteria

The routine commissioning of ear wax removal in secondary care is only accepted when:

1) The patient is receiving ongoing treatment, such as de-waxing a mastoid cavity

OR

2) The patient is suffering from significant symptoms due to ear wax build up including hearing loss or pain

AND

5-7 days of ear wax softeners have been trialled (unless there is a current perforation of the tympanic membrane)

AND ONE OR MORE OF THE FOLLOWING APPLY

Electronic irrigation has been attempted twice* by a suitably trained practitioner in the community, unless contraindicated**

OR

Microsuction has been attempted once by a suitably trained practitioner in the community***

OR

The patient has a history of ear surgery (e.g., stapedotomy or mastoid surgery) or documented history from an ENT specialist which advises that treatment for ear wax removal outside of secondary care should be avoided due to a current / ongoing issue.

* Once in Children under the age of 8

** Contraindications to irrigation include:

• Recent perforation of the tympanic membrane (within 12 months)
• Suspected current perforation of the tympanic membrane
• Recently (within the last 6 weeks) active acute or chronic otitis media
• Acute otitis externa with an oedematous ear canal and painful pinna
• Active skin complaint such as dermatitis, eczema or psoriasis of the ear canal
• Presence of a mastoid cavity
• Abnormality of the ear canal such as exostoses or stenosis that makes irrigation not possible
• Presence of grommets (Ears can be irrigated if previous grommets have been inserted, provided they have extruded and drum has healed)
• Presence of a foreign body in the ear, including vegetable matter which could swell and / or cause infection
• Inability to cooperate, for example young children and some people with learning difficulties.

The following conditions ARE NOT contraindications to ear irrigation in primary care:

• Tinnitus
• Vertigo
• Surgically repaired cleft palate

*** Inclusive of a documented recent attempt made by a private provider

Referrals for microsuction should detail the prior community management. Referrals submitted without this information will be returned.

Referral Instructions

Referral to ENT

e-Referral Service Selection

• Specialty: ENT
• Clinic Type: Ear
• Service: DRSS-Western-ENT- Devon ICB-15N

Referral to ENT for children

e-Referral Service Selection

• Specialty: Children's & Adolescent Services
• Clinic Type: ENT
• Service: DRSS-Western-ENT - (Children)-Devon ICB-15N

Referral Form

DRSS referral form

Patient Information

MyHealth patient information - ear wax build up

Pathway Group

This guideline has been signed off of NHS Devon.

Publication date: November 2015

Updated: February 2023