The following editor's note by Anne D. Walling, M.D., appeared with a "Tips from Other Journals" in the February 15, 2003 issue of American Family Physician. (1) The "Letter to the Editor" that follows was chosen from numerous responses we received.
EDITOR'S NOTE: Ear syringing is a very common procedure in nursing homes--and the patients hate it! I have heard rumors of removing earwax in children by using liquid stool-softening agents but cannot find references or colleagues who have used this method in adults. If anyone knows a better way to remove earwax, please let us know.--A.D.W.
REFERENCE
(1.) Walling AD. How effective is ear syringing in improving hearing? [Tips] Am Fam Physician 2003; 67:870.
TO THE EDITOR: For many years, I have used a mixture of the contents of one capsule of docusate calcium (Surfak, 240 mg) and a few mL of water for removing earwax. I fill the ear canal with this mixture, have the patient lie still for at least 30 minutes, and then irrigate the ear with warm water. This treatment is usually successful. I do not use the docusate calcium solution for anything but removing cerumen.
THOMAS SWEAT, M.D.
P.O. Box 790
Corinth, MS 38835
IN REPLY: Ask and ye shall receive! We would like to thank everyone who sent suggestions on earwax removal. Judging from the number of responses, this is a common and stubborn problem. All of the responses demonstrate that doing unglamorous things well is one hallmark of a being a good family physician.
Earwax removal is performed for various reasons, including hearing loss, sensation of ear blockage, and visualization of the tympanic membrane. The most common clinical practice is ear syringing, which is limited by patient tolerance and complications. Although syringing is considered the clinical standard, there are no high-quality studies comparing syringing with other methods or no treatment. (1)
Wax softeners and ceruminolytics are used to improve the success and tolerability of irrigation. They also can be used as solo agents for home therapy. However, studies evaluating ceruminolytics have used inconsistent methods. Thus, there is no clear evidence that one type of softener is superior to another. (1,2) Furthermore, most studies lack a "no treatment" group, so it is impossible to discern more than relative efficacy in most cases. (1) No studies exist comparing home and office treatment. (3)
One promising treatment is liquid docusate sodium (Colace). It is more effective than triethanolamine (Cerumenex) for augmenting irrigation. In one study, (4) instilling 1 mL of Cerumenex fifteen minutes before irrigation allowed tympanic membrane visualization in 81 percent of study participants. However, another study (5) did not find either treatment better than a normal saline control. The accompanying table lists other softening options. For those seeking more information on this common clinical problem, we recommend the following reading (Aung T, Mulley GP. Removal of ear wax. BMJ 2002;325:27, and references 1 and 2).
Options For Cerumen Removal
Mechanical
Cerumen loop
Ear jet irrigator
Ear syringing
Suction
Ceruminolytics or softeners
Arachis oil, chlorobutanol, p-dichlorobenzene (Cerumenol)
Carbamide peroxide (Debrox)
Docusate sodium (Colace)
Ethylene oxide polyoxypropylene (Addax)
Glycerin
Hydrogen peroxide
Oil (olive or mineral)
Propylene glycol
Sodium bicarbonate in glycerol
Triethanolamine (Cerumenex)
2 percent acetic acid
Water, normal saline
CHUCK CARTER, M.D.
Medical Editing Fellow, American Family Physician
Washington, D.C.
ANNE WALLING, M.D.
Associate Editor, American Family Physician
Wichita, KS
REFERENCES
(1.) Browning G. Wax in ear. Clin Evid 2002;7:490-7.
(2.) Burton MJ, Doree CJ. Ear drops for the removal of ear wax. Cochrane Database Syst Rev 2003;3: CD004400.
(3.) Wilson SA, Lopez R. What is the best treatment for impacted cerumen? J Fam Pract 2002;51:117.
(4.) Singer AJ, Sauris E, Viccellio AW. Ceruminolytic effects of docusate sodium: a randomized, controlled trial. Ann Emerg Med 2000;36:228-32.
(5.) Whatley VN, Dodds CL, Paul RI. Randomized clinical trial of docusate, triethanolamine polypeptide, and irrigation in cerumen removal in children. Arch Pediatr Adolesc Med 2003;157:1181-3.
EDITOR'S NOTE: I am particularly grateful to those who referred to or sent copies of the article by Singer and colleagues (Ann Emerg Med 2000;36:228-32). It took some persuasion, but the staff at the nursing home finally agreed to use docusate sodium (Colace), and my elderly patients are grateful. They now complain that they can hear me but can't understand my Scottish accent!--A.D.W.
COPYRIGHT 2004 American Academy of Family Physicians
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