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Where is Ear Wax Removal Done in the UK? A Guide for PLAB 2 Candidates

Updated: Aug 2


❓ Initial Question

A fellow IMG doctor preparing for PLAB 2 asked:

“If a patient presents to a GP clinic in the UK with impacted wax, where would the procedure of irrigation or microsuction be done according to the current guidelines?”

This is a common and relevant question in both real-life NHS practice and PLAB 2 OSCE stations. Here’s the current guidance on managing impacted cerumen (ear wax) in the UK, including when and where procedures are performed and how to ensure patient safety before offering ear drops or irrigation.


🧠 Background

Impacted earwax is a common cause of hearing loss, discomfort, and difficulty examining the ear. The initial management typically includes ear softening drops, but if this fails, further intervention is often needed.


The key question is: Where and how should this be managed?


✅ NICE Guidelines and NHS Recommendations


🔹 1. Start with Softening Drops

According to NICE Clinical Knowledge Summary (CKS) and NICE Quality Standard QS185:

  • Patients with earwax impaction should first be advised to use earwax softening agents for up to 5 days (e.g. olive oil, sodium bicarbonate).


🔹 2. If Drops Fail: Wax Removal Is Recommended

NICE states that patients who do not respond to drops and continue to have symptoms should be offered earwax removal within primary care or community settings, not routinely referred to secondary care.


🛑 Before You Start Drops or Irrigation: Rule Out


Contraindications

Offering softening drops or ear irrigation isn’t always safe. First, assess for contraindications.


🔍 How to Rule Out Contraindications


1. History Taking

Ask about:

  • Ear pain, especially sudden or severe

  • Ear discharge (watery, mucopurulent, or foul-smelling)

  • Sudden hearing loss or trauma

  • Previous ear surgery or mastoid surgery

  • Known perforation of the tympanic membrane

  • Itching, fever, or signs of infection

  • Only one functioning ear

2. Physical Examination

If the tympanic membrane is visible on otoscopy, confirm:

  • No signs of perforation (e.g. visible hole, absent light reflex)

  • No signs of active infection or external ear inflammation


⚠️ If wax completely blocks the view of the tympanic membrane, assume possible perforation and avoid irrigation.



⚠️ Contraindications Summary Table

Condition

Softening Drops

Irrigation

Suspected or known perforation

❌ Avoid

❌ Avoid

Active infection (otitis media/externa)

❌ (unless antimicrobial drops)

❌ Avoid

Ear surgery (e.g., mastoidectomy)

⚠️ Case-dependent

❌ Avoid

Only hearing ear

⚠️ Case-dependent

❌ Avoid

Allergy to drops

❌ Avoid

✅ (if no allergy to flush solution)


💬 PLAB 2 Example Script for Safety Screening

“Before I suggest any ear drops, can I check—have you had any recent ear infections, ear pain, or fluid coming out of your ear? Have you had any surgery on your ear or been told you had a hole in your eardrum before?”

🏥 Where Is the Procedure Done?


Option 1: At the GP Surgery

If the GP practice is commissioned to offer earwax removal:

  • It can be done by trained practice nurses, GPs, or audiologists.

  • Procedures include electronic irrigation or microsuction.

  • The older method of manual syringing is no longer recommended due to safety concerns.


Option 2: Community Ear Care Services

If the GP clinic doesn’t offer wax removal:

  • The patient is referred to locally commissioned community services.

  • These are usually NHS-funded, and may be run by:

    • Local audiology services

    • Community ENT providers

    • Specialist aural care teams




💷 Is It Covered by the NHS?


✅ NHS-Funded (Free to Patient)

  • If the local Integrated Care Board (ICB) or Primary Care Network (PCN) has commissioned the service, it is free under the NHS.

  • Most urban areas and some rural areas do offer this under NHS care.


❌ Self-Funded (Private)

  • In areas where earwax removal is not commissioned, patients may need to pay privately for microsuction (typically £50–£100/session).


📌 NHS statement:

“Your GP may not offer earwax removal. In this case, you'll need to go to a private provider.”

❗ When to Refer to ENT?



ENT referral is appropriate only if:

  • Perforated tympanic membrane

  • Recurrent infections

  • Only one hearing ear

  • Failed removal attempts

  • Complex ear canal anatomy or severe symptoms




📋 Summary for PLAB 2 and IMG Doctors

Scenario

Action

Patient with impacted wax

Start with softening drops

Drops fail, symptoms persist

Earwax removal (irrigation/microsuction)

GP practice has commissioned service

Removal done at GP

GP doesn’t provide removal

Refer to local NHS community ear care clinic

Local service not available

Private treatment may be needed

Red flags or complications

ENT referral


📝 Key Points to Remember for PLAB 2

  • Always start with conservative management: drops first.

  • Always rule out contraindications before suggesting ear drops or irrigation.

  • GP practices may or may not offer earwax removal—check local availability.

  • NHS community services cover it in most areas if commissioned.

  • Refer to ENT only if removal is contraindicated or unsuccessful.

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