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Research Article

In vitro comparison of three earwax removal formulations for the disintegration of earwax

[version 1; peer review: 1 approved with reservations, 1 not approved]
PUBLISHED 29 Nov 2016
Author details Author details
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Abstract

Introduction: Impacted cerumen is a widespread reason that patients visit their health care providers. It effects approximately 2-6% of the general population and disproportionately impacts up to 65% of patients over 65. This study compared a new cerumen (earwax) removal product (Solution 1; EOS-002; a glycolic acid/bicarbonate formulation) versus two commercially available products (Solution 2 and Solution 3; both containing carbamide peroxide 6.5%) for their cerumenolytic activity in vitroMethods: Samples of human cerumen were placed in 10 x 75 mm polypropylene test tubes. Approximately 1 mL of each test solution was added and incubated at room temperature for 30 minutes. The vials were shaken at the 15- and 30-minute time points to simulate rinsing in a clinical setting. Breakdown of the cerumen was graded at 5-, 10-, 15-, and 30-minute time points in a masked manner on a 5-point scale (Grade 0 = no change; Grade 4 = complete disintegration). Results: Significantly greater disintegration of the cerumen was observed in the samples exposed to EOS-002 at every time point (P < 0.0001). At 5 minutes, disintegration was observed in 39 out of 43 samples exposed to EOS-002, 0 out of 24 samples exposed to Solution 2, and 1 out of 19 samples exposed to Solution 3. Mean disintegration scores at 5, 10, 15, and 30 minutes were 1.65, 2.38, 2.95, and 3.24 for EOS-002; 0, 0, 0, and 0.2 for Solution 2; and 0.05, 0.13, 0.16, and 0.21 for Solution 3, respectively. Discussion: EOS-002 exhibited a significantly greater ability to breakdown cerumen than the two other products. Disintegration of cerumen occurred with EOS-002 within 5 minutes in 91% (39/43) of the samples. Therefore, EOS-002 provides rapid disintegration of human cerumen in vitro.

Keywords

Earwax, Cerumen, Cerumenolytic, Cerumen impaction

Introduction

The excess accumulation of cerumen (earwax) is a common cause for patients to seek treatment by a general physician, family physician, or otolaryngologist1. At least 8 million ear irrigations are performed each year for this condition2. Cerumen impaction is estimated to affect between 2 and 6% of the general population in the United States. As many as 65% of individuals over 65 years of age and up to 36% of those with mental retardation experience cerumen impactions25.

Cerumen impaction has important clinical implications in terms of the general well-being of patients and may be associated with temporary hearing loss, pain, itching, tinnitus, external otitis, vertigo, and even chronic cough5. Cerumen impaction can temporarily decrease hearing acuity by as much as 45 dB6. For the elderly, this hearing impairment can have a negative impact on quality of life by causing difficulties with communication, cognition, social isolation, anxiety, depression, and even physical mobility1,7,8. All too often, decreased hearing with advancing age, either gradual or acute, is perceived by the patients and/or their caregivers as a natural, almost expected, phenomenon, which does not warrant intervention1. However, studies have shown that hearing is significantly improved following the removal of impacted cerumen4,9.

There are currently several commercially available cerumen removal products. These products include oil-based (e.g., almond oil), water-based (e.g., acetic acid), and non-water, and non-oil-based (e.g., propylene glycol) preparations10. Unfortunately, these preparations are minimally effective at disintegrating cerumen impactions and often require multiple doses per day over several days to achieve satisfactory results11,12.

None of the agents that are currently available has shown a clear advantage in terms of efficacy in removing cerumen2,10,13,14. Previous studies have found that these products are often less effective or no better than deionized water12,15. Moreover, they typically clear cerumen less than half of the time10,16. Systemic reviews have found no topical cerumenolytic clearly superior to any other or to saline or sterile water10,13,14.

