Everything You Wanted to Know About Earwax* (But Were Afraid to Ask)

*Cerumen, if we’re being formal.

Let’s talk about something sticky. The unsung hero of the external auditory canal. The reason your otoscope view is frustratingly blocked just when the tympanic membrane matters most. Yes, we’re talking about earwax.

Whether it’s glinting at you from a child’s canal, the cause of a failed school hearing screen, or an unexpected reason for a persistent cough, earwax – or cerumen – plays a bigger role in clinical care than we often give it credit for.

But how much do you actually know about it?

• What is earwax made of?
• Why is it wet in some people and dry in others?
• What does it do (and why is removing it sometimes the wrong move)?
• Are ear candles ever safe (spoiler: no)?
• And what’s the actual danger of cotton buds?

This blog dives deep into the science, genetics, myths, and management of cerumen. It’s one of those everyday paediatric topics where a little knowledge goes a long way – whether you’re advising anxious parents, screening schoolchildren, or just trying to get a clear look at that TM.

And then, every so often, there’s that moment when a child turns their head, and a congealed orb of keratin plops into your kidney dish with the elegance of a dropped meatball. It’s oddly satisfying, mildly horrifying, and strangely memorable.

What is earwax?

Earwax – or cerumen – is a complex, waxy substance secreted in the outer third of the external auditory canal.

Cerumen is made up of:

• Sebum from sebaceous glands
• Sweat from modified apocrine (ceruminous) glands
• Desquamated keratin (aka dead skin)
• Dust, debris, and environmental particles
• The occasional rogue eyelash, glitter speck, or whatever else life throws at a toddler’s ear canal

This concoction creates a protective, hydrophobic, antimicrobial coating – part moisturiser, part microbial bouncer. It’s designed to protect the delicate skin of the ear canal from water, infection, and trauma.

Importantly, it’s not static. The ear canal has its own built-in conveyor belt: as new skin grows from the tympanic membrane outward, it slowly shifts wax toward the canal opening. Jaw movement (chewing, talking) helps drive this process, giving cerumen its quiet, methodical exit strategy.

Earwax contains some waxy components, particularly long-chain fatty acids, cholesterol, and squalene, which give it its hydrophobic, sticky nature. But it’s not pure wax in the chemical sense.

It’s more accurate to say earwax is a biological secretion that includes lipids, proteins, cellular debris, and environmental particles. It’s part moisturiser, part microbe trap, and part self-cleaning gel. So the name “wax” is more textural than technical – it behaves like wax, but isn’t chemically a wax in the strict sense.

What does earwax actually do?

Earwax isn’t just a nuisance – it’s a multitasking marvel of natural design. Here’s what it’s quietly achieving while you’re busy peering through the otoscope:

Barrier protection

Cerumen forms a physical shield that repels water, traps dust and debris, and prevents the invasion of pathogens and foreign bodies. It’s your ear canal’s first line of defence.

Antimicrobial action

Earwax has a slightly acidic pH and contains enzymes such as lysozyme and antimicrobial peptides, which inhibit bacterial and fungal growth. Studies have found it to be active against Staphylococcus aureus and Candida albicans, among others.

Self-cleaning system

Thanks to epithelial migration (skin grows outward from the tympanic membrane) and the mechanical motion of jaw movement, cerumen is gradually conveyed out of the canal, along with anything it’s caught along the way.

Moisturising the canal

The lipids in cerumen help lubricate the skin, preventing dryness, itching, and small fissures that would otherwise provide a perfect entry point for infection.

This is why routine removal isn’t necessary – and why overzealous cleaning can cause more problems than it solves. Cerumen is doing its job. Most of the time, we just need to let it.

Genetics: Wet vs Dry – and What Your Earwax Says About You

Not all earwax is created equal. There are two main types of cerumen:

• Wet – sticky, yellow-brown, and more common in people of African and European ancestry
• Dry, grey, crumbly, and predominant in people of East Asian and Native American ancestry

This variation isn’t due to climate, hygiene, or diet – it’s down to a single-nucleotide polymorphism (SNP) in the ABCC11 gene, located on chromosome 16 (16q12.1).

