More than two million people a year in the UK experience build-up of earwax that requires removal, according to the National Institute of health and Care Excellence (Nice). As well as being uncomfortable, excessive earwax can cause hearing difficulty and even social isolation and depression. For these reasons, it is important that excessive earwax is removed.

Tapping into gap in provision

Nice guidelines suggest adults should have earwax removed in primary care or community ear care services if:

• build-up is causing hearing loss or other symptoms
• the wax could hinder an ear examination
• an impression of the ear canal is to be performed.

Last year, health minister Edward Argar confirmed that ear syringing is no longer one of the core services GPs are obliged to provide, and so increasing numbers of patients are asking community pharmacy teams for help.

Even in areas where GP surgeries continue to provide earwax removal as an enhanced service, the COVID-19 pandemic has resulted in some face-to-face appointments being suspended. In some cases this has included earwax removal.

As a result, pharmacies have an increased opportunity to help people with this condition.

Identifying patients

As the first ‘port of call’ for people with many different ailments, community pharmacy teams are well placed to identify and target customers who may be experiencing excessive earwax. For example, a build-up of earwax is more likely in older people and users of hearing aids and earphones, Nice suggests.

Symptoms of earwax build-up include:

• Dizziness or feeling sick (vertigo)
• Tinnitus
• Sensation of blocked ears
• Earache
• Itchiness
• Loss of hearing.

Source: Earwax build-up - NHS (www.nhs.uk)

Pharmacists operating an ear care service are therefore in an ideal position to check if patients reporting these symptoms are affected by a build up of earwax or blockage.

Management

Earwax build-up is usually initially managed by the patient with ear drops. Olive oil may be used to soften the earwax and this may help with some of the symptoms. Softening the earwax may enable the earwax to fall out of by itself. Medical grade olive or almond oil can be used by applying 2-3 drops into the ear canal, 3-4 times per day for approximately 3-5 days. The earwax may then gradually fall out over two weeks.

Despite this, some people will require a healthcare professional to remove the earwax for them.

Manual syringing of earwax is no longer recommended by Nice as a removal option. Instead, practitioners in primary or community ear care services should use an electronic irrigator (flushing with water), microsuction (vacuuming the earwax out under microscope) or another method, such as manual removal using a probe.

Microsuction is an option that is growing in popularity and has the advantage of no upper or lower age limit, as long as the patient is able to stay still throughout the procedure. It is also a useful alternative for people who have tinnitus, a painful or tender ear canal due to infection or evidence of a middle ear infection in the last six weeks, as well as patients with a cleft palate even if it has been repaired.

If irrigation is to be used, the earwax should be softened before treatment, either immediately before or up to five days before treatment. Irrigation may be attempted twice, if after the second attempt it is still unsuccessful the patient should be referred to a specialist ear care service.

Patients should be advised to never try to remove earwax from their own ears, using cotton buds, fingers or anything else. These methods risk causing damage to the ear drum and can result in wax being further pushed in. There is no evidence that advertised products claiming to remove earwax are safe or effective to use and they can result in damage.

Training for earwax removal

Before the service can be offered the practitioner needs to ensure they have appropriate training for that service and they have the necessary equipment. Practitioners also need to be aware of any contraindications to the service for which they are providing.

A variety of  providers offer ear irrigation training, which usually includes an overview of the anatomy and physiology of the ear, common ear problems, how to examine the ear and decide if ear irrigation is the best option for the patient, and how to perform the procedure.

Many providers offer microsuction training, ranging from in-person day courses, costing a few hundred pounds, to a mix of blended learning over a few days, which are more expensive.

The necessary equipment also varies in price, depending on the chosen procedure, with microsuction kits being the most expensive – training providers are most suitably placed to advise on reputable suppliers.

Pharmacists may decide to invest in a patient group direction in order to be able to supply treatments for ear infection, which usually involves completing associated continued professional development to confirm competency.

Providing an earwax removal clinic

Whichever procedure is offered, it is useful to run the clinic using an appointments system, because the starting point is an initial ear examination, which is usually followed by recommendation to use olive oil for 5-7 days before determining if another method of earwax removal is required.

Some pharmacists may decide to charge a nominal fee for the initial appointment to cover the pharmacist’s time and then take this off the cost of earwax removal if the patient returns for treatment—for many private services this starts at around £25-£30 for one ear.

Further information about ear care

Nice recently released an updated earwax clinical knowledge summary, revised March 2021, available here.

The Rotherham Primary Ear Care Centre and Audiology Services’ offer individual guidelines available to download on earwax removal methods, which can be accessed here. This centre also offers a one-day intensive microsuction course for healthcare professionals, combining practical and taught sessions.

This article has been peer reviewed by Jacob Warner, professional practice pharmacist