These results have prompted the search for a better cerumenolytic agent, and we have identified ingredients that could quickly, effectively, and safely breakdown or dissolve human cerumen when combined. Consequently, a new product has been developed, which benefits from a dual-action mechanism for breaking down human cerumen. The current study compared the new cerumen removal product (EOS-002) with two commercially available products for their ability to breakdown or disintegrate samples of human cerumen in vitro.

Methods

Institutional Board Approval of the University of North Texas Health Science Center (UNTHSC) and patient informed consent were obtained prior to commencement of this study.

Human cerumen samples (approximately 30 to 50 μg each) were placed in 10 x 75 mm polypropylene test tubes at room temperature. The samples were taken without restriction in terms of patient characteristics. The physician utilized a curette to remove the cerumen from the subjects outer ear canal. The samples were placed in small plastic storage tubes with lids, labeled with date of extraction along with a general description of the physical characteristics (dry, wet or mixed). The samples were required to be at least 30 μg in size. Approximately 1 mL of each test solution was added to each test tube, and the samples were incubated at room temperature for 30 minutes, with grading recorded at 5, 10, 15 and 30 minutes. Photographs were taken for representative samples at 2.5-minute intervals. Each comparison for each time point was performed in replicate tubes (n = 24 or 19). The sample size was driven by the availability of subjects willing to participate in the collection trial. A total of 86 cerumen samples were available during the duration of the testing. The comparative products were used as controls, as these products are well recognized by physicians and consumers.

The samples were graded at 5 minute and 10 minute time points, without moving the tubes. However, the test tubes were shaken at the 15 minute and 30 minute time points to simulate the rinse procedure that would normally occur in the clinical use setting.

The test solutions were as follows:

  • Solution 1 - Glycolic acid/bicarbonate formulation (EOS-002; Eosera Inc., Fort Worth, TX; 2016)

  • Solution 2 - Carbamide peroxide 6.5% (Debrox, Prestige Brands, Tarrytown, NY; 2016)

  • Solution 3 - Carbamide peroxide 6.5% (Murine Earwax Removal System, Prestige Brands, Tarrytown, NY; 2016)17

A grader (affiliated with the sponsor company) was blinded as to the identity of the test solutions assessed the disintegration (breakdown) of cerumen at 5, 10, 15, and 30 minutes. A 5-point disintegration grading scale was developed for assessing the effects of different formulations on human cerumen (Table 1). This grading scale was adapted from those of Jimenez et al.18 and Fraser19.

Table 1. Cerumen disintegration scale.

Adapted from Jimenez et al., 200818 and Fraser, 197019.

GradeDescription
Grade 0No change in wax appearance
Grade 1Slight disintegration
Swelling and/or minor changes in
appearance, small fragment disruption
Grade 2Moderate disintegration
Moderate swelling and/or moderate disruption
Grade 3Substantial disintegration
Substantial swelling and/or disruption
Grade 4Complete disintegration
Major swelling and/or disruption

Means and standard deviations were calculated for each treatment group at the 5, 10, 15, and 30 minute time points. Between-group comparisons were performed using Student’s t test. A P value of ≤ 0.05 denoted a statistically significant difference between treatment groups. Statistical analysis was conducted with Microsoft Excel for Mac 2011, version 14.6.0.

Results

For the comparison between EOS-002 and Solution 2, 24 samples each were available for each time point. The time course found significant differences between EOS-002 and Solution 2 (P < 0.0001) in grading scores at all time points (5 min, 10 min, 15 min, and 30 min) (Figure 1). The mean disintegration scores at 5 minutes were 1.63 ± 0.7 for EOS-002 and 0 ± 0 for Solution 2. No sample out of the 24 samples in the Solution 2 group had a score above 0 at 5 minutes compared with 24 out of 24 for EOS-002 (range 1 to 3).

e3656a54-f56e-4150-8961-799fce6080b5_figure1.gif

Figure 1. Time course of cerumen incubations with EOS-002 (n = 24) and Solution 2 (n = 24) showing disintegration scores.

