Earwax is made up of a number of different substances that form a protective coating over the skin that lines the ear canal (the passage between the outer and middle ear).

The substances contained in earwax help to prevent the skin that lines the ear canal from drying and cracking. Earwax consists of:

• desquamated keratin squames: dead, flattened cells on the outer layer of skin,
• cerumen: a wax-like substance produced by sweat glands,
• sebum: an oily substance produced by the sebaceous glands (glands in the skin), and
• various other substances, such as cosmetics and dirt.

Types of earwax

Earwax can be wet or dry. There are two types of wet earwax:

• Soft wet earwax is moist and sticky and is more common in children.
• Hard wet earwax is drier and more common in adults. Hard wax is more likely to become impacted (firmly lodged in the ear canal).

Dry earwax is flaky and a golden-yellow colour. It is more common among people who originate from Asia.

Earwax functions

Earwax has a number of important functions. It:

• cleans,
• lubricates, and
• protects the lining of your ear by trapping dirt and repelling water.

Earwax is also slightly acidic and has antibacterial properties. Without earwax, the skin inside your ear would become dry, cracked, infected, or waterlogged and sore.

Earwax problems

Earwax can sometimes cause problems. It can cause your ear canal to become blocked, which leads to temporary hearing loss or pain. Every year in Ireland, thousands of people experience problems with earwax and need to have it removed.

Some people produce an excessive amount of earwax. If you have too much earwax, the risk of it becoming impacted increases. This is where the earwax is pushed into your ear canal by, for example, a cotton bud or hearing aid. If this happens, your hearing is likely to become impaired and the earwax will need to be removed.

Ear irrigation is a common treatment that is used to remove earwax. A pressurised flow of water removes the build-up of earwax. See Treatment for more information.

Earwax is produced by tiny sweat glands in your ear canal, which are known as ceruminous glands. The earwax forms a protective coating inside your ear canal, which traps dust and other tiny objects and prevents them from entering the delicate interior of your ear.

Earwax plug

Some people produce more earwax than others. It usually falls out of your ear gradually, in small pieces or flakes. However, in some cases earwax can build up, harden and form a blockage called a 'plug'.

If you have an earwax plug, it can cause slight discomfort and loss of hearing as your ear canal becomes blocked.

Hearing loss is often blamed on earwax but, in some cases, it may be caused by something else. However, if you have an excessive amount of earwax, any hearing impairment that you have may improve once the blockage is removed.

Discomfort and earache

As well as a physical feeling that something is blocking your ear, if you have a build-up of earwax, you may experience the following symptoms:

• discomfort in your ear,
• earache, tinnitus
• : noises in your ear that come from an internal source,
• itchiness, and vertigo
• : the sensation that you are spinning even when you are standing still. Not all experts believe that earwax causes vertigo.

In rare cases, you may also have a cough that is caused by the stimulation of a nerve inside your ear. This occurs as the result of increased pressure created by the impacted earwax.

People who produce a lot of earwax are more likely to experience a blockage in their ear compared with those who only produce a small amount.

Risk factors

Your risk of developing problems as a result of a build-up of earwax also increases if you:

• have narrow or deformed ear canals,
• have a lot of hair in your ear canals,
• have benign (non-cancerous) bony growths in the outer part of your ear canal (osteomata),
• have a skin condition of your scalp or preauricular area (the area just in front of your earlobe),
• have hard wax, as it is more likely to become impacted (firmly lodged in your ear canal),
• are elderly: as you get older, your earwax becomes drier,
• have recurrent (repeated) ear infections,
• have a history of recurrent impacted earwax, and
• have learning difficulties (the reason for this is unknown). 

If you produce a lot of earwax, further blockages may occur, even after you have had an earwax plug removed by your GP or practice nurse.

Further blockages are also likely to occur if you have particularly narrow ear canals that become blocked more easily.

Your chances of developing impacted earwax also increase if you:

• use cotton buds: they can push the earwax deeper into your ear canal and pack it harder together, which creates an earwax plug, or
• wear a hearing aid or earplugs: they prevent the wax from being excreted (falling out of your ear naturally).

• No tests are necessary to confirm the presence of earwax. If you have a history of recurrent earwax problems, it is likely that you will know when you have another build-up of earwax.

