What's new in: neurology

What is best preparation for removing ear wax?

QIs there any good evidence that a particular preparation is better than another for ear wax? Are any associated with more adverse effects (for example otitis externa is said to be caused by organic solvents)?

A There have been two recent systematic reviews on this topic. The bottom line is that, on current evidence, there is little to choose between different preparations for softening/removing ear wax. Most studies are not of high quality, and although the data on adverse effects is not reported consistently, these events are uncommon and not confined to one preparation in particular.

One of the reviews classified preparations into water-based (saline), oil-based (such as olive oil), and non-water non-oil based (such as Audax, Exterol, Otex) and performed meta-analyses.

There was some evidence that non-water non-oil based preparations may be more effective at clearing ear wax and facilitating successful ear syringing. But several days' treatment is required and the evidence to date is weak.

When it comes to syringing, most preparations achieve success rates of more than 90 per cent, but 75 per cent can be cleared using no preparation at all.

Applying a water-based or oil-based preparation 15 to 30 minutes before syringing is probably as effective as applying it for several days. Plain water may suffice.

Syringing ears takes up a lot of practice nurse time. More research is needed to see if non-water non-oil based preparations are more effective than simpler preparations.

Dr Christopher Hand is a GP and

honorary senior lecturer at the School of Medicine, Health Policy and Practice at

the University of East Anglia

No progestogen-only pill for raised lipids patients?

Q We have just had a letter from a specialist lipid clinic saying patients with raised lipids are not to have the progestogen-only pill, as it decreases high density lipoproteins (HDLs). The clinic recommended Ovysmen or Brevinor as these are better for their lipid profile. We find this strange advice, but is it correct?

A Progestogen-only methods of contraception (pills, injectables, implants and the levonorgestrel-releasing intrauterine system) have been shown to decrease HDL concentration. However, this appears to have no clinical effects.

The reduction in HDL concentration with levonorgestrel or norethisterone is reversed when

given in combination with oestrogen as combined oral contraception (COC).

Nevertheless, low-dose COC users (<50µg ethinylestradiol)="" had="" significantly="" lower="" hdl="" concentrations="" than="">

The highest HDL concentrations were in users of low-dose COCs containing norethisterone or desogestrel but this was not statistically significant compared with non users.

This may be the rationale for advising the use of COCs Ovysmen and Brevinor with 35µg ethinylestradiol and 0.5mg norethisterone.

The summary of product characteristics for Ovysmen and Brevinor advise caution. There is no randomised trial data comparing different COCs and their effects on HDL concentrations in women with or without hyperlipidaemia. The evidence to support the use of Brevinor or Ovysmen over other COCs is therefore indirect.

The World Health Organisation's Medical Eligibility Criteria for Contraceptive Use provides evidence-based recommendations for contraceptive use by women with specific medical conditions.

A WHO category 2 (benefits outweigh risks) or 3 (risks outweigh benefits) is given for hormonal contraceptive use by women with hyperlipidaemia.

Some hyperlipidaemias (familial combined hyperlipididaemia and familial hypercholesterolaemia)

are associated with vascular disease and would warrant a WHO

category 3.

The use of hormonal contraception (COC, progestogen-only pills, injectables or implants) to a woman with a condition classified as WHO 3 in general is not usually recommended unless other more appropriate methods are unacceptable.

The benefits of using a levonorgestrel-releasing intrauterine system outweigh the risks (WHO 2) and a copper intrauterine device has no restriction on its use by women with hyperlipidaemia (WHO 1).

For women with non-familial hyperlipidaemia progestogen-only methods are often considered first. Nevertheless, WHO supports the use of COC in the absence of multiple risk factors or co-existing disease.

Ms Gillian Stephen is researcher,

and Dr Susan Brechin is co-ordinator,

of the Faculty of Family Planning and Reproductive Healthcare Clinical Effectiveness Unit