The safety and effectiveness of different methods of earwax removal: a systematic review and economic evaluation.

BACKGROUND: Build-up of earwax is a common reason for attendance in primary care. Current practice for earwax removal generally involves the use of a softening agent, followed by irrigation of the ear if required. However, the safety and benefits of the different methods of removal are not known for certain. OBJECTIVES: To conduct evidence synthesis of the clinical effectiveness and cost-effectiveness of the interventions currently available for softening and/or removing earwax and any adverse events (AEs) associated with the interventions. DATA SOURCES: Eleven electronic resources were searched from inception to November 2008, including: The Cochrane Library; MEDLINE (OVID), PREMEDLINE In-Process & Other Non-Indexed Citations (OVID), EMBASE (OVID); and CINAHL. METHODS: Two reviewers screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text or retrieved papers and data were extracted by two reviewers using data extraction forms developed a priori. Any differences were resolved by discussion or by a third reviewer. Study criteria included: interventions - all methods of earwax removal available and combinations of these methods; participants - adults/children presenting requiring earwax removal; outcomes - measures of hearing, adequacy of clearance of wax, quality of life, time to recurrence or further treatment, AEs and measures of cost-effectiveness; design - randomised controlled trials (RCTs) and controlled clinical trials (CCTs) for clinical effectiveness, cohort studies for AEs and cost-effectiveness, and costing studies for cost-effectiveness. For the economic evaluation, a deterministic decision tree model was developed to evaluate three options: (1) the use of softeners followed by irrigation in primary care; (2) softeners followed by self-irrigation; and (3) a 'no treatment' option. Outcomes were assessed in terms of benefits to patients and costs incurred, with costs presented by exploratory cost-utility analysis. RESULTS: Twenty-six clinical trials conducted in primary care (14 studies), secondary care (8 studies) or other care settings (4 studies), met the inclusion criteria for the review - 22 RCTs and 4 CCTs. The range of interventions included 16 different softeners, with or without irrigation, and in various different comparisons. Participants, outcomes, timing of intervention, follow-up and methodological quality varied between studies. On measures of wax clearance Cerumol, sodium bicarbonate, olive oil and water are all more effective than no treatment; triethanolamine polypeptide (TP) is better than olive oil; wet irrigation is better than dry irrigation; sodium bicarbonate drops followed by irrigation by nurse is more effective than sodium bicarbonate drops followed by self-irrigation; softening with TP and self-irrigation is more effective than self-irrigation only; and endoscopic de-waxing is better than microscopic de-waxing. AEs appeared to be minor and of limited extent. Resuts of the exploratory economic model found that softeners followed by self-irrigation were more likely to be cost-effective [24,433 pounds per quality-adjusted life-year (QALY)] than softeners followed by irrigation at primary care (32,130 pounds per QALY) when compared with no treatment. Comparison of the two active treatments showed that the additional gain associated with softeners followed by irrigation at primary care over softeners followed by self-irrigation was at a cost of 340,000 pounds per QALY. When compared over a lifetime horizon to the 'no treatment' option, the ICERs for softeners followed by self-irrigation and of softeners followed by irrigation at primary care were 24,450 pounds per QALY and 32,136 pounds per QALY, respectively. LIMITATIONS: The systematic review found limited good-quality evidence of the safety, benefits and costs of the different strategies, making it difficult to differentiate between the various methods for removing earwax and rendering the economic evaluation as speculative. CONCLUSIONS: Although softeners are effective, which specific softeners are most effective remains uncertain. Evidence on the effectiveness of methods of irrigation or mechanical removal was equivocal. Further research is required to improve the evidence base, such as a RCT incorporating an economic evaluation to assess the different ways of providing the service, the effectiveness of the different methods of removal and the acceptability of the different approaches to patients and practitioners.

Implementation of influenza immunisation policy in general practice: 1997 to 1998.

Influenza immunisation policy and practice in primary care in central southern England was surveyed in early 1998, when national guidelines advised immunisation only for people with specified 'higher risk' medical conditions or who lived in long stay facilities such as nursing or residential homes. Three hundred and one questionnaires were returned from 441 general practices (68%). Between 71% and 82% of all respondents stated that they 'always' offered influenza immunisation to adults with the specified 'higher risk' medical conditions. For children the corresponding range was 33% to 43%. We estimated that 11.5% of the combined practice population of two million had received influenza immunisation late in 1997. The age data supplied suggested that 64% of those aged over 75 years had been immunised. Seventy-four per cent of respondents said they would be willing to follow an age based policy. The total coverage figures mask suboptimal uptake in target groups, coupled with immunisation of those outside the target groups. This could be partly addressed by rewarding high coverage of target groups such as elderly people aged over 75 years and by clarifying the guidelines for immunisation of children with 'higher risk' medical conditions.

The effectiveness of waiting room notice-boards as a vehicle for health education.

To determine whether patients read and remembered health promotion messages displayed in waiting rooms, 600 patients in a UK general practice were given a self-complete questionnaire. Two notice-boards carried between 1 to 4 topics over four study periods. Three-hundred and twenty-seven (55%) of subjects responded. Twenty-two per cent recalled at least one topic. Increasing the number of topics did not increase the overall impact of the notice-boards. The numbers of patients recalling a topic remained constant, but increasing the number of topics reduced the number remembering each individual topic. Patients aged over 60 years were less likely to recall topics, but waiting time, gender and health professional seen had no effect on results. Very few patients (< 10%) read or took health promotion leaflets. These results suggest that the role of waiting room notice-boards should be reassessed. More modern methods of communication such as electronic notice-boards or videos could be used. However, the waiting room might best function not as an area where a captive audience can be bombarded with health promotion messages, but rather as a place for relaxation before consulting a health professional, making patients more receptive to health advice in the consultation.