All incubations were performed at room temperature. *P < 0.0001.

Product and timeDebrox 5 minEOS-002 5minDebrox 10 minEOS-002 10 minDebrox 15 minEOS-002 15 minDebrox 30 minEOS-002 30 min
Sample 10202.50404
Sample 203040404
Sample 303040404
Sample 403040404
Sample 501.502.50404
Sample 60101.502.503.5
Sample 702.5040404
Sample 80203.50404
Sample 90102.502.513.5
Sample 100101.50202
Sample 110101.501.502
Sample 12010101.501.5
Sample 130101.501.502
Sample 1401.501.502.503
Sample 1501.501.501.502.5
Sample 160202.502.503
Sample 170202.503.504
Sample 18010101.502
Sample 1901.50203.503.5
Sample 2001.5020303.5
Sample 2101.501.50303
Sample 2201030303
Sample 2301.50203.504
Sample 240101.502.502.5
sample sizen=24n=24
mean01.6302.2902.90.043.19
stdev00.701010.20.8
t-test1.06E-153.01E-151.81E-199.37E-23
Summary of Means/stdev
5 minute10 minute15 minute 30 minute
Debrox0000.04
Earwax MD1.632.292.93.19
Debrox stdev0000.2
Dataset 1.Raw data for Figure 1.
EOS-002 vs Solution 2

For the evaluations of EOS-002 and Solution 3, 19 samples each were available for each time point. Similarly, the time course demonstrated significant differences between EOS-002 and Solution 3 (P < 0.0001) in grading scores at all time points (Figure 2). The mean disintegration scores at 5 minutes were 1.68 ± 1.0 for EOS-002 and 0.05 ± 0.2 for Solution 2. Only 1 out of 19 samples in the Solution 2 group had a score above 0 (1) at 5 minutes, compared with 16 out of 19 samples for EOS-002 (range 0 to 3).

e3656a54-f56e-4150-8961-799fce6080b5_figure2.gif

Figure 2. Time course of cerumen incubations with EOS-002 (n = 19) and Solution 3 (n = 19) showing disintegration scores.

All incubations were performed at room temperature. *P < 0.0001.

Product and timeMurine 5 minEOS-002 5minMurine 10 minEOS-002 10 minMurine 15 minEOS-002 15 minMurine 30 minEOS-002 30 min
Sample 101.5020303
Sample 20202.50404
Sample 303040404
Sample 40312.51414
Sample 501.501.50202
Sample 601.5020303
Sample 701.5030304
Sample 801.5040404
Sample 903030304
Sample 1003030404
Sample 1102040404
Sample 1202040404
Sample 1302030303.5
Sample 1400010102
Sample 1502.5040404
Sample 16000101.502
Sample 17101.5021.531.5
Sample 180101.50203
Sample 190101.502.503
sample sizen=19n=19
mean0.051.680.132.500.163.030.213.32
stdev0.21.00.41.20.51.00.70.9
t-test1.616E-086.74294E-102.3025E-131.76122E-14
Summary of means and stdev5 minute10 minute15 minute 30 minute
Murine0.050.130.160.21
Earwax MD1.682.53.033.32
Murine STDEV0.20.40.50.7
Dataset 2.Raw data for Figure 2.
EOS-002 vs Solution 3

When the data for both comparisons were combined, the mean disintegration scores at 10 minutes were 2.38 ± 1.1 for the EOS-002-treated samples and 0.06 ± 0.3 for the carbamide peroxide 6.5%-treated samples (n = 43 for both groups; Figure 3). As expected, all time points showed significant differences in favor of EOS-002 in terms of the disintegration scores.

e3656a54-f56e-4150-8961-799fce6080b5_figure3.gif

Figure 3. Time course of all cerumen incubations with EOS-002 (n = 42) and carbamide peroxide (n = 42) showing disintegration scores.

All performed were conducted at room temperature. *P < 0.0001.

