What are the recommended first-line treatments for patients with earwa

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Recommended first-line treatments for earwax impaction in primary care:

Offer earwax removal if the wax is causing hearing loss, other symptoms, or obstructs examination of the tympanic membrane or ear canal impression ,.
Advise the use of ear drops to soften the wax and aid removal. Suitable options include sodium bicarbonate 5% ear drops, olive or almond oil drops, and sodium chloride 0.9% nasal drops (off-label use as ear drops). The drops should be used 3–4 times daily for 3–5 days initially .
Warn patients that ear drops may cause transient hearing loss, discomfort, dizziness, or skin irritation, and that removal of wax may not always relieve symptoms such as hearing loss if it is sensorineural .
Do not recommend ear drops if there is suspicion of a perforated tympanic membrane, active dermatitis, or active ear canal infection .
If symptoms persist after initial treatment with ear drops, consider ear irrigation using an electronic irrigator, provided the practitioner has the expertise, there are no contraindications, and the patient is informed of risks ,.
Do not offer manual syringing with large metal syringes due to potential harm; electronic irrigation or microsuction are preferred methods if available ,.
If irrigation is unsuccessful after two attempts, refer the patient to a specialist ear care or ENT service for further management ,.
Advise patients not to insert objects such as cotton buds into the ear canal to remove wax, as this can cause damage and worsen impaction .

What are the recommended first-line treatments for patients with earwax impaction in primary care?