Hearing Loss and Its Most Common Drug List

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Hearing Loss and Its Most Common Drug List

Introduction

Hearing is a gift to living beings to enjoy the various sounds of nature, the chirping of birds, sounds of water fall and the music of your loved one’s heart beat. Ears are our music box that help us in hearing. Any damage to these auditory organs can deprive us of the joys of hearing.

Hearing loss is a condition in which a person is unable to listen to sounds of 25 dB or better in one ear or both. Such people cannot enjoy the sounds of nature or a conversation like a person with normal hearing. Profound hearing loss leads to deafness, in which a person has very little or no hearing.

‘Hard of hearing’ is a phrase that is used for people who have mild to moderate hearing difficulties and these people can benefit with the use of hearing aids and implants. On the other hand, disabling hearing loss occurs when a person cannot hear

The condition of hearing loss can either be temporary or permanent. Although hearing loss develops gradually with age, it can also be sudden. We can blame our modern lifestyle to some extent for making this condition increasingly common. Increased use of earphones and exposure to loud noises for a prolonged period of time are some of the main causes of development of hearing problems in the people. Those who are living in the city have more chances of developing hearing difficulties than people who live in the serene country.

Symptoms of Hearing Loss

Hearing loss generally happens over time and it is difficult to determine it. However, like any other condition there are some signs and symptoms of hearing disability we just have be aware of them and these are:

  • Trouble in hearing to other people
  • Difficulty in understanding what the other person is saying, especially when in noisy places
  • Repeatedly asking people to restate themselves
  • Loudly listening to television or radio
  • Need to concentrate more while conversing to understand other people
  • Difficulty in keeping up with a conversation

It is possible to develop hearing loss only in one ear. Given below are the signs and symptoms of hearing loss occurring in one ear:

  • Difficulty in hearing when sound comes from one side
  • All sounds seem quieter
  • Difficulty in pointing out the direction of sound
  • Trouble in distinguishing among sounds
  • Speech appears unclear
  • Trouble in hearing when in noisy places or while talking over long distances

Hearing loss in adults is much easier to diagnose than in children. Parents should look out for following signs in their children to determine whether they have any hearing difficulty:

  • Slow in learning to talk
  • Unclear speech
  • Do not respond when called
  • Talk very loudly
  • Repeatedly ask to repeat sentences
  • Respond inappropriately to questions
  • Listen to television or radio at high volumes

Babies undergo hearing test in the few weeks of their birth and any problem in hearing is diagnosed during this check-up. However, parents should be careful and look out for hearing difficulty signs and symptoms in their babies:

  • No startling to loud noises
  • Seem to hear some noises but not all
  • Respond only when they see you and not when called upon
  • Do not turn towards sound by the time they reach 4 months
  • Do not recognize any words till 15 months old

Treatment of Hearing Loss

Hearing loss can be sensorineural, conductive or mixed. In sensorineural type of hearing loss, there is difficulty in the transmission or generation of nerve impulse to the ear. Conductive hearing loss occurs when there is some mechanical problem in the conduction of sound waves. When a combination of sensorineural and conductive hearing loss occurs, it is called mixed type of hearing loss.

Only conductive hearing loss caused due to accumulation of ear wax or infection can be treated with the help of medicines. For all other types of hearing loss, hearing aids and implants are required, which can be fitted surgically or non-surgically.

a. Treatment of Conductive Hearing Loss

Treatment of any disease is based on alleviating its cause. Conductive hearing loss is caused either due to congenital malformation of the ear or due to any disease in the ear. Congenital absence, dysfunction or malformation of ear structures like those of middle ear and internal ear. Ear diseases that result in hearing loss include infections and tumors. Eustachian tube, a canal that joins middle ear with nasopharynx, can become dysfunctional or a foreign object can become lodged in the ear canal or a trauma to the head or ear can also result in conductive hearing loss. It is generally temporary in nature and can be reversed, especially if it is being caused due to infection.

Infections can be acute or chronic. Acute infections can be treated with antibiotics or anti fungal medicines depending on the causative organism. However, in case of chronic infection, if medicines fail to provide any relief, surgical treatment can be an option.

Conductive hearing loss occurring due to head trauma in which the middle ear structures are damaged, can be treated with the help of surgery. When conductive hearing loss occurs due to genetic disorder in which the bones of middle ears are malformed, it gives rise to a condition known as otosclerosis. This situation can be treated by the help of surgery. Some studies show that exposure to measles virus in the womb can increase a genetically predisposed baby’s chances of developing otosclerosis.

