Cerumen impaction is one of the most common reasons UK patients ask their pharmacist for help. The condition is rarely dangerous, but it causes hearing loss, discomfort, tinnitus and, in hearing aid users, recurrent device malfunction. Since NICE updated its 2018 guideline on hearing loss in adults, cerumen has also become one of the clearest examples of the NHS commissioning gap: many integrated care boards (ICBs) no longer fund routine GP-practice ear irrigation, and patients increasingly rely on pharmacy advice and private microsuction.

This guide summarises the over-the-counter options, when they work, and when to refer, drawing on the NICE Clinical Knowledge Summary on earwax and the BNF.

What over-the-counter drops do

Over-the-counter cerumenolytics soften wax to allow it to migrate naturally out of the ear canal. They do not, except in mild cases, dissolve impacted wax completely. The Cochrane review by Aaron et al. (2018) compared cerumenolytics against placebo and against each other, and found that almost all softening agents are more effective than no treatment, but the difference between agents is small.

For most patients, NICE recommends 2–3 drops of olive oil or sodium bicarbonate twice daily for 3–7 days. If symptoms have not improved, the patient should be reassessed.

Counselling points for safe self-treatment

• Warm the bottle in the hand to body temperature before use; cold drops cause transient dizziness
• Lie on the side with the affected ear uppermost; remain in position for 5–10 minutes
• Do not use cotton buds, hair clips or ear candles — all have been associated with traumatic perforation, infection and burns
• Hearing aid users should remove the device for at least an hour after drops
• Stop and seek advice if pain develops, drainage occurs, or hearing worsens suddenly

Contraindications and cautions

Most drops are contraindicated where there is a known or suspected perforation, recent ear surgery, grommets in situ or active middle-ear infection. Hydrogen peroxide-based products should be used with caution in patients with eczema or otitis externa as they may exacerbate canal inflammation.

Patients with diabetes, immunosuppression or recurrent otitis externa should be assessed before any cerumenolytic is recommended, because of the elevated risk of necrotising otitis externa.

When self-care is not enough

The NICE CKS lists indications for clinical removal:

• Persistent hearing loss after 3–7 days of drops
• Pain or impaired quality of life from impaction
• Hearing aid users where the impaction is preventing device use
• Required clear ear canal for assessment (audiology, ENT clinic)
• Recurrent symptomatic impaction

The irrigation gap

NICE guideline NG98 (Hearing loss in adults, 2018) advises that ear irrigation by a trained clinician is one of three appropriate methods for clinical wax removal, alongside microsuction and manual removal. In practice, the picture has changed:

• Many ICBs have decommissioned routine GP-practice irrigation as part of "low-priority procedure" lists
• The Royal College of GPs (RCGP) and the British Society of Audiology have both raised concerns about the resulting access gap
• Patients increasingly pay privately for microsuction (typically £45–£90 per ear in 2026, varying by region)

The result is that community pharmacy is often the first — and sometimes the last — NHS contact a patient has for this problem. A clear conversation about cerumenolytic use, realistic timelines and onward signposting is therefore particularly important.

Microsuction versus irrigation

Microsuction uses a low-pressure suction device under direct visualisation with a microscope or video otoscope. It is preferred where the patient has a perforation history, mastoid surgery, very narrow canals, or a particularly hard impaction. Irrigation, performed by a trained nurse or healthcare assistant, uses warm water at controlled pressure to dislodge softened wax.

The British Society of Hearing Aid Audiologists keeps a directory of accredited microsuction providers; pharmacy teams can signpost patients without recommending a specific provider.

Self-irrigation kits

A growing market of self-irrigation kits and "bulb syringes" is sold online. NICE and ENT UK have warned that self-irrigation carries a risk of perforation, infection and chronic canal inflammation. Pharmacy teams should advise patients to use them only after professional assessment, and never with previous ear surgery, perforation, narrow canal or active infection.

Children and ear wax

NICE recommends a more conservative approach in children. Olive oil drops 2 drops twice daily for up to a week is reasonable; if hearing or pain remains a concern, refer to the GP. Cotton buds are particularly likely to push wax further into the canal in children and should be avoided.

Hearing aid users

Hearing aids accelerate cerumen migration and frequently cause both hearing impairment and feedback. NHS audiology services in many regions offer a regular cerumen-clearance pathway for hearing aid users; community pharmacy can confirm the local arrangement when the patient asks.

Red flags for urgent referral

• Sudden hearing loss
• Otorrhoea (discharge) of any kind
• Severe pain
• Vertigo
• Suspected perforation
• Previous middle-ear surgery without ENT clearance
• Foreign body in the ear (especially a button battery — A&E urgent)

PharmSee's pharmacy directory helps patients find their nearest community pharmacy for a face-to-face consultation; the pharmacist career hub covers the wider clinical role of the community pharmacist in ENT triage. The PharmSee jobs board lists pharmacist and pharmacy technician vacancies across the UK.

Sources

• NICE Clinical Knowledge Summary: Earwax
• NICE Guideline NG98 — Hearing loss in adults: assessment and management
• BNF — Removal of earwax
• Cochrane Review — Ear drops for the removal of earwax (Aaron 2018)
• ENT UK — Self-care guidance on earwax