How should I approach the management of a patient presenting with earwax impaction?

Approach to managing earwax impaction begins with confirming the diagnosis through history and otoscopic examination to identify symptoms such as hearing loss, ear fullness, or discomfort caused by cerumen blockage ¹. Initial management should consider whether the impaction is symptomatic and if removal is necessary, as asymptomatic cases may not require intervention ¹.

First-line treatment involves the use of cerumenolytic agents such as olive oil, sodium bicarbonate, or commercially available ear drops to soften the wax, typically applied for a few days before attempting removal ¹. This step facilitates easier and safer extraction of the wax.

Removal techniques include manual removal with appropriate instruments by trained healthcare professionals or irrigation using warm water or saline, provided there is no contraindication such as a perforated tympanic membrane or active infection ¹. Irrigation should be performed cautiously to avoid ear trauma or vertigo (Roland et al., 2008).

Referral criteria include failure of removal attempts, presence of complications (e.g., infection, pain, bleeding), or if the patient has a history of ear surgery or anatomical abnormalities ¹. In such cases, referral to an ENT specialist is recommended.

Patient education is important to prevent recurrence by advising against the use of cotton buds or other objects in the ear canal and encouraging regular use of cerumenolytics if prone to impaction ¹.

This integrated approach aligns with UK NICE guidelines emphasizing safe, stepwise management and referral pathways, while the clinical practice guideline by Roland et al. (2008) supports the use of cerumenolytics and cautions on irrigation risks, reinforcing the need for professional assessment and individualized care.