The specific SNP, rs17822931, determines whether you inherit:

• The AA genotype → dry wax, reduced body odour, and less apocrine gland activity
• The GA or GG genotype → wet wax, with associated axillary sweating and odour

This isn’t just an ENT curiosity – it’s one of the first identified Mendelian traits with a clearly understood molecular basis. And yes, it also explains why some people smell less than others.

When Wax Goes Rogue: Impaction

Earwax is meant to migrate gently outward and drop off unnoticed. But sometimes, the system stalls – and impaction happens.

What causes impacted earwax?

Impacted cerumen occurs when wax builds up and blocks the external auditory canal. It can happen because:

• The canal is narrow, tortuous, or hairy
• The wax is dry, sticky, or unusually abundant
• There’s interference from cotton buds, hearing aids, earplugs, or even earphones
• The natural migration system is disrupted by age, skin conditions, or surgery

While your parents may have told you that earphones cause earwax build-up, the evidence doesn’t support it. It’s a persistent myth – likely because it feels intuitive: something blocking the ear must trap wax, right? However, a 2021 study by Çam examined this topic and found no significant association between earphone use, including in-ear, over-ear, and silicone-tipped types, and cerumen impaction.

The frequency of medical ear cleanings and self-care habits was similar in users and non-users alike. It turns out that anatomy, genetics, and the natural efficiency of epithelial migration play a much bigger role than what’s hanging off your earlobe.

That said, in children with narrow canals, existing impaction, or chronic eczema, earphones may still aggravate symptoms, so it’s not a free pass for all-day AirPods use. But for most people, volume matters far more than wax. Listening at high volume, especially over extended periods, poses a significantly greater risk to hearing than any potential wax build-up from earphone use.

So if you’re going to talk about earphone safety, skip the wax myth – and talk about decibels instead.

Who’s most at risk?

• Children, especially under 5, due to narrow canals and flaky skin
• Older adults, where drier wax and slower migration are common
• People with developmental delay, who may not report symptoms clearly
• Hearing aid and earbud users, due to physical obstruction and irritation
• Those with eczema or dermatological conditions affecting the canal
• Anyone who’s ever thought, “I’ll just clean this out with a cotton bud…”

In school-aged children, the prevalence rates of cerumen impaction vary widely in the literature, ranging from approximately 12% to over 30%, depending on the region, age group, and method of detection. A Bosnian study of 1,344 children aged 7–10 found a prevalence of 24.4%, with bilateral impaction being common, particularly among younger pupils. In this cohort, wax was a leading cause of hearing screening failure, underlining its impact on communication, learning, and developmental milestones.

Among older adults, cerumen impaction is even more prevalent, with studies suggesting that up to one-third of elderly patients may be affected at any given time, especially those with cognitive impairment or in residential care.

When earwax makes you cough: the vagus nerve reflex

The auricular branch of the vagus nerve – also known as Arnold’s nerve – provides somatic sensory innervation to parts of the external auditory canal and the outer surface of the tympanic membrane.

In some individuals, especially children and older adults, mechanical stimulation of this nerve, say, by a firm plug of impacted wax, can activate a reflex arc, triggering a chronic, non-productive cough. This is referred to as the Arnold’s reflex.

It’s a subtle presentation: no signs of upper respiratory infection, no wheeze, no post-nasal drip – just a persistent cough and, when you check the ears, a waxy blob staring back at you.

A brief Lancet case series reported the complete resolution of cough in several adults following cerumen removal, with no other underlying pathology identified. While not common, this is an important non-respiratory cause of cough to keep in mind, especially when the rest of the exam is unremarkable.

So, if you’re faced with a healthy child (or a mildly bemused parent) reporting a cough with no clear trigger, don’t forget the ears.

When do symptoms appear?

Most people don’t notice anything until the canal is at least 80% occluded. Then, symptoms might include:

• Hearing loss
• Fullness or pressure
• Itching or discomfort
• Tinnitus
• Dizziness
• Cough

It’s a slow-motion problem – often painless, but disruptive. In children, impacted earwax can accumulate gradually without causing any noticeable symptoms. They may not report hearing changes, especially if the process is bilateral or slow. Instead, it might present as inattentiveness, difficulty following instructions, or unexplained speech or language delay.

Parents might assume it’s behavioural. Teachers might suspect concentration issues. But all the while, a solid plug of wax could be quietly dampening auditory input, affecting classroom engagement, speech discrimination, and overall learning. The child may appear distracted or slow to respond, not because they aren’t listening, but because they quite literally can’t hear clearly.

