Adult Wax Occlusion Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.


This guidance refers to:

  • The management of external ear canal wax occlusion problems in adults, with a referral process for audiology assessment if required
  • The removal of ear wax, which in most circumstances should be undertaken in primary care

This guidance does not cover:

  • Children


Signs and Symptoms

  • Hearing loss
  • Earache
  • Tinnitus
  • Itchiness
  • Vertigo
  • Ear infections

History and Examination

Clinical history should include:

  • Determining if hearing problems in one or both ears
  • Extent of hearing difficulty when having a conversation in a quiet environment
  • Extent of hearing difficulty in a noisy background
  • Effect of hearing difficulty on one's own life or others
  • Previous use of hearing aids/assisted listening devices
  • Presence/history of tinnitus
  • Presence/history of dizziness/balance problems
  • Presence/history of ear pain
  • Presence/history of ear discharge (mucus/watery)
  • Diabetes mellitus
  • Repeated occlusion of wax


  • Presence of wax – complete/partial blocked, type wax hard/soft
  • Swelling and redness of pinna/opening to auditory canal
  • Swelling and narrowing of external ear canal with/without discharge
  • Normal tympanic membrane?
  • Abnormal tympanic membrane with hearing loss, pain or discharge is suggestive of middle ear pathology


Please note: Ear wax should be removed in Primary Care in most circumstances

Clinical Management

Wax is a normal bodily secretion and need only to be removed if it causes deafness or interferes with a proper view of tympanic Membrane.

If wax requires removal follow the 3 stages below:

  1. Olive Oil
    1. If wax is hard, suggest olive oil morning and night to soften wax for 10 - 14 days
  2. Pulse pressure irrigation (see contra indications below)
    1. If wax is still present, use Pulse pressure irrigation or manually remove wax if appropriate
    2. Choose the most appropriate intervention based on patient presentation. Instrument used could be a Jobson-Horne probe.
  3. .Microsucton
    1. If wax is still present refer for microsuction as per referral guidance

Contra-indications and cautions for pulse pressure irrigation:

    • Middle ear infection in the previous six weeks
    • Pain
    • Discharge
    • History of previous perforations
    • History of tinnitus - or current tinnitus
    • Eczema/psoriasis to canal/pinna
    • Previous problems with irrigation
    • Unable to verify tympanic membrane intact
    • Discharge from ear canal, i.e. Mucus which can indicate undiagnosed perforation/infection
    • Grommets
    • Cleft palate
    • Foreign body
    • Mastoid cavities
    • Otitis externa/media
    • Perforated tympanic membrane
    • Confused/agitated patient that may not sit still for irrigation
    • Hearing in only one ear if it is the only ear to be treated
    • Patients with extremely dry skin to canal/pinna
    • Extremely narrow ear canals
    • Facial palsy
    • Itchy ear canals (Fungal infection)
    • Swelling
    • Inflammation
    • Inability to co-operate e.g. people with learning difficulties
    • A history of any ear surgery (except extruded grommits within the last 18 months, with subsequent discharge from ENT Dept)


Referral Criteria

  • Ear wax should be removed in Primary Care in most circumstances.
  • Referral for Microsuction should be made to:
    • Mid-Yorkshire Hospitals NHS Trust

Referral Instructions

  • e-consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient information/Public Health/Self Care

Evidence/additional information

Assurance & Governance

  • This guidance was developed on: 08.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 09.2017
  • Publication Date: 09.2017
  • Review Date: 08.2019
  • Ref No: ENT4 - 08.2018
Any feedback or suggestions to improve this guidance should be sent to:
Only the electronic version is maintained, once printed this is no longer a controlled document


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