Product and timeDebrox + Murine Ear 5 minEOS-002 5minDebrox + Murine Ear 10 minEOS-002 10 minDebrox + Murine Ear 15 minEOS-002 15 minDebrox + Murine Ear 30 minEOS-002 30 min
Sample 10202.50404
Sample 203040404
Sample 303040404
Sample 403040404
Sample 501.502.50404
Sample 60101.502.503.5
Sample 702.5040404
Sample 80203.50404
Sample 90102.502.513.5
Sample 100101.50202
Sample 110101.501.502
Sample 12010101.501.5
Sample 130101.501.502
Sample 1401.501.502.503
Sample 1501.501.501.502.5
Sample 160202.502.503
Sample 170202.503.504
Sample 18010101.502
Sample 1901.50203.503.5
Sample 2001.5020303.5
Sample 2101.501.50303
Sample 2201030303
Sample 2301.50203.504
Sample 240101.502.502.5
Sample 2501.5020303
Sample 260202.50404
Sample 2703040404
Sample 280312.51414
Sample 2901.501.50202
Sample 3001.5020303
Sample 3101.5030304
Sample 3201.5040404
Sample 3303030304
Sample 3403030404
Sample 3502040404
Sample 3602040404
Sample 3702030303.5
Sample 3800010102
Sample 3902.5040404
Sample 40000101.502
Sample 41101.5021.531.5
Sample 420101.50203
Sample 430101.502.503
sample sizen=43n=43
5min5 min10 min10 min15 min15 min30 min30 min
mean0.021.650.062.380.072.950.123.24
stdev0.20.80.31.10.310.50.8
t-test1.01E-212.64E-232.13E-311.83E-35
Summary of means and stdev5 min10 min15 min30 min
Debrox or Murine Ear (n=43)0.020.060.070.12
Earwax MD (n=42)1.652.382.953.24
Competition STDEV0.20.30.30.5
Dataset 3.Raw data for Figure 3.
EOS-002 vs combined data from Solutions 2 & 3

For the comparison between EOS-002 and Solution 2, the cerumen samples started to swell and disintegrate within 2.5 minutes of exposure to EOS-002 (Figure 4). At 15 minutes, these samples were noticeable disrupted and dispersed compared with their appearance prior to treatment. However, after 15 minutes of exposure to Solution 2, there was no discernable change to the samples.

e3656a54-f56e-4150-8961-799fce6080b5_figure4.gif

Figure 4. Photos of representative cerumen samples incubated in EOS-002 and Solution 2 for up to 15 minutes.

All incubations were performed at room temperature.

As with the above experiments, for the evaluations of EOS-002 and Solution 3, within 2.5 minutes of exposure to EOS-002, the cerumen samples started to swell and disintegrate (Figure 5). At 15 minutes, the EOS-002 sample was noticeable disrupted and dispersed compared with its appearance before treatment. However, after 15 minutes of exposure to Solution 3, there was little to no change to the sample.

e3656a54-f56e-4150-8961-799fce6080b5_figure5.gif

Figure 5. Photos of representative cerumen samples incubated in EOS-002 and Solution 3 for up to 15 minutes.

All incubations were performed at room temperature.

Discussion

Both photographic records and the time course studies for disintegration scores demonstrated that EOS-002 was effective at quickly breaking down human cerumen under room temperature conditions. Samples incubated in EOS-002 demonstrated significantly higher disintegration scores than the two comparators at every time point measured (P < 0.0001). From the photographic studies, differences between EOS-002 and the other two products could be seen within 2.5 minutes. Differences in disintegration scores were also observed within 5 minutes (the earliest graded time point). Only a small amount of disintegration was observed for the samples exposed to the 2 products containing carbamide peroxide 6.5%, even after 30 minutes.