And then there’s the bath-time factor: when wax becomes wet – after a swim, shower, or hair wash – it can expand and soften, pressing more tightly against the tympanic membrane. This often results in a sudden, dramatic drop in hearing, leading to that classic “my ear’s gone funny” complaint. It’s not painful, but it can be quite distressing and, for a child, temporarily deafening.

Once occlusion reaches a critical point – often exceeding 80% – symptoms such as a blocked sensation, intermittent hearing loss, cough, or even dizziness can become more pronounced.

How to Manage Excess Wax

Most of the time, earwax doesn’t need managing. It’s self-limiting, self-cleaning, and self-exiting.

But when it doesn’t – when it obstructs the view, triggers hearing loss, fails a hearing screen, or causes pain or cough – it’s time to intervene. The trick is knowing how.

Do nothing (no, really)

For asymptomatic earwax – wax that isn’t causing hearing loss, discomfort, or obscuring the view of the tympanic membrane – the best approach is often watchful waiting.

There’s no need to intervene just because wax is visible. It’s not dirt, it’s not unhygienic, and it doesn’t need to be “cleared out” unless it’s actually causing a problem. Routine removal – especially in children – can be counterproductive, disrupting the ear’s natural defence system and leading to irritation, infection, or even trauma.

That said, it can be tempting. Parents often expect action, and there’s satisfaction in removing “the problem” – but in many cases, the most effective management is educating families: explaining what earwax is, what it does, and when it’s worth leaving alone.

Cerumenolytics (softening drops)

These are often the first-line option. Cerumenolytics soften, break down, or lubricate the wax, encouraging it to migrate out or making it easier to remove.

Common agents include:

• Olive oil – gentle and widely available
• Sodium bicarbonate drops – alkaline, can dry or irritate
• Urea hydrogen peroxide – effective but may sting or bubble
• Commercial mixed drops – often contain surfactants or solvents

A 2009 Cochrane review found that both water-based and oil-based cerumenolytics are effective for softening wax, with no clear evidence that one formulation is superior to another. The key factor isn’t what you use – it’s how you use it. Consistency, contact time, and patient comfort matter more than the brand or active ingredient.

For most children (and adults), the goal is to soften the wax enough to encourage natural migration or make removal safer and easier. This usually involves instilling 2–3 drops once or twice daily for 3–5 days, ideally with the child lying on their side and the treated ear facing up. Holding the position for a minute or two can help ensure the drops reach the wax.

If symptoms persist or the wax remains hard after several days, consider referral for microsuction.

Bottom line: drops work best with patience and positioning. It’s not what’s in the bottle – it’s what you do with it.

Irrigation (with caution)

Irrigation – or ear syringing – remains a widely used method of wax removal in general practice and community settings. It involves flushing the ear canal with warm water or saline, delivered via a bulb syringe, manual ear irrigator, or electronic device.

The aim is to dislodge and flush out softened wax, especially when cerumenolytics alone haven’t worked. It can be quick and effective – but only when used appropriately and with care.

Why warm water?

The temperature of the fluid matters. It should always be body temperature (around 37°C). Using cold or overly warm water can stimulate the vestibular system via the semicircular canals, leading to vertigo, dizziness, and nausea – a phenomenon known as the caloric reflex. This is particularly unsettling in children and can make a relatively minor procedure feel traumatic.

Who should not have irrigation?

Irrigation should be avoided or used with extreme caution in:

• Children under 6 years (unless trained personnel and visualisation are available)
• Anyone with a history of tympanic membrane perforation, grommets, or ear surgery
• Patients with eczema, psoriasis, or chronic otitis externa
• Immunocompromised patients or those at risk of otitis externa (e.g. diabetic patients)
• Uncooperative or anxious children where movement could lead to injury

When it’s safe and how to do it:

If the ear canal and drum are healthy, and there’s no contraindication:

1. Pre-treat with cerumenolytics for 3–5 days to soften the wax.
2. Use body temperature water – never cold.
3. Aim the stream gently toward the posterior superior canal wall, not directly at the eardrum.
4. Use a catch basin (kidney dish or towel) under the ear.
5. Re-check the canal after irrigation to confirm wax clearance and visualise the TM.