Some of the commonly seen ear infections that can give rise to hearing loss are as follows:

(i) Otitis externa, a condition in which there is inflammation or infection of the ear canal.
(ii) Otitis media, a group of inflammatory diseases affecting the middle ear
(iii) Viral infection
(iv) Ear wax accumulation
(v) Fluid retention

Drugs used for treating conductive hearing loss arising due to the above mentioned reasons are as follows:

A. Antibiotics

Antibiotics are the drugs that are used for killing or inhibiting the growth of bacteria. The following classes of antibiotics are used for treating otitis media and otitis externa:

1. Fluoroquinolones

These are the drugs that stop multiplication of bacteria by binding with their genetic material. Drugs belonging to this class are:

  • Generic Name: ciprofloxacin hydrochloride
    Brand Name: Cetraxal
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Ear drops
    Indicated in Pregnancy: No
    Alcohol Content: Absent
    Side Effects: Itching or pain after use, fussiness or irritability, stuffy nose, headache and sore throat
  • Generic Name: ofloxacin
    Brand Name: Ofloxacin
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Ear drops
    Indicated in Pregnancy: Not assigned
    Alcohol Content: Absent
    Side Effects: Dizziness, ringing in ear, fever, stuffy nose and sore throat
  • Generic Name: finafloxacin
    Brand Name: Xtoro
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Suspension for ear
    Indicated in Pregnancy: No
    Alcohol Content: Traces
    Side Effects: Itching of ear, nausea, cough, skin rash and dizziness

2. Penicillin-like antibiotics

Penicillin is the first antibiotic discovered and belongs to beta-lactams family of antibiotics. There are a number of medicines that belong to this group and follow the same mechanism. These medicines inhibit the synthesis of cell wall which inhibits cell division. Eventually, the weak cell wall ruptures and the bacteria is killed.

  • Generic Name: amoxicillin
    Brand Name: Amoxil
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Capsule
    Indicated in Pregnancy: No, unless benefit outweighs
    Alcohol Content:
    Side Effects:

3. Cephalosporins

These medicines are bactericidal in nature. They disrupt the cell wall synthesis of bacteria and with a compromised cell wall, the bacteria die.

  • Generic Name: cefdinir
    Brand Name: Cefdinir
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Capsule
    Indicated in Pregnancy: No, unless benefit outweighs risk
    Alcohol Content: Absent
    Side Effects: Diarrhea, chills, swollen glands and sore throat
  • Generic Name: cefixime
    Brand Name: Suprax
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Tablet
    Indicated in Pregnancy: No, unless benefit outweighs risk
    Alcohol Content: Absent
    Side Effects: Diarrhea, Loose or frequent stools, chills, stomach pain and headache
  • Generic Name: cefuroxime
    Brand Name: Ceftin
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Tablet
    Indicated in Pregnancy: No, unless benefit outweighs risk
    Alcohol Content: Absent
    Side Effects: Chills, diarrhea, sweating, headache, fever and itching in genital area
  • Generic Name: cefpodoxime proxetil
    Brand Name: Cefpodoxime proxetil
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Tablet
    Indicated in Pregnancy: No, unless benefit outweighs risk
    Alcohol Content: Absent
    Side Effects: Abdominal pain, diarrhea, nausea, vomiting and cough

4. Macrolides

These are a class of antibiotics that arrest the synthesis of proteins in bacteria, due to which the bacteria get killed.

  • Generic Name: azithromycin
    Brand Name: Zithromax
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Tablet
    Indicated in Pregnancy: No, unless benefit outweighs risk
    Alcohol Content: Absent
    Side Effects: Diarrhea/loose stools, abdominal pain, nausea and vomiting
  • Generic Name: clarithromycin
    Brand Name: Biaxin
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Tablet
    Indicated in Pregnancy: No, unless benefit outweighs risk
    Alcohol Content: Absent
    Side Effects: Abnormal taste, diarrhea, vomiting, rash, headache and abdominal pain.
  • Generic Name: erythromycin
    Brand Name: Eryc
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Capsule
    Indicated in Pregnancy: No, unless benefit outweighs risk
    Alcohol Content: Absent
    Side Effects: Diarrhea, dizziness, chills, cough, sore throat and wheezing

5. Sulfonamide

These are the antibiotics that disrupt the synthesis of folic acid in the bacteria in the absence of which they cannot divide and multiply. They are bacteriostatic in nature because they arrest the growth of bacteria.

  • Generic Name: sulfisoxazole
    Brand Name: Sulsoxin
    U.S. FDA Status: Discontinued
    Dosage Form: Tablet
    Indicated in Pregnancy: No, unless benefit outweighs risk
    Alcohol Content: Absent
    Side Effects: Anxiety, chills, confusion, dizziness and headache

6. Bactrim

Bactrim refers to a combination of two antibiotics, sulfamethoxazole and trimethoprim. These antibiotics complement each other’s actions. Sulfamethoxazole disrupts the synthesis of folic acid in the bacteria which arrests its growth. Trimethoprim interferes with the synthesis of genetic material in the bacterium and kills it.

  • Generic Name: sulfamethoxazole and trimethoprim
    Brand Name: Bactrim
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Tablet
    Indicated in Pregnancy: No, unless benefit outweighs risk
    Alcohol Content: Absent
    Side Effects: Abdominal pain, chills, diarrhea, fever and headache

B. Anti-infective drugs

a. Acetic acid
Acetic acid has been long known to act as an anti-infective agent. It works by crossing the cell membrane and rupturing the bacterial call.

b. Chloroxylenol
It is another anti-infective that is used for treating mild infections of ear. It works by disrupting the cell wall and inhibiting the action of various cellular enzymes.