Chlamydia trachomatis associated with chronic inflammation in abdominal specimens from women selected for tuboplasty.

Chronic inflammation is a frequent cause of tuboplasty failure. Therefore, it would be useful for one to know the microbiologic agent of infection and to treat it before the tuboplasty. By laparoscopy, a search for Chlamydia trachomatis, Ureaplasma urealyticum, and other microbiologic agents was carried out in the peritoneum and tubes of 118 women divided into 3 groups. Sixty-nine had a checkup before tuboplasty, of which 30 were found to have a chronic inflammatory condition discovered during laparoscopy (group 1) and 39 to have no sign of inflammation (group 2). Forty-nine women with a completely normal pelvis, being followed for possible sterility, were used as a control group. Cultures and serodiagnosis show a significant difference for C. trachomatis between the pathologic groups and the control group. They show no noticeable difference for U. urealyticum. These findings, compared with those by other authors, indicate that C. trachomatis could be an important microbiologic agent in tubal sterility, strongly connected with a low-grade chronic inflammatory condition, and their presence at the time of tuboplasty is to be considered.

Microbiology of specimens obtained by laparoscopy from controls and from patients with pelvic inflammatory disease or infertility with tubal obstruction: Chlamydia trachomatis and Ureaplasma urealyticum.

We cultured for Chlamydia trachomatis, Ureaplasma urealyticum, and Mycoplasma hominis and performed chlamydial serologic studies in 99 women undergoing laparoscopy. These women included patients with acute salpingitis, infertile women with and without mild pelvic inflammatory disease, and controls. C. trachomatis infection was significantly more common in patients than in controls. We also identified low-grade "silent" PID among women with infertility resulting from tubal obstruction and suggest this may be caused by chlamydiae.

[A microbiological study of swabs taken laparoscopically in cases of salpingitis and tubal sterility. Research for Chlamydia trachomatis and for mycoplasmas (author's transl)]. / Etude microbiologique des prélèvements coelioscopiques dans les annexites et les stérilités tubaires. Recherche de Chlamydia trachomatis et de mycoplasmes.

Research was made for chlamydia trachomatis and ureaplasma urealyticum in the peritoneum and the tubes of 99 women divided into 4 groups: 17 of them were being investigated because of acute salpingitis (Group A), 17 were being investigated for tubal sterility with chronic inflammation diagnosed laparoscopically (Group B), 29 were being investigated for tubal sterility without any laparoscopic evidence of inflammation (Group C) and 36 women had absolutely normal pelves and were being investigated for sterility. These were the control group (D). Swabs were also taken from the lower genital tracts as well as serological tests for chlamydia trachomatis and cytological samplings of the fluid from the Pouch of Douglas and the histology of the tubes. In the 17 women who had acute salpingitis the swabs 4 cases of C.T. and 4 of U.U. In the 46 women who had tubal sterility the laparoscopic swabs showed cases of C.T. and 7 of U.U. The swabs were most often positive in Group B. This group is characterised by a special appearence of the inflammation, with fluid present and viscous adhesions as well as peritoneal inflammatory cysts. These altogether help to make a presumptive diagnosis of C.T. infection on laparoscopy. In the control group of 36 cases there was no sign of C.T. in any case, although 2 swabs from the peritoneum showed U.U. So there is a statistically significant difference between the groups that were suspicious and the control group whether the results were obtained by cultures or by serological diagnosis. On the other hand there is no definitive difference as far as U.U. is concerned. These observations, which are similar to those published by other authors, lead us to think that micro-organisms and especially chlamydia trachomatis could be the bacteriological agent responsible for chronic inflammatory states found so frequently in women with tubal sterility.

[Bacteriological cultures by laparoscopy in salpingitis (author's transl)]. / Etude bactériologique des prélèvements per-coelioscopiques dans les annexites aiguës. Flore aérobie-anaérobie.

Out of a series of 50 salpingitis, we have made bacteriological swabs of tubes and peritoneum in 37 cases (25 cases by laparoscopy and 2 cases by laparotomy). 27 women had received no antibiotic treatment before swabbing: bacteriological culture was positive in 14 cases and gram Stain positive in 15 cases: thus we had either a complete study, either a "good idea" of pathological flora in 20 cases out of 27. 10 women received some antibiotic treatment before swabbing: bacteriological culture was positive in 2 cases, gram stain positive in 3 cases. We had idea of pathological flora in 4 cases out of 10. Tubal cultures show either a one-agent infection (gonococcus, E. Coli or anaerobic agent) either a various aero-anaerobic flora. In 18 cases we could compare abdominal flora and low genital tract flora: results were identical in half of cases only (7 cases on 18). Gonococcus was cultured either in women with P.I.D. either in their partner's genital tract, in 11 cases on 37. Both cultures and gram stain were negatives in 13 cases: in these cases, we could perhaps incriminate either a supplement requiring bacterie, either other micro-organisms (chlamydia trachomatis or Mycoplasma) which will be studied in a further series (to be published).