An in vitro study, conducted by Saxby et al.15, evaluated the cerumenolytic activity of 6 different preparations (distilled water; olive oil; sodium bicarbonate 5%, dexamethasone 0.05% + framycetin sulphate 0.5% + gramicidin 0.005% [Sofradex, Sanofi-Aventis, Guildford, UK]; urea + hydrogen peroxide 5% in glycerol; and bethamethasone sodium phosphate 0.1% [Vistamethasone, Cardinal Health Martindale Products, Brentwood, UK]). Each cerumen sample (5 mm in diameter and 3 mm thick) was placed into a test tube that contained 5 mL of one of the test solutions and allowed to incubate at room temperature. At 30 minutes of exposure, the aqueous-based solutions had caused a slight amount of disintegration, while the oil-based solutions (olive oil or urea + hydrogen peroxide) produced no visible change to the cerumen samples (Table 2). Distilled water and sodium bicarbonate 5% produced the greatest amounts of disintegration. It should be noted that it might not be feasible for a patient to treat their ears with a cerumenolytic for 30 minutes prior to irrigation. The current study suggests substantial disintegration of cerumen might be possible in as little as 5 minutes of exposure with the novel glycolic acid/bicarbonate formulation.

Table 2. Comparison of cerumen disintegration in vitro under different conditions.

1Grading scale adapted from Fraser et al., 1970, and Jimenez et al., 2008. Grade 0 = no change; Grade 1 = slight disintegration; Grade 2 = moderate disintegration; Grade 3 = substantial disintegration; Grade 4 = complete disintegration.

2 – = no visible change; + = slight disintegration; ++ = partial disintegration; +++ = substantial disintegration.

3 – = no visible change; + = coloration of the agent; ++ = slight disintegration; +++ = partial disintegration; ++++ = substantial disintegration; +++++ = complete disintegration.

4 – = no visible change; + = slight solvent effect; ++ = partial disintegration; +++ = complete disintegration.

Min = minutes; h = hours; d = days

5 min10 min15 min30 min1 h2 h3 h12 h3 d
Current study1,2 (Performed in test tubes at room temperature)
EOS-0021.652.382.953.24
Carbamide peroxide 6.5%0.020.060.070.12
Saxby et al., 20132 (Performed in centrifuge tubes at room temperature)
Distilled water++++++
Olive oil---
Sodium bicarbonate++++++
Dexamethasone 0.05%/framycetin
sulphate 0.5%/gramicidin 0.005%
+++++
Urea + hydrogen peroxide---
Betamethasone sodium phosphate
0.1%
+++++
Bellini et al., 19893 (Performed in centrifuge tubes at 36.4°C)
Arachis oil base containing 10 %
oil of terebinth (turpentine) and
dichlorobenzene, chlorbutol, and
benzocaine
-+++
Dioctyl sodium sulphosuccinate+++++++++++++++
Earex-+++
Stores Own+++++++++++++
Olive oil-+++
Water+++++++++++++++
Bicarbonate+++++++
Bellini et al., 19893 (Performed in pasteur pipettes at 36.4°C)
Arachis oil base containing 10 %
oil of terebinth (turpentine) and
dichlorobenzene, chlorbutol, and
benzocaine
--++
Dioctyl sodium sulphosuccinate+++++++++++++++++
Earex--++
Acetone---+
Olive oil++++
Water++++++++++++++++
Water (2)++++++++++++++
Bicarbonate++++++++
Fraser et al., 19704 (Performed in test tubes at 37°C)
Arachis oil base containing 10 %
oil of terebinth (turpentine) and
dichlorobenzene, chlorbutol, and
benzocaine
---
Dioctyl sodium sulphosuccinate-++++
Olive oil---
Sodium bicarbonate--+++
Triethanolamine polypeptide
oleate 10% in propylene glycol
--++
Dioctyl sodium sulphosuccinate in a
corn oil base (ear capsules)
---

