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Cerumen Removal – Adult/Pediatric - Ambulatory

Cerumen Removal – Adult/Pediatric - Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, In the Clinic


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Cerumen Removal - Adult/Pediatric
-Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ................................................................................................ 3
SCOPE ............................................................................................................................ 4
METHODOLOGY ............................................................................................................ 5
DEFINITIONS ................................................................................................................. 5
INTRODUCTION ............................................................................................................. 6
RECOMMENDATIONS ................................................................................................... 6
Indications for Cerumen Removal ...................................................................................... 6
Procedure Types ............................................................................................................... 6
UW HEALTH IMPLEMENTATION.................................................................................. 8
APPENDIX A. EVIDENCE GRADING SCHEMES ......................................................... 9
APPENDIX B. PROCEDURAL INSTRUCTIONS FOR EAR IRRIGATION .................. 11
REFERENCES .............................................................................................................. 11
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org

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Contact for Irrigation Procedure:
Name: Department of Clinical Staff Education
Email Address: staff.educators@uwmf.wisc.edu
Contact for Guideline Content:
Name: J. Scott McMurray, MD- Surgery- ENT/Otolaryngology
Phone Number: (608) 262-7181
Email Address: mcmurray@surgery.wisc.edu
Contact for Guideline Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Coordinating Team Members:
Kathy Wilkinson, PA- Surgery- ENT/Otolaryngology
Julia Hunter, CNS- Pediatrics
Carmen Griffith, RN- Internal Medicine
Michelle Weidner, RN- Internal Medicine
Melisa Arndt, RN- Family Medicine
Melanie McDougal, MA- Family Medicine
Christine Thompson, MA- Internal Medicine/Geriatrics
Kelby Mack, MA- Internal Medicine
Rosemary Monaco, RN- Nursing Informatics
Deanna Blanchard- Nursing Education
Diane Mikelsons- Clinical Staff Education
Review Individuals/Bodies:
Sara Shull, PharmD- Drug Policy Program
Committee Approvals/Dates:
Primary Care Leadership Committee (PCLC) (08/14/2015)
Clinical Knowledge Management (CKM) Council (08/27/2015)
Release Date: August 2015 | Next Review Date: August 2018
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org

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Executive Summary
Guideline Overview
This guideline contains recommendations for the removal of cerumen from the ear canal
and was developed internally by a multidisciplinary workgroup. The content was heavily
influenced by recommendations within the 2008 Otolaryngology- Head and Neck
Surgery Clinical Practice Guideline for cerumen impaction.1
Key Practice Recommendations
General Recommendations:
ξ Cerumen removal should only be completed when the impaction prevents clinical
examination (O-HNS Grade B Recommendation) or the patient presents with symptoms
(i.e., hearing loss, pain, etc.).1 (O-HNS Grade C Recommendation)
ξ Irrigation or combination therapy (cerumenolytic agents and irrigation) is
recommended for cerumen which is hard or dry. (O-HNS Grade B Option; UW Health Class
IIa, Level of Evidence B)
ξ Manual removal or suctioning* is recommended when the cerumen is wet or runny.
(UW Health Class IIb, Level of Evidence C)
ξ Candling is ineffective and should never be completed for cerumen removal. (AFP
Grade C)
Special Considerations:
Patient Characteristics Recommended Procedure Procedure(s) to Avoid
Uncooperative Ear irrigation or ENT referral
Avoid manual
removal/suctioning due to
risk of injury
Anticoagulant therapy Ear irrigation
Avoid manual
removal/suctioning due to
bleed risk
Tinnitus or history of tinnitus Ear irrigation
Avoid manual
removal/suctioning due to
loud noise exposure
Immunosuppression
(i.e., HIV, organ transplant)
Cerumenolytic agent or ENT
referral
Avoid ear irrigation due to
risk of infection
Vertigo Manual removal/suctioning* Avoid ear irrigation
History of ear surgery or
middle-ear disease Manual removal/suctioning*
Avoid ear irrigation and use
of cerumenolytic agents
Open middle ear air space
(i.e., tympanic membrane
perforation or ear tubes)
Manual removal/suctioning* Avoid ear irrigation and use
of cerumenolytic agents
Ear infection Manual removal/suctioning* Avoid use of cerumenolytic agents or ear irrigation
*NOTE: Manual removal/suctioning may only be completed by a trained physician.