If there is no improvement after 2–3 attempts or if symptoms persist, refer for microsuction or an ENT review. Repeat irrigation shouldn’t be done repeatedly over short periods due to the risk of inflammation and otitis externa.

Although irrigation is a commonly performed and generally low-risk procedure, it’s not without potential complications. Estimates suggest that up to 1 in 1,000 irrigations may result in a significant adverse event, and the risk increases notably when the procedure is performed by inexperienced or untrained staff.

The most serious complication is tympanic membrane perforation, which can occur if water is directed too forcefully, used at an incorrect angle, or if the drum is already thinned, retracted, or previously injured. Other potential issues include canal laceration, pain, bleeding, and the development of otitis externa, particularly if residual moisture remains in the ear after irrigation.

In children, the risks are compounded by small ear canals, limited cooperation, and the difficulty of accurately assessing drum integrity in a moving target. It’s easy to underestimate how traumatic an unpleasant irrigation experience can be, not just physically, but psychologically, particularly for anxious children or those with sensory sensitivities.

Microsuction (gold standard in many cases)

Microsuction is widely regarded as the safest and most effective method of earwax removal, particularly when direct visualisation and clinical accuracy are essential. The procedure involves using a fine suction tube, typically under the guidance of a microscope or high-powered otoscope, to gently remove cerumen without introducing moisture or pressure into the ear canal.

The key advantage of microsuction is its dry technique. Unlike irrigation, it doesn’t involve water or saline, which means there’s a lower risk of infection, no risk of caloric-induced vertigo, and far less chance of triggering otitis externa..

Microsuction also allows for greater control and precision, making it particularly valuable in children with small or anatomically complex canals. Children may be more cooperative because the procedures is quick and causes minimal discomfort. The real-time visual guidance helps the clinician avoid trauma to the ear canal or tympanic membrane.

Microsuction is especially recommended for:

• Children with grommets or known TM perforation
• Patients with narrow or stenotic canals
• Recurrent otitis externa
• Failed attempts at irrigation or cerumenolytics

Mythbusting: Ear Candles, Cotton Buds & Other Calamities

Every now and then, an article comes along that reminds me that some of the old wives’ tales are true. This is one of them…

My mother (not really an old wife) always used to tell me to put nothing in my ears that was smaller than my elbow. If you read this trawl of the National Electronic Injury Surveillance System, you will see why…

Ameen ZS, Chounthirath T, Smith GA, Jatana KR. Pediatric Cotton-Tip Applicator-Related Ear Injury Treated in United States Emergency Departments, 1990-2010. The Journal of Pediatrics. 2017 May 1.

❌ Ear candles

Despite what wellness influencers, spa menus, and alternative health websites might suggest, ear candling is neither a safe nor effective method for earwax removal. The practice involves inserting a hollow, cone-shaped wax candle into the ear canal, lighting the exposed end, and letting it burn for several minutes. Proponents claim that the heat creates a gentle suction effect, drawing wax and toxins out of the ear.

It’s an appealing narrative – fire as purifier, visible residue as proof – but it doesn’t hold up to scientific scrutiny. No measurable vacuum is created during the burning process, and controlled studies have repeatedly shown that the “wax” found inside the cone afterwards is simply candle residue, not extracted cerumen.

The entire mechanism is biologically implausible, and the risks are well-documented. Ear candling has been associated with burns, canal obstruction from melted wax, infection, and even tympanic membrane perforation. Children are particularly vulnerable, with smaller canals and a lower tolerance for discomfort or confusion during a procedure that’s both unsafe and unnecessary.

Multiple regulatory and professional bodies, including the BMJ, ENT UK, and the FDA, have issued formal warnings against this practice. In some countries, ear candles are banned for therapeutic use altogether.

The risks are real and well-documented:

• Burns to the ear, face, or scalp
• Obstruction of the canal with candle wax
• Tympanic membrane perforation

Multiple ENT societies and a BMJ review concur: there is no clinical benefit, only harm. Cerumen removal doesn’t need fire.

Verdict: No evidence, high risk. Extinguish the idea.

