How can I differentiate between earwax impaction and other causes of hearing loss in a patient?

To differentiate between earwax impaction and other causes of hearing loss in a patient:

• Perform otoscopic examination to check for visible earwax obstructing the external auditory canal; earwax impaction typically presents as a physical blockage that may obscure the tympanic membrane.
• If earwax is present and contributing to hearing loss or other symptoms, removal should be considered to see if symptoms improve, as earwax impaction causes conductive hearing loss.
• If the ear canal is obstructed by wax preventing full examination of the eardrum, removal is necessary to exclude other pathologies.
• If hearing loss persists after earwax removal, or if there are additional symptoms such as pain lasting more than one week, discharge other than wax, abnormal appearance of the ear or tympanic membrane, or unilateral/asymmetric hearing loss, consider referral for further diagnostic assessment to exclude other causes such as middle ear effusion, sensorineural loss, or more serious pathology.
• Use audiological assessment and tympanometry if indicated to differentiate conductive hearing loss from sensorineural causes.
• Do not assume hearing loss is due to wax alone; if symptoms persist after wax removal, further investigation is warranted.

These steps help distinguish earwax impaction, a common and reversible cause of conductive hearing loss, from other causes that may require specialist referral and management.

References: NICE CKS,NICE NG98