  If you have problems as a result of a build-up of earwax, your GP or a specialist will examine both of your ear canals with an auriscope. An auriscope, also known as an otoscope, is an instrument that incorporates a light and a lens to enable a doctor to examine the inside of your ear.

  Using the auriscope, your GP or specialist can see whether there is earwax inside your ear, and whether or not it appears to be impacted (firmly lodged in your ear canal). If you have hearing loss, it may be the result of impacted earwax.

  Detecting hearing loss

  Hearing loss can be detected using tuning fork tests, such as the Rinne test and Weber test. These are outlined below.

  Rinne test

  The Rinne test involves placing a vibrating tuning fork at different points on your ear to test your hearing.

  The tuning fork is held close to the entrance of the ear canal (external auditory meatus), then it is held behind the ear lobe (mastoid bone).

  Normally, the ear picks up sound through the external auditory canal and middle ear (air conduction), rather than through the skull (bone conduction). If the sound of the tuning fork is louder when it is held against your mastoid bone, there may be a problem with your external auditory canal or middle ear.

  Weber test

  During a Weber test, a vibrating tuning fork is placed on the middle of your forehead. As with the Rinne test, the Weber test enables the tester to determine whether your hearing loss is sensorineural (sound loss through the air), conductive (sound loss through bone), or whether it is a combination of both.

  Overall, tuning fork tests can sometimes be misleading, particularly if there is a combination of sensorineural and conductive hearing loss, or if you are completely deaf in one ear and have good hearing in the other.

  Other causes of hearing loss

  As well as a build-up of earwax, hearing loss may be caused by a number of other conditions, including:

  • otitis externa: inflammation (swelling) of the external ear canal as a result of an allergy or infection,
  • a foreign body in the ear, which is a common cause in children, and
  • keratosis obturans: a rare condition where an excess of keratin (a fibrous substance containing protein) produces a dense, pearly white plug in the external ear canal, which, in some cases, can erode the bony canal.

  • In the majority of cases, earwax falls out on its own without the need to remove it. However, if earwax is totally blocking your ear, or if any of the following symptoms are present, it may need to be removed:

    • hearing loss,
    • earache,
    • tinnitus (noises in your ear that come from an internal source),
    • vertigo (the feeling that you are moving while you are still), or
    • a cough.

    Sometimes, earwax may also need to be removed to make an impression of the ear canal for a hearing aid mould, or if the earwax is causing the hearing aid to whistle.

    Treatment to remove an earwax plug usually starts with eardrops to soften the plug. If eardrops do not work, a process known as irrigation may be needed.

    Eardrops

    Your pharmacist or GP or a specialist may advise eardrops to soften your earwax so that it is easier to remove. 
     
    Eardrops should only be used when they are at room temperature. Pour a few drops into the affected ear and lie on your side for a few minutes with the affected ear facing upwards.

    This allows the eardrops to soak into the wax and soften it. If you repeat this two to three times a day for three to five days, the plug should eventually soften and may gradually fall out of your ear, bit by bit.

    Eardrops are not suitable if you have a perforated eardrum.

    Ear irrigation

    Ear irrigation may be recommended if the earwax blockage persists, even after using eardrops.

    Ear irrigation involves using a pressurised flow of water to remove the build-up of earwax. Nowadays, an electronic ear irrigator should always be used rather than a metal syringe, to avoid damaging the ear. The irrigator has a variable pressure control so that syringing can begin at the minimum pressure.

    During the procedure, a controlled flow of water is squirted into your ear canal to 'clean' out the earwax. The water is about the same temperature as your body.

    The healthcare professional treating you may hold your ear at different angles in order to straighten your ear canal, which ensures that the water reaches all areas. They may also look inside your ear a number of times using an auriscope (an instrument for examining the inside of the ear) to check whether the wax is coming out.

    The irrigation procedure is painless, but you are likely to feel a strange sensation in your ear as the water is squirted around your ear canal. Inform the person who is irrigating your ear if you have the following symptoms at any time:

    • pain,
    • inflammation (swelling) of the external auditory meatus (tube running from the outer ear to the middle ear),
    • dizziness,
    • vertigo (the sensation of movement while still),
    • discharge from the ear, or
    • hearing loss.

    These symptoms may be caused by infection, and will need further examination.

