The presence of earwax plugs (cerumen) in the external ear canal is normal and physiological. Cerumen is a hydrophobic protective coating of the external auditory canal. Its function is to protect the skin of the canal from damage caused by water, trauma, infections, and foreign bodies (including insects).
Anatomy:
The ear is divided into three parts: the inner ear, which contains the cochlea and vestibular system; the middle ear, which includes the tympanic cavity with the ossicular chain; and the outermost part, the external ear.
The external ear consists of the auricle and the external auditory canal. The latter is further divided into an inner bony portion covered by skin and an outer cartilaginous portion also covered by skin, which contains ceruminous glands, sebaceous glands, and hair follicles. The skin of the external auditory canal is unique in that it has a directional desquamation pattern, representing a highly effective self-cleaning system.
Predisposing Factors for Earwax Plugs:
Some individuals have a tendency to accumulate earwax and form plugs, either because they naturally produce more wax or due to specific predisposing factors such as:
- Very narrow external auditory canal
- Excessive hair in the ear canal
- Dry skin
- Presence of exostoses (“surfer’s ear”) that block natural wax expulsion
- Use of cotton swabs to remove wax
- Use of hearing aids
- Use of headphones
- Use of earplugs for sleeping
Earwax plugs do not need to be removed unless they cause symptoms such as hearing loss, ear pain, itching, dizziness, tinnitus, or if examination of the tympanic membrane is necessary.
Other indications for removal include:
- External otitis
- Before making ear molds for hearing aids
- Suspected chronic cholesteatomatous otitis media
- Suspected tumors in the external or middle ear
- As part of follow-up in patients who have undergone tympanoplasty
- Before placement of transtympanic drains and during follow-up
- Ear itching
- Foreign body removal in children
- Patient request
Methods for Ear Cleaning:
Conservative approach:
Patients are generally advised to avoid using cotton swabs to remove earwax. The natural desquamation process of the external canal typically pushes wax outward. Cotton swab use can push wax deeper, causing blockage.
Cerumen-softening drops:
Many products exist for this purpose, and opinions vary on which is most effective. These products are classified by their base: water-based (e.g., hydrogen peroxide), oil-based (e.g., olive oil), and others (e.g., glycerol). Applying these drops may be enough to unblock the canal, aided by skin desquamation. However, in some cases, symptoms may worsen by turning a partial obstruction into a complete one, requiring irrigation or suction for removal.
Irrigation removal:
This method involves using warm water applied under pressure to mechanically extract the earwax. It carries some risk of tympanic membrane damage, especially when excessive pressure is used or if performed by inexperienced hands. It is contraindicated in patients with a history of tympanic perforation, ear surgery, or active ear discharge.
Microscopic removal:
This technique uses a microscope to enhance visualization, allowing for safer removal using suction or fine otological instruments. Patient cooperation is essential—they must remain still to minimize the risk of canal injury or tympanic membrane damage.
Complications from Earwax Removal:
Most patients tolerate wax removal without the need for painkillers or other measures. A small percentage may experience mild discomfort or pain.
Some may develop temporary vertigo, especially after irrigation or suction, particularly in those with a history of ear surgery.
Due to the noise produced by the suction device, patients with preexisting tinnitus may notice a worsening of symptoms, so this method is discouraged for those with symptomatic tinnitus.
When cerumen is severely impacted and hard, removal with forceps or curettes may cause minor bleeding from canal laceration.
Tympanic membrane damage is another potential complication, although it usually heals spontaneously within weeks.
Finally, although rare, cases of conductive or sensorineural hearing loss have been described following wax removal due to inadvertent pressure on the ossicular chain.
As always, at Altiorem ENT Clinic, we recommend consulting your otolaryngologist, who—based on your medical history and the characteristics of the wax plug—will determine the safest and most appropriate removal method.