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-MadisonCopyright © 201 5University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org

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Pertinent UW Health Policies & Procedures
1. Policy 4.11AP- Ear Irrigation with Examination of the External Auditory Canal (Adult
& Pediatric)
2. Policy 13.12A- Basic Care Standards (Inpatient Adult)
Patient Resources
1. HFFY #4698- Otic (Ear) Medicines- General Information
2. Healthwise: Earwax Blockage
3. Healthwise: Earwax Blockage: Pediatric
Scope
Disease/Condition(s): Cerumen blockage or foreign body within the ear canal
Clinical Specialty: Primary or Specialty Care
Intended Users: Physicians, Advanced Practice Providers, Registered Nurses,
Licensed Practice Nurses, Medical Assistants
Objective(s): To provide evidence-based recommendations for clearing the ear canal
of cerumen.
Target Population: Pediatric or adult patients seen within a clinic setting.
Interventions and Practices Considered:
1. Manual removal/suctioning
2. Ear irrigation
3. Cerumenolytic Agents
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org

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Methodology
Methods Used to Collect/Select the Evidence: Electronic database searches
(i.e., PUBMED) were conducted by the Center for Clinical Knowledge Management and
workgroup members to collect evidence for review. Expert opinion, clinical experience,
and regard for patient safety/experience were also considered during discussions of the
evidence.
Methods Used to Formulate the Recommendations: The interdisciplinary
workgroup members agreed to adopt recommendations developed by external
organizations or developed internally derived recommendations. All recommendations
were derived by establishing group consensus through discussion of the literature
evidence and expert/institutional experiences.
Methods Used to Assess the Quality and Strength of the
Evidence/Recommendations: Recommendations developed by external
organizations maintained the evidence grades assigned within the original document
and were adopted for use at UW Health. Internally developed recommendations during
the workgroup meetings were evaluated using the Grading of Recommendations
Assessment, Development and Evaluation (GRADE) modified by the American Heart
Association (AHA) to establish evidence grades for each individual piece of literature
and/or recommendation.
Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for rating schemes used within this guideline.
Definitions
ξ Manual removal/suctioning: Using either a curette, probe, hook, or forceps to
reach in the ear canal and manually remove cerumen
ξ Irrigation: Inserting microsuction equipment into the ear and using low pressure to
pull cerumen out of the ear. This is conducted with equipment (either home-made
such as a bulb syringe or specifically for ear irrigation) or a syringe (plastic or metal
with various types of extensions) and may be conducted with various types of liquid
(water, hydrogen peroxide, normal saline, etc.).
ξ Candling: Sticking a candle (fabric soaked in warm beeswax, then hardened) into
the ear of the patient and lighting the far end of the candle, which then burns slowly
for about 15 minutes. The candle is extinguished and the content of the near end of
the candle is displayed for inspection.
ξ Cerumenolytic Agents: A variety of agents (water, oil, or organic-based) meant to
soften the cerumen to ease removal.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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Introduction
Cerumen removal is the most common ear, nose, and throat (ENT) procedure
performed by primary care, with approximately 8 million procedures performed each
year in the United States.2 Cerumen impaction is the primary cause of adult conductive
hearing loss,3 and is more likely to occur in persons of Asian descent (due to a different
genetic make-up of the cerumen making it dry and scaly), geriatric patients (due to loss
of function of sebaceous glands leading to dry cerumen), and persons with a mental
disability.4
A variety of procedures exist to remove cerumen including: manual removal with an
instrument, suctioning, irrigation, candling, or use of cerumenolytic agents. These
procedures may be performed independently or in combination with one another.