❌ Cotton buds

We’ve all seen it. A well-meaning parent, holding a cotton bud with a slightly guilty look, saying, “I didn’t go in far – just the tip,” as you peer into a canal that’s red, scratched, and tightly packed with impacted wax. It’s a common scene in both primary care and ENT clinics, and it usually starts with good intentions: trying to keep the ears clean, prevent wax build-up, or get “just that bit” out.

But the problem is that cotton buds don’t clean – they compact. Even a gentle swipe at the entrance of the canal can push wax deeper, disrupt the normal migratory mechanism, and lead to the formation of a dense plug that’s harder to remove. In children, whose ear canals are narrower and more sensitive, this can quickly become a problem, not just in terms of hearing, but also risks canal trauma and infection.

Repeated use can also cause abrasions to the canal wall, creating ideal conditions for otitis externa, and in some cases, tympanic membrane perforation. According to Ameen et al., over a twenty-year period (1990 to 2010), they found over a quarter of a million (!) visits due to cotton-tip applicators. This amounted to 17.6 injuries per 100,000 children. What is fascinating to me is that the greatest number of these (40.2%) took place in children under three years of age. My children are very curious, but it would seem that a parent’s quest for clean ears might be more to blame.

Leo Gerstenzang, founder of Baby Gays (which were renamed Q-tips© in 1926), is cited as the first to come up with the idea. The apocryphal tale is that he saw his wife wrapping wads of cotton around the end of a toothpick and had a lightbulb moment. In case you are wondering, the Q stands for ‘Quality’.

And yet, the myth persists – partly because cotton buds are marketed as tools for hygiene, and partly because the idea of leaving wax alone feels counterintuitive to many parents. That’s where we come in: to explain that earwax isn’t dirt, that the ear has its own cleaning system, and that nothing smaller than your elbow really is the best rule of thumb.

Cotton-tip applicators should only be used for art and craft projects. The bottom line is, the old wives were right – nothing bigger than your elbow. And next time you are in Japan, don’t go to a mimikaki salon  (thanks, Petria, for the link).

Verdict: They don’t clean – they compact, scratch, and risk rupture.

Verdict: Novel packaging, same bad idea.

The Bottom Line

Earwax is normal, protective, and usually doesn’t need removing.

Impaction is common in children and older adults.

Cerumenolytics and microsuction are safest; avoid candles, cotton buds, and TikTok gadgets.

When in doubt, look in the ears. That cough might just be wax.

References

Brkić F. Significance of ear wax impaction in school children. Acta Med Sal. 2010;39(1):23–25.

Burton MJ, Doree CJ. Ear drops for the removal of ear wax. Cochrane Database Syst Rev. 2009;(1):CD004326.

Çam OH. The effects of earphone usage on ear wax (cerumen) impaction. Northwestern Med J. 2021;1(2):48–52.

Ear Science Institute Australia. Ear Wax 101 – Understanding the basics. 2023. Available from: https://www.earscience.org.au/2023/04/11/ear-wax-101/

Ernst E. Ear candles: a triumph of ignorance over science. J Laryngol Otol. 2004;118(1):1–2.

Jegoux F, Legent F, de Montreuil CB. Chronic cough and ear wax. Lancet. 2002;360(9333):618.

Naples JG. Understanding Ear Wax (Cerumen) and Ear Cleanings. JAMA Otolaryngol Head Neck Surg. 2022;148(4):388.

Queensland Health. Unveiling 10 secrets about ear wax: essential tips for healthy ears. 2024. Available from: https://www.health.qld.gov.au/newsroom/features/unveiling-10-secrets-about-ear-wax-essential-tips-for-healthy-ears

Schwartz SR. Ear wax: the good, the bad, and the ugly. ENT & Audiology News. 2022;31(1):40–42.

Sevy JO, Liedtke M. Dangers of cotton-tipped swab use for cerumen removal: Measuring the risk of ear injury. JAMA Otolaryngol Head Neck Surg. 2016;142(3):284–285.

Sharp JF, Wilson JA, Ross L, Barr-Hamilton RM. Ear syringing in general practice: an unsafe procedure? BMJ. 1990;301(6763):1251–1253.

Yoshiura K, Kinoshita A, Ishida T, Ninokata A, Ishikawa T, Kaname T, et al. A SNP in the ABCC11 gene is the determinant of human earwax type. Nat Genet. 2006;38(3):324–330.