    Further treatment

    If irrigation proves unsuccessful at removing the earwax, your GP may recommend one of the following:

    • using eardrops again and returning for another irrigation,
    • placing water into the ear before irrigating again after 15 minutes, or
    • you may be referred to an ear, nose and throat (ENT) specialist to remove the earwax.

    When not to use ear irrigation

    Ear irrigation is not suitable for everyone. It should not be used if you have:

    • had previous problems with irrigation, such as pain in your ear or severe vertigo,
    • a perforated eardrum,
    • a history of perforation of the eardrum in the last 12 months,
    • a mucus discharge from your ear, which may indicate an undiagnosed perforation within the last 12 months,
    • had a middle ear infection (otitis media) in the previous six weeks,
    • a grommet, which is a small, hollow tube surgically inserted into your ear if you have a build-up of fluid that causes hearing difficulties (see below),
    • had any ear surgery, apart from cases of extruded grommets within the last 18 months (see below),
    • a cleft palate (whether repaired or not),
    • a foreign body (object) in your ear, or
    • severe external ear infection (acute otitis externa) with pain in the ear canal or pinna (the visible part of your ear).

    Ear irrigation is not recommended if you have a grommet because the grommet creates a passage in your middle ear, allowing water to enter during syringing.

    Grommets come out naturally, and the passage created by the grommet eventually heals. If your grommet has come out naturally, and you have been discharged by the ear, nose and throat (ENT) department, the passage will have healed, which means that you can have your ear syringed.

    You should not have ear irrigation if the ear to be treated is your only hearing ear. This is because there is a very small chance that it could cause permanent deafness.

    Young children who are uncooperative, and some people with learning difficulties, may not be suitable for ear irrigation.

    If you have a history of outer ear infections (otitis externa) or tinnitus (noises in your ear that come from an internal source), ear irrigation may aggravate your symptoms.

    Other treatments for removing earwax

    If your earwax cannot be removed with eardrops and/or ear irrigation, or if you are unsuitable for these treatments, a number of other treatment options may be considered. These include:

    • microsuction: a noisy and possibly uncomfortable technique that uses a gentle level of suction under a microscope, or
    • aural toilet: under direct vision, the specialist uses an instrument known as a Jobson Horne probe to manually remove the earwax.

    Although there is no clinical evidence to show the effectiveness of mechanical methods of removing earwax (apart from irrigation), many ear, nose and throat (ENT) specialists regard microsuction as a routine treatment method.

    Glossary

    Inflammation

    Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

    Complications of impacted earwax

    The following complications may occur as a result of impacted earwax:

    • infection, or
    • if the earwax is in contact with the eardrum (tympanic membrane), it can sometimes cause discomfort and vertigo (the feeling that you are moving even though you are still).

    Complications following ear irrigation

    The following complications have been reported after ear irrigation:

    • failure to remove earwax,
    • otitis externa (inflammation of the external ear canal),
    • otitis media (middle ear infection),
    • perforation of eardrum,
    • damage to the external auditory meatus (tube running from the outer ear to the middle ear),
    • pain,
    • vertigo, and
    • worsening of pre-existing tinnitus (noises in your ear that come from an internal source).

    Sometimes, light bleeding may occur, but it usually stops on its own. Nausea, vomiting and vertigo may occur as a result of variations in the temperature of the irrigating fluid.

    Rare complications of ear irrigation

    Rarely (in approximately one in every 1,000 ears that are irrigated) serious complications can occur. These complications are described below.

    Severe infection

    In rare cases, infection may progress to the base of the skull and cause cranial paralysis, meningitis and even death. The elderly, people with diabetes and those with a weak immune system are the most likely to be affected.

    Chronic tinnitus

    Chronic (long-term) tinnitus can occur following earwax removal or ear irrigation. However, this is rare.

    Heart attack

    Heart attack (cardiac arrest) has been associated with ear syringing, although it is a very rare complication. It is thought that it may be caused by the stimulation of the vagus nerve, which supplies the externa auditory meatus, the eardrum and the heart.

    To reduce the risk of developing problems with your ears, avoid putting objects in your ears, such as cotton buds, matchsticks or hair pins. 
    
    Putting objects in your ears can:

    • damage the wall of your ear canal, which increases your chances of developing otitis externa (inflammation of the ear canal),
    • cause the wax to become impacted (firmly lodged in your ear canal) by pushing it further into the canal, and
    • perforate (puncture) your eardrum.