Bellini et al.20 performed an in vitro study on eight different preparations (Waxsol, dioctyl sodium sulphosuccinate 0.5% in a water-miscible base; Cerumol, paradichlorobenzene 2%, chlorbutol 5%, and turpentine oil 10%; Earex, arachis oil 33.3% v/v, almond oil 33.3% v/v, rectified camphor oil 33.3% v/v; dioctyl sodium sulpho-succinate 5% w/v; olive oil; sodium bicarbonate; distilled water; and acetone). The tubes containing the samples (40 mg) and test solutions (0.5 mL) were incubated at 36.4˚C for up to 2 hours in either pasteur pipettes (Series 1) or plastic centrifuge tubes (Series 2) (Table 2). Bellini and colleagues found a modest amount of cerumenolytic activity with sodium bicarbonate, a component of the EOS-002 formulation. No changes were observed at 15 minutes for Earex and the preparations containing arachis oil, and olive oil. Conversely, the present study found moderate to substantial disintegration of cerumen with EOS-002 at 15 minutes at room temperature. One might expect even more rapid disintegration with this formulation at body temperatures.

Fraser and colleagues19 also conducted their studies of different cerumenolytic preparations in test tubes incubated at 37˚C for up to 3 days. Interestingly, they found no visible change with any of the preparations at 15 minutes (Table 2). Contrast this with the cerumen samples in the current study exposed to EOS-002, which showed observable disintegration within 5 minutes.

Another in vitro study, by Uppal et al.21 compared 5 ear drop formulations (5% NaHCO3, 3% H2O2, dexamethasone sodium metasulphobenzoate 0.05%, framycetin sulphate 0.5%, gramicidin 0.005%), 0.33% acetic acid and 0.9% NaCl) for clearing grommets blocked with freshly harvested thick middle ear effusion fluid. These grommets were housed in models of the ear canal constructed using 2 mL syringes. In the intervention groups five drops of each formulation were instilled into each syringe 3 times a day for a total of 7 days. The number of grommets cleared ranged from 1.3% (no drops) to 36.7% (29/79; 5% NaHCO3). Acetic acid 0.33% produced clearing in 27.2% (22/81) of the grommets. The glycolic acid/bicarbonate formulation of EOS-002 has similar but enhanced characteristics compared with some of the most effective eardrops tested in the Uppal et al. study21.

Another in vitro study evaluated a liquid enzyme-based cerumenolytic formulation18. Samples of cerumen (30 mg) were incubated in glass test tubes at 37˚C without agitation. After 5 minutes of exposure, there was evidence of disintegration with the enzyme-based formulation. However, at 30 minutes, there was almost no qualitative change in the samples exposed to the commercial formulations, one of which was the same product as Solution 3 in the current study. The results of the current study corroborate this previous observation. Little change to the samples were observed after 15 minutes with Solution 3.

It is proposed that EOS-002 uses a dual-action mechanism to disintegrate human cerumen. Wax ester and fatty acid lipid components of the cerumen are disrupted by the bicarbonate system of the formulation22,23. This system breaks carboxylic acids down to their more water-soluble carboxylate salts. The glycolic acid system of the product chelates calcium ions from the calcium-dependent cell adhesion molecules resulting in the disruption of cadhedrins, which allows the cells of the keratin sheet to break apart24,25. It is feasible that the glycolic acid also works in conjunction with a osmolarity variance between the formulation and the keratinocytes, leading to an influx of water into the cells leading to swelling and disruption of the wax mass26.

The current study is limited by its in vitro design. The incubations were conducted at room temperature and results could vary at body temperatures in vivo. These results should be confirmed in a prospective randomized clinical study.

Overall, evidence from the literature suggests aqueous preparations are better for disrupting human cerumen than oil-based preparations15,19,20. Furthermore, bicarbonate formulations have demonstrated efficacy for causing the disintegration of cerumen in vitro. Another study showed that an acidic preparation had moderate efficacy in breaking down cerumen in vitro21. These findings support the results of the current study, which demonstrated the rapid disintegration of cerumen in sample exposed to EOS-002 comprising a glycolic acid/bicarbonate formulation. Conversely, two commercially available products, both containing carbamide peroxide 6.5%, had minimal effects on the cerumen samples. The in vitro results with EOS-002 are promising. A small exploratory study in humans has recently been performed, which demonstrated efficacy of the product in disintegrating cerumen, in order to aid in the removal of impactions (unpublished study; Fullington, D, Song, J, Gilles, A, Guo, X, Hua, W, Anderson, C, Griffin, J).

