Cerumenolytics

Cerumenolytics soften or dissolve ear wax to allow natural clearance or removal by irrigation, suction or instruments. Wax is a normal protective secretion and needs removal only if it causes symptoms (hearing loss, fullness, pain, itch, tinnitus) or blocks the view of the eardrum.

Mechanism. Oil-based agents (olive oil, almond oil) lubricate and soften wax. Water-based agents (sodium bicarbonate 5 percent, saline) hydrate and break up wax. Surfactants (docusate sodium) disperse wax. Peroxide agents (carbamide peroxide, hydrogen peroxide) release oxygen, which loosens wax by effervescence.

Pharmacokinetics. Local action only; no meaningful absorption through an intact eardrum.

• Olive oil or almond oil: gentle, cheap, safe in most patients.
• Sodium bicarbonate 5 percent in glycerol or water: more effective than oil.
• Docusate sodium 0.5 percent: dispersing; can irritate the ear canal.
• Carbamide peroxide 6.5 percent in glycerol: effective; can cause irritation.
• Hydrogen peroxide 3 percent (diluted): short-term use.
• Saline or water irrigation: after softening.

Regimens.

• Softening alone: olive oil or almond oil 2 to 3 drops in the affected ear twice daily for 3 to 5 days, lying on the side for 5 to 10 minutes.
• Before irrigation or microsuction: sodium bicarbonate 5 percent or oil, 5 drops three times daily for 3 to 5 days, or a single application 15 to 30 minutes before irrigation.
• Carbamide peroxide 6.5 percent: 5 drops twice daily for up to 4 days.
• Irrigation: water at body temperature (37 degrees Celsius), directed along the canal wall, by a trained person using a low-pressure syringe; stop with pain or dizziness.
• Live insect in the ear: fill the canal with mineral oil, olive oil or lidocaine solution to immobilise it, then remove by irrigation or suction.
• Children: oil drops are suitable from infancy; irrigation in older children who cooperate.

Selection. Drops alone clear wax in a proportion of patients, so try them first. Avoid irrigation in all patients with a risk of a perforated eardrum. Refer for microsuction when irrigation is unsuitable or fails.

Contraindications. Known or suspected tympanic membrane perforation, grommets, previous ear surgery or discharge, otitis externa or acute otitis media (drops that irritate, and irrigation), cleft palate, a single hearing ear, and recent ear surgery or trauma (irrigation); hypersensitivity to ingredients.

Effects. Irritation, itch, mild discomfort, and transient hearing reduction as wax swells; contact dermatitis; otitis externa after irrigation; ototoxicity or vertigo if peroxide or water enters the middle ear through a perforation; tympanic membrane perforation, canal skin damage, tinnitus and hearing loss from irrigation or instrumentation; vertigo from cold water.

Interactions. None clinically relevant.

Monitoring. Re-examine after treatment; refer if wax recurs often, if symptoms persist after wax removal, or if there is discharge, severe pain, dizziness or sudden hearing loss.

Special groups. Pregnancy and breastfeeding: oil and bicarbonate drops are suitable. Children: no cotton buds; avoid irrigation in the uncooperative. Older adults: frequent wax impaction with hearing aids; regular checks. Diabetes and immunosuppression: higher risk of external ear infection after irrigation. Region: ear cleaning by untrained operators, sticks, and traditional oils and herbal drops are common and cause trauma and infection; examine the eardrum after any injury and avoid putting unknown liquids in the ear.