Recommendations
Indications for Cerumen Removal
Cerumen removal should only be completed when the impaction prevents clinical
examination (O-HNS Grade B Recommendation) or the patient presents with symptoms (i.e.,
hearing loss, pain, etc.).1 (O-HNS Grade C Recommendation)
Procedure Types
The procedure type should be based upon clinician comfort and competency, available
equipment, and cerumen consistency or patient characteristics.5 (UW Health Class IIa, Level
of Evidence C) A referral to ENT should be made whenever the clinician is uncomfortable
with performing the procedure or when previous attempts are unsuccessful.1 (UW Health
Class I, Level of Evidence C) In patients with a history of adverse events or expressed
discomfort related to cerumen removal, it is recommended to provide cerumenolytic
agents and to avoid any procedure. A referral to ENT may be considered. (UW Health
Class IIb, Level of Evidence C)
Candling1,2,5
Ear candling has been shown as an ineffective and unsafe practice for cerumen
removal and should not be completed. (AFP Grade C) The literature unanimously advises
against use of ear candling for cerumen removal. Complications from this procedure
include: burns, occlusions of the ear canal, tympanic membrane perforation, external
otitis, and temporary hearing loss.
Manual Removal/Suctioning1,2,6,7
The College of Audiologists and Speech-Language Pathologists of Ontario support the
consideration of using manual instrumentation or suctioning when the cerumen is
identified as wet or runny. (UW Health Class IIb, Level of Evidence C)
Manual removal or suctioning may be preferred in patients at risk for infection, or who
experienced previous ear surgery, because of the absence of moisture and the ability
for the provider to directly visualize the ear canal. (O-HNS Grade C Option)
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Risks of this type of procedure include laceration to the ear canal, trauma to the meatal
wall or underlying structures, tympanic membrane rupture, and infection. Hard cerumen,
probes, specula, and suction devices (specifically large-bore close to the tympanic
membrane) may all cause lacerations to the ear canal skin or perforation of the ear
drum. Suctioning has been shown to cause worsening of pre-existing tinnitus due to
loud noise exposure. Therefore, manual removal or microsuction should be avoided in
patients with previous severe exacerbation of tinnitus, symptomatic tinnitus, very hard
cerumen, or in uncooperative patients. (UW Health Class III, Level of Evidence C)
Irrigation1,2,6,8,910,11
Ear irrigation is the most commonly performed method for cerumen removal, and has
been associated with hearing improvement and patient reports of symptom relief. (O-
HNS Grade B Option) A systematic review of the available evidence suggests that
pretreatment with an otic drop improves the efficacy of aural irrigation, regardless of
solution type. Therefore, saline and tap water may be beneficial as specially formulated
products. (UW Health Class IIa, Level of Evidence B)
Ear syringes are inexpensive, portable and readily available; however some can be
slow, poorly balanced, or cause minor ear trauma. Risk of tympanic membrane
perforation can be lessened by using an ear irrigator tip to prevent water from hitting the
eardrum which eliminates pressure buildup. Regardless of the system, the irrigant
should be introduced at body temperature to prevent a caloric-reflex response.
Risks associated with this procedure type include pain, vertigo, trauma to the ear canal
or tympanic membrane, infection, and hearing loss. Patients with history of middle-ear
disease, ear surgery, radiation therapy to the area, severe otitis externa, sharp foreign
objects in the external auditory canal, or vertigo should not undergo irrigation. (UW Health
Class III, Level of Evidence A)
Cerumenolytic Agents1,2,10-15
Clinicians may use cerumenolytic agents (including water or saline solution) in the
management of cerumen impaction. (O-HNS Grade C Option) The cerumenolytic available
on UWHC formulary is carbamide peroxide. Water-based agents are preferred to oil-
based or organic agents. Oil-based agents are criticized for only lubricating and
softening cerumen, unlike true cerumenolytic agents which disintegrate the cerumen.