Data availability

Dataset 1: Raw data for Figure 1. EOS-002 vs Solution 2. DOI, 10.5256/f1000research.10279.d14437327.

Dataset 2: Raw data for Figure 2. EOS-002 vs Solution 3. DOI, 10.5256/f1000research.10279.d14437428.

Dataset 3: Raw data for Figure 3. EOS-002 vs combined data from Solutions 2 & 3. DOI, 10.5256/f1000research.10279.d14437529.

Ethics statement

Institutional Board Approval of the University of North Texas Health Science Center (UNTHSC IRB Project # 2015-114) and patient informed consent were obtained prior to commencement of this study.

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Knebl J, Harty B, Anderson CE et al. In vitro comparison of three earwax removal formulations for the disintegration of earwax [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2016, 5:2784 (https://doi.org/10.12688/f1000research.10279.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
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Cite
Reviewer Report 15 Jun 2017
Carlotta Pipolo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy 
Not Approved
VIEWS 43
Persistence of Earwax during otoscopy still represents a challenge especially for paediatricians and general practitioners during diagnosis. Finding appropriate and efficacious solutions that can make removal easier is surely very important.

The article by Knebl et al ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Pipolo C. Reviewer Report For: In vitro comparison of three earwax removal formulations for the disintegration of earwax [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2016, 5:2784 (https://doi.org/10.5256/f1000research.11070.r23502)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 29 Apr 2025
    Joe Griffin, Eosera, Inc., Fort Worth, USA
    29 Apr 2025
    Author Response
    Reviewer 1 Responses: (Yehudah Roth)
    Comment 1: The test reported is of very simple methodology, of preliminary and partial nature, compared with other, similar in-vitro studied that are cited by the authors. There ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 29 Apr 2025
    Joe Griffin, Eosera, Inc., Fort Worth, USA
    29 Apr 2025
    Author Response
    Reviewer 1 Responses: (Yehudah Roth)
    Comment 1: The test reported is of very simple methodology, of preliminary and partial nature, compared with other, similar in-vitro studied that are cited by the authors. There ... Continue reading
Views
48
Cite
Reviewer Report 11 Jan 2017
Yehudah Roth, Department of Otolaryngology-Head and Neck Surgery, The Edith Wolfson Medical Center, Tel-Aviv University Sackler School of Medicine, Holon, Israel 
Approved with Reservations
VIEWS 48
This is a brief report on an in-vitro assessment which may or may not be applicable to earwax removal, hence the title is somewhat misleading.

The test reported is of very simple methodology, of preliminary and partial ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Roth Y. Reviewer Report For: In vitro comparison of three earwax removal formulations for the disintegration of earwax [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2016, 5:2784 (https://doi.org/10.5256/f1000research.11070.r19185)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 29 Apr 2025
    Joe Griffin, Eosera, Inc., Fort Worth, USA
    29 Apr 2025
    Author Response
    Reviewer 1 Responses: (Yehudah Roth)
    Comment 1: The test reported is of very simple methodology, of preliminary and partial nature, compared with other, similar in-vitro studied that are cited by the authors. There ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 29 Apr 2025
    Joe Griffin, Eosera, Inc., Fort Worth, USA
    29 Apr 2025
    Author Response
    Reviewer 1 Responses: (Yehudah Roth)
    Comment 1: The test reported is of very simple methodology, of preliminary and partial nature, compared with other, similar in-vitro studied that are cited by the authors. There ... Continue reading

Comments on this article Comments (0)

Version 2
VERSION 2 PUBLISHED 29 Nov 2016
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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