Refer a patient with earwax impaction to an ear, nose, and throat (ENT) specialist if irrigation is unsuccessful after the second attempt NICE CKS.
Additionally, refer if the patient has symptoms or conditions that require further examination or intervention, such as if the tympanic membrane cannot be fully examined due to wax obstruction, or if there is a history of discharge, abnormal appearance of the ear or eardrum, or persistent symptoms despite initial management NICE CKS.
Specifically, consider referral if the patient has partial or complete obstruction of the external auditory canal preventing full examination, pain lasting 1 week or more that has not responded to treatment, or abnormal findings such as inflammation, polyp formation, perforation, swelling, or blood in the ear canal NICE CKS.