Hand et al. (2004) found that triethanolamine was more effective than saline and that a
longer treatment duration with softening agents was better than a shorter duration. The
effect of docusate sodium was not statistically different from that of triethanolamine or
saline. A randomized controlled trial comparing docusate, triethanolamine polypeptibe,
and irrigation in children did not find any statistically significant differences between
either treatment method.
Literature supports the use of the cerumenolytic agents in conjunction with irrigation,
and suggests that pretreatment with cerumenolytic agents may improve the efficacy and
cost-effectiveness of irrigation. (AFP Grade B) Applying water or a cerumenolytic agent 15
to 30 minutes before irrigation is as effective as applying a cerumenolytic agent for
several days before irrigation.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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The use of cerumenolytics alone (without irrigation) has also been shown to be superior
to no treatment. (AFP Grade B) However, efficacy of these agents alone increases with
longer treatment duration and they may only clear ear wax up to 40 percent of the time.
Cerumenolytic agents may result in discomfort, transient hearing loss, dizziness, and
skin irritation. These agents should be avoided in patients with a suspected breach of
the tympanic membrane from previous surgery, insertion of myringotomy tubes, or
tympanic membrane perforation. Use should be avoided in patients with active
infections of the ear canal. Many products contain possible irritants or may be harmful
for patients with epidermal sensitivity or allergies. (UW Health Class III, Level of Evidence A)
UW Health Implementation
Potential Benefits:
ξ Removal of cerumen or foreign body from ear canal
ξ Improved hearing
Potential Harms:
ξ Tympanic membrane perforation
ξ Hearing loss and/or tinnitus16
ξ Infection
ξ Vertigo
ξ Cardiac suppression (leading to mortality)
Implementation Plan/Tools
1. Guideline will be housed on U-Connect in a dedicated folder for CPGs.
2. Release of the guideline will be advertised in the Clinical Knowledge Management
Corner within the Best Practice newsletter.
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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Appendix A. Evidence Grading Schemes
Figure 1. GRADE modified by AHA/ACC
Figure 2. American Family Physician Grading Scheme (using SORT)
Grade Description
A Consistent, good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, disease-oriented evidence, usual practice, expert
opinion or case series
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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Figure 3. Otolaryngology- Head and Neck Surgery (O-HNS) Grading Scheme
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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Appendix B. Procedural Instructions for Ear Irrigation
SUPPLIES:
ξ Hand-held otoscope
ξ Cerumenolytic agent if ordered
ξ 60cc syringe with blunt tip (blue Irriclear irrigation) [Traditional water piks or cut off angiocaths WILL
NOT be used due to the excess force they apply to the eardrum]
ξ Prescribed solution such as 1:10 dilution hydrogen peroxide. Warm tap water or saline may be just as
effective. Temperature of solution should be +/- 5 degrees of patient’s body temperature
ξ Ear or kidney basin
ξ Towel or chux
ξ Cerumen loop
EAR ASSESSMENT –See Ear Irrigation Competency Form
1. Cerumen should NOT be removed if patient is asymptomatic, as it protects the ear canal against
infection and trauma.
