The ears are susceptible to a number of minor conditions that can be treated OTC as long as more serious problems have been ruled out. Alan Nathan explains

WHAT’S AVAILABLE

Treatments are available without prescription for earache (acute otitis media, AOM), ear wax, otitis externa, and otitis media with effusion (OME, glue ear).

EARACHE

Earache is often associated with an upper respiratory tract infection and, as long as the pain is not severe, can be treated with oral analgesics for up to 48 hours, before referring if the condition does not improve. There are no OTC analgesic ear drops available. Earache in very young children should be referred immediately, as the possibility of secondary bacterial infection of the Eustachian tube, requiring antibiotic treatment, is relatively high.

EAR WAX

Cerumen (ear wax) is a complex oily fluid secreted by sebaceous and apocrine glands in the external auditory canal, which combines with exfoliated skin cells to form a protective waxy layer. This is normally moved outwards by movement of the jaw in speaking and chewing and removed by washing. In some individuals, however, excessive cohesive cerumen is produced. This forms a waxy plug that affects hearing and causes discomfort. Although syringing is usually necessary to remove ear wax, cerumenolytics can be used in advance to soften, loosen and partially dissolve the wax.

Several approaches to softening and removing ear wax are employed in cerumenolytic ear drops:

• Fixed and volatile oils As wax contains a high proportion of oily components, it is logical to assume that it can be dissolved, at least partially, by oils. The BNF recommends the use of olive oil or almond oil to soften wax before removal. Proprietary ear drops contain variously the fixed oils olive, arachis (peanut) and almond, and volatile cajeput (obtained from trees of the myrtle family), rosemary and camphor oils.
• Urea hydrogen peroxide Three proprietary ear drop brands contain 5% urea hydrogen peroxide in a glycerol base. In contact with tissues containing the enzyme catalase, hydrogen peroxide releases its oxygen to create effervescence, which helps to break up wax by a mechanical action. Glycerol assists in softening the wax and urea increases penetration of the solution into the plug. Hydrogen peroxide solution BP 20 volume (6%), diluted one part with three parts water, can also be used but may not penetrate so effectively.
• Docusate sodium A surface active agent that increases water penetration into the wax plug. Two proprietary brands of ear drops contain 5% docusate sodium.
• Sodium bicarbonate Sodium bicarbonate ear drops BP contains 5% sodium bicarbonate and 30% glycerol in water and are recommended in the BNF.

Efficacy

A Cochrane Review found that ear drops (of any sort) can help to remove ear wax, but that water and saline drops appear to be as good as more costly commercial products. However, the quality of the trials reviewed was generally low.¹

Use of cerumenolytic ear drops

The following technique is recommended for the most effective use of ear drops:

• It is best to have a second person instil the ear drops
• Before use, the drops should be slightly warmed by holding the container in the hands for a few minutes
• The patient should lay their head on a flat surface such as a table, with the affected ear uppermost
• The auricle (pinna) should be lifted upwards and backwards in adults, or downward and backwards in children, to straighten the ear canal
• The requisite number of drops should be instilled
• The tragus (the small projection in front of the external opening) should be pressed gently once or twice, to assist the drops down the ear canal and to expel air bubbles
• The patient should remain with their head down for at least five minutes. A cotton-wool plug moistened with the drops should be placed into the ear
• Unless directed otherwise, the drops should be used night and morning for three or four days before syringing.

OTITIS EXTERNA

Otitis externa is inflammation of the external auditory canal. The acute form is usually caused by bacterial infection, but may also be fungal or viral. The chronic form is eczematous and may be atopic or a contact dermatitis. Dermatitis may become infected and the two types of otitis externa can exist together. OTC treatments available are:

• Hydrocortisone cream Mild eczematous otitis externa affecting the pinna can be treated with hydrocortisone cream.
• Acetic acid Acetic acid has antibacterial activity, and is reported to be active against Haemophilus, Pseudomonas, Candida and Trichomonas species. A 2% solution of acetic acid is available as a pump-action spray, licensed for the treatment of superficial infections of the external auditory canal in adults and children over the age of 12 years. It is used three to eight times daily until two days after symptoms have disappeared, for up to seven days. Use should be discontinued and medical advice sought if symptoms do not improve within 48 hours of starting treatment. A Cochrane Review found that acetic acid was effective and comparable to antibiotic/steroid for treatment of otitis externa for up to one week of treatment, but less effective thereafter.²

OTITIS MEDIA WITH EFFUSION

In this condition fluid builds up in the middle ear and Eustachian tube, preventing the eardrum from vibrating properly and resulting in hearing loss. It mainly affects children and is often self-limiting, with 50 per cent of cases clearing spontaneously within three months. A medical device is available to relieve OME – an auto-inflator consisting of a nosepiece applicator attached to a small balloon. It works by generating positive pressure in the middle ear and Eustachian tube and allowing built-up fluid to drain. The nosepiece is inserted into each nostril in turn with the other nostril held shut, and the patient exhales through the nose to inflate the balloon. When the balloon is inflated the air is allowed to re-enter the nostril whilst swallowing. The device is prescribable on the NHS as well as being available for OTC sale.

A Cochrane Review concluded that the evidence for the use of autoinflation in the short term appears favourable. But given the small number of studies found and the lack of long-term follow-up, the long-term effects associated with the use of such devices cannot be determined.³

REFERENCES

1. Burton MJ, Doree C. Ear drops for the removal of ear wax. Cochrane Database of Systematic Reviews 2009, Issue 1. Art No: CD004326. DOI: 10.1002/14651858.CD004326.pub2
2. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database Syst Rev. 2010 Issue 1. Art No: CD004740. DOI: 10.1002/14651858.CD004740.pub2
3. Perera R, Glasziou PP, Heneghan CJ, McLellan J, Williamson I. Autoinflation for hearing loss associated with otitis media with effusion. Cochrane Database of Systematic Reviews 2013, Issue 5. Art No: CD006285. DOI: 10.1002/14651858.CD006285.pub2