When ear blockage isn't wax: signs you need ENT, not microsuction

The differential is wide

The symptom of "blocked ear" can come from a long list of conditions. Some need microsuction. Some need topical drops. Some need ENT urgently. Some need watchful waiting. The first step is always otoscopy — looking down the canal at the tympanic membrane (eardrum) with a magnifying ear scope.

At otoscopy we are checking for:

• Wax — brown, yellow, dark or wet, partially or fully occluding the canal.
• Inflammation of the canal walls (otitis externa).
• Discharge.
• The state of the eardrum — intact, retracted, bulging, perforated, fluid behind it.
• The light reflex and the malleus handle through a healthy eardrum.
• Foreign bodies (cotton bud tip, hearing aid dome, insect).
• Skin debris suggesting cholesteatoma.

Otitis externa (swimmer's ear, eczema)

Otitis externa is inflammation or infection of the canal skin. It is much more common than otitis media in adults. The typical presentation:

• Pain on pulling the pinna or pressing the tragus (the cartilage in front of the ear opening).
• Discharge — often thin and watery initially, then thicker or pus-like.
• Itching that precedes pain.
• Reduced hearing as the canal swells.

Causes include water exposure (swimming, showering, sweating), trauma (cotton buds, fingers, hearing aids), allergic reactions to hair products, and chronic eczema or psoriasis affecting the canal.

Microsuction is not the answer. Treatment is topical antibiotic + steroid drops (commonly EarCalm, Otomize, Sofradex), water avoidance, and resolution of the trigger. Patients who use hearing aids may need a temporary aid break. See our brand ear health page for more.

Otitis media with effusion (glue ear)

Glue ear is fluid behind the eardrum without acute infection. It is common in children (peak incidence age 2–7) and adults often have residual fluid after a URTI or sinus infection. The picture:

• Reduced hearing.
• Sensation of fullness or popping.
• Often no pain.
• On otoscopy: dull, retracted eardrum with visible fluid level or bubbles behind.

Microsuction is not appropriate — the fluid is behind the eardrum, not in the canal. Treatment is typically watchful waiting. Most cases resolve within 3 months. Persistent glue ear with significant hearing impact needs ENT referral and may require grommets (ventilation tubes).

Eustachian tube dysfunction

The eustachian tube connects the middle ear to the back of the nose and equalises pressure. When it fails (after a cold, with allergies, on aeroplanes, with sinus disease), the middle ear cannot equalise:

• Pressure sensation, fullness.
• Popping, crackling, intermittent hearing change.
• Often bilateral.

Treatment is decongestants (oral pseudoephedrine, nasal sprays) for short-term relief, treatment of the underlying cause (allergies, sinusitis), and the Valsalva manoeuvre (gentle ear-popping with the nose pinched). Persistent symptoms need ENT review for balloon eustachian tuboplasty or other interventions.

Perforated eardrum

A perforation can result from a sudden barotrauma (slap to the ear, deep diving), an acute middle ear infection that bursts, a foreign body, or chronic ear disease. The classic story:

• Sudden sharp pain followed by sudden relief.
• Sudden hearing loss in the affected ear.
• Sometimes blood-stained discharge.
• Tinnitus.

Otoscopy shows the perforation directly. Microsuction is contraindicated in active perforation — it can introduce infection into the middle ear and cause vertigo from the temperature mismatch. Irrigation (syringing) is absolutely contraindicated. Most perforations heal spontaneously within 6–12 weeks; persistent perforations need ENT referral.

If you have a known perforation and need wax removal, this needs ENT-led management, not standard microsuction. We will refer you appropriately.

Cholesteatoma

Cholesteatoma is an abnormal growth of skin within the middle ear. It is locally destructive and can erode bone, including the ossicles (hearing bones) and the bony plate that separates the ear from the brain. The classic features:

• Chronic, foul-smelling discharge — often described as cheesy or rotten.
• Gradual hearing loss.
• Otoscopy shows white debris in a retraction pocket or pearly mass.

This is a surgical condition. We refer urgently. Cholesteatoma can present in any age group and is a not-to-be-missed diagnosis. If you have had chronic discharge for months, please book an otoscopic check at our Manchester clinic or local pages including Old Trafford, Sale, Altrincham and Chorlton.

Foreign body

Foreign bodies in the ear are mostly seen in children (beads, small toys, dried peas) but adults present with insects, cotton bud tips and hearing aid domes that have detached. Some foreign bodies can be safely removed under microscope with fine instruments. Others (impacted, organic and swelling, deeply embedded, near the eardrum) need ENT.

If you suspect a foreign body, do not push it further. Do not irrigate. Do not use cotton buds. Book an otoscopic check and let the clinician decide.

When microsuction is still the right answer

For most patients, the differential resolves at otoscopy in a few seconds. If we see wax, microsuction or another wax removal technique is appropriate — see microsuction vs syringing vs ear drops. If we see wax plus another finding (for example, wax with mild otitis externa), we may remove the wax to allow drops to reach the canal skin, with the patient warned that some discomfort is expected.

Hearing aid users have specific patterns of mixed wax and canal irritation — see our companion article on hearing aid users and ear wax.

Red flags that need ENT urgently

• Vertigo with hearing change — inner ear involvement, needs investigation.
• Facial weakness — cranial nerve VII close to middle ear; cholesteatoma or tumour.
• Bloody discharge — perforation, trauma, rarely tumour.
• Chronic foul-smelling discharge — cholesteatoma until proven otherwise.
• Sudden hearing loss — sensorineural sudden deafness needs steroid treatment within 72 hours; this is an emergency.
• Severe pain disproportionate to otoscopy findings — deep-seated infection, malignant otitis externa in diabetics.

For these, ENT urgent referral via your GP or A&E is appropriate. We will refer onwards rather than attempt to manage in a pharmacist-led setting.

How we run the screen at Trafford Clinic

Every wax removal appointment begins with otoscopy and a brief targeted history. If we see wax and the ear is otherwise healthy, we proceed. If we see something else, we explain what we have found, what it means, and what to do next — ENT referral letter, GP referral, topical drops, or watchful waiting. We charge for the consultation regardless of whether we proceed with microsuction — the consultation is the value, the procedure is the outcome.

See our local pages and our background article on why the NHS stopped doing routine ear wax removal in 2019. For the practical question of using olive oil drops before an appointment, see olive oil ear drops, how to use them. Brand ear health page covers the wider context. For a similar diagnostic framework in blood testing see reading blood test results in plain English.