2. Obtain a history from the patient regarding any ear problem or past medical or surgical problems
related to the ears, including any history of draining ears, past perforation or any complication from
previous ear irrigation. Examine both ears and assess ear canals using appropriate sized
speculum. If one ear is less problematic, assess (inspect) that ear first. Locate impacted cerumen or
foreign object with otoscope.
a. DO NOT IRRIGATE IF PERFORATION IS PRESENT.
b. DO NOT IRRIGATE IF OTITIS EXTERNA IS PRESENT.
c. DO NOT IRRIGATE IF THE PATIENT HAS A HISTORY OF EAR SURGERY.
d. DO NOT IRRIGATE IF TUBES IN PLACE.
e. DO NOT IRRIGATE IF PATEINT HAS A HEARING LOSS AND THE OCCLUDED EAR IS
THE “HEARING EAR”.
f. DO NOT IRRIGATE IF VEGETABLE MATTER (peas, beans, etc.) IS VISIBLE AS A
FOREIGN BODY. Vegetable matter absorbs water and will further wedge the foreign body in
the ear canal and cause intense pain. (Provider should refer to ENT for removal.)
g. Use caution when irrigating the ear of a patient who is on anticoagulants due to the risk for
excessive bleeding.
h. Consider a cerumenolytic agent or referral to ENT in immunosuppressed patients due to risk
of infection.
IRRIGATION PROCEDURE:
NOTE: Inspection of ear using otoscope must be performed by a qualified clinician prior to any irrigation.
1. Assemble appropriate equipment (see equipment list above).
2. Confirm order and patient’s identity.
3. After explaining the procedure to the patient, position patient sitting upright, with the head slightly
tilted toward the affected ear. Position a towel or chux to protect the patient’s clothing.
4. Wash your hands.
5. If there is a large amount of hard cerumen, instill the ceruminolytic agent ordered by
MD/NP/PA. Canal should be entirely filled with liquid ceruminolytic agent, and cotton ball put in
ear. Instruct patient to lay on side or tilt head to the opposite side to keep the liquid agent in the ear
canal. Wait 15 to 30 minutes before continuing with irrigation.
6. Prepare appropriate irrigating solution, tap water or saline to tepid temperature. Solutions that are too
hot or too cold are uncomfortable and may initiate dizziness.
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7. Prepare irrigating system and fill with irrigating solution. Expel any air.
8. Place the kidney basin close to the patient’s head and under the ear. If the patient is unable to hold
the basin, a second person will be required to hold it in place during the irrigation.
9. Gently pull the outer ear upward and backward (for an adult) or downward and backward (for a
child). Place the tip of the syringe near the opening of the ear and gently direct the stream of solution
towards the 1:00 position for the left ear and the 11:00 position for the right ear. The tip of the syringe
should remain in the outer ear one-third (no more than 8mm into) of the canal. Repeat this step until
particles of cerumen are visible in the basin. If the patient reports any pain, becomes dizzy or
nauseated, stop the irrigation and check with provider.
10. Stop the procedure if the patient complains of pain or if the canal becomes red or irritated. It is not
uncommon to find otitis externa beneath cerumen impactions, and these may need to be treated
before the ear can be completely cleared. Having an otitis externa makes the canal particularly
susceptible to trauma.
11. If the ear remains impacted after a maximum of 500ml of solution is used for irrigation, it is better to
send the patient home with a ceruminolytic agent and try again later (or refer to ENT). Repeated
attempts with additional fluid usually only serve to damage the external auditory canal. If you are
unable to clear the ear, notify the ordering provider for appropriate orders (referral to a specialist or
for a ceruminolytic agent for home use).
12. Throughout the procedure, it is recommended to keep inspecting the ear for removal of cerumen (i.e.,
cerumen debris in the basin); use cerumen loop if needed to gently remove debris only if it is visible
to the naked eye and in the outer ear.
13. After the irrigation, dry the ear with cotton, tissue or a towel, taking care not to enter the canal itself.
Possible complications may include: allergic reaction to cerumenolytic agent, otitis externa, earache,
transient hearing loss and dizziness. Retained water may predispose to infection. Tympanic
membrane perforation, bleeding, hearing loss, tinnitus, pain and vertigo can occur, usually due to
aggressive irrigation.
POST-IRRIGATION PROCEDURE
1. Instruct the patient in appropriate ear care procedures as indicated.
a. Some cerumen in the ear canal is a normal finding.
b. Avoid putting bobby pins and toothpicks into the ear canal due to the danger to the eardrum.
c. Cotton-tipped swabs are not to be used to clean ears; the cerumen is pushed backwards into
the canal and may end up pushed on top of the eardrum.
d. In patients with recurrent (more than once yearly) cerumen impaction and no significant ear
disease suggest weekly use of a cotton ball dipped in mineral oil placed in the external canal
to help liquefy cerumen and aid normal elimination.
2. Documentation: Record in the electronic medical record:
a. Baseline assessment of ear canal and tympanic membrane.
b. Date and time of irrigation.
c. Type, amount and temperature of solution used. Any cerumenolytic agent used.
d. Appearance of returned fluid.
e. Assessment of ear canal and tympanic membrane following treatment.
f. Response of patient to irrigation and discharge instructions.
3. Report any abnormal findings to the ordering provider.
Questions? Contact Clinical Staff Education (staff.educators@uwmf.wisc.edu)
Procedure last reviewed/revised: 08/2015
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org

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References
1. Roland PS, Smith TL, Schwartz SR, et al. Clinical practice guideline: cerumen
impaction. Otolaryngol Head Neck Surg. Sep 2008;139(3 Suppl 2):S1-S21.
2. McCarter DF, Courtney AU, Pollart SM. Cerumen impaction. Am Fam Physician.
May 2007;75(10):1523-1528.
3. Mitka M. Cerumen removal guidelines wax practical. JAMA. Oct
2008;300(13):1506.
4. Jabor MS, Gianoli GJ. Chapter 4: Cerumen Impaction. Philadelphia,
Pennsylvania: Versa Press; 2001.
5. Ernst E. Ear candles: a triumph of ignorance over science. J Laryngol Otol. Jan
2004;118(1):1-2.
6. van Wyk FC, Modayil PC, Selvadurai D. Cerumen Impaction Removal. 2012.
http://emedicine.medscape.com/article/1413546-overview.
7. Sinclair S. Preferred Practice Guideline for Cerumen Management: College of
Audiologists and Speech-Language Pathologists of Ontario; 2005.
8. Memel D, Langley C, Watkins C, Laue B, Birchall M, Bachmann M. Effectiveness
of ear syringing in general practice: a randomised controlled trial and patients'
experiences. Br J Gen Pract. Nov 2002;52(484):906-911.
9. Coppin R, Wicke D, Little P. Managing earwax in primary care: efficacy of self-
treatment using a bulb syringe. Br J Gen Pract. Jan 2008;58(546):44-49.
10. Hand C, Harvey I. The effectiveness of topical preparations for the treatment of
earwax: a systematic review. Br J Gen Pract. Nov 2004;54(508):862-867.
11. Eekhof JA, de Bock GH, Le Cessie S, Springer MP. A quasi-randomised
controlled trial of water as a quick softening agent of persistent earwax in general
practice. Br J Gen Pract. Aug 2001;51(469):635-637.
12. Burton MJ, Doree C. Ear drops for the removal of ear wax. Cochrane Database
Syst Rev. 2009(1):CD004326.
13. Keane EM, Wilson H, McGrane D, Coakley D, Walsh JB. Use of solvents to
disperse ear wax. Br J Clin Pract. 1995 Mar-Apr 1995;49(2):71-72.
14. Chalishazar U, Williams H. Back to basics: finding an optimal cerumenolytic
(earwax solvent). Br J Nurs. 2007 Jul 12-25 2007;16(13):806-808.
15. Whatley VN, Dodds CL, Paul RI. Randomized clinical trial of docusate,
triethanolamine polypeptide, and irrigation in cerumen removal in children. Arch
Pediatr Adolesc Med. Dec 2003;157(12):1177-1180.
16. Folmer RL, Shi BY. Chronic tinnitus resulting from cerumen removal procedures.
Int Tinnitus J. 2004;10(1):42-46.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org