C. Local anesthetic

Ear infections can cause a lot of pain and to counteract it, local anesthetics are added to ear drops.

a. Benzocaine
Benzocaine is a common local anesthetic that is added in cough syrups as well as ear drops to counteract pain. It works by desensitizing the nerve endings at its place of application due to which a person is unable to feel the pain.

D. Anti- fungal

Sometimes, ear infections are caused by fungus and to cure it, anti-fungal medicines are used.

1. Azoles
Azoles are a class of anti-fungal drugs that are involved in curing fungal infections. They inhibit the synthesis of ergosterol in the fungal membrane due to which a faulty membrane is formed. This hinders the multiplication of fungus.

  • Generic Name: clotrimazole
    Brand Name: CLotrimazole
    U.S. FDA Status: Approved
    Availability: Prescription, OTC
    Dosage Form: Topical cream
    Indicated in Pregnancy: No, unless clearly needed
    Alcohol Content: Traces
    Side Effects: Skin rash, itching, burning, hives, redness, skin irritation and stinging

E. Topical Calcineurin Inhibitors

Although this class of drugs is used for suppressing the immune system as in case of organ transplantation, but tacrolimus has been shown to provide relief from eczema. Itchiness is a common problem in case of ear infections, which can be treated with the help of tacrolimus.

Tacrolimus is known to inhibit calcineurin which is an enzyme involved in activating the T-cells of the immune system. Tacrolimus can be used topically for decreasing the inflammatory response which will decrease itchiness.

  • Generic Name: tacrolimus
    Brand Name: Protopic
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Topical ointment
    Indicated in Pregnancy: No, unless benefit outweighs risks
    Alcohol Content: Traces
    Side Effects: Burning sensation of skin, fever, redness and nausea

F. Analgesics

Ear infection can be quite painful. If even after using ear drops there is no relief in pain, analgesics can be taken.

1. Non-steroidal Anti-inflammatory Drugs (NSAIDs)
This group of drugs block the synthesis and release of a chemical, known as prostaglandins. This chemical induces pain and inflammation. An enzyme called cyclooxygenase enzyme (COX) enzyme is required to produce prostaglandins. NSAIDs block COX enzyme and thus inhibit the release of prostaglandins. By doing so, it relieves the abdominal pain experienced in abdominal migraine.

  • Generic Name: aspirin
    Brand Name: Excedrin tablet
    U.S. FDA Status: Approved
    Availability: Over-the-counter
    Dosage Form: Tablet
    Indicated in Pregnancy: Absolutely contraindicated in third trimester as it may affect the fetal cardiovascular system
    Alcohol Content: Absent
    Side Effects: Hives, itching, rash, upset stomach, coughing up blood, black, red or tarry stools, blood in urine
  • Generic Name: acetaminophen
    Brand Name: Tylenol
    U.S. FDA Status: Approved
    Availability: Over-the-counter
    Dosage Form: Tablet
    Indicated in Pregnancy: Only if absolutely indicated
    Alcohol Content: Absent
    Side Effects: Bloody or cloudy urine, black or tarry stools, hives, skin rash, sore fatigue
  • Generic Name: ibuprofen
    Brand Name: Motrin IB
    U.S. FDA Status: Approved
    Availability: Over-the-counter
    Dosage Form: Tablet
    Indicated in Pregnancy: Absolutely contraindicated in third trimester as it may affect the fetal cardiovascular system
    Alcohol Content: Absent
    Side Effects: Bloating, belching, acidity, cloudy urine, diarrhea, heartburn, decreased amount of urine
  • Generic Name: diclofenac
    Brand Name: Zorvolex
    U.S. FDA Status: Approved
    Availability: Prescription only
    Dosage Form: Capsule
    Indicated in Pregnancy: Absolutely contraindicated in third trimester as it may affect the fetal cardiovascular system
    Alcohol Content: Absent
    Side Effects: Bloating, cloudy urine, belching, constipation, dizziness

G. Steroids

Steroids are organic molecules that are known to perform a number of functions in the human body, anti-inflammatory being one of them. They can be prescribed to a person with otitis media or otitis externa for speedy recovery. They can be used alone or in combination with antibiotics for speedy recovery. They are even added to ear- drops for local and fast action.

  • Generic Name: hydrocortisone
    Brand Name: Hydrocortisone
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Tablet
    Indicated in Pregnancy: No, unless benefit outweighs risks
    Alcohol Content: Absent
    Side Effects: Irritation, acne, lightening of normal skin color, dryness and nausea
  • Generic Name: dexamethasone
    Brand Name: Dexamethasone
    U.S. FDA Status: Approved
    Availability: Prescription
    Dosage Form: Tablet
    Indicated in Pregnancy: No, unless benefit outweighs risks
    Alcohol Content: Absent
    Side Effects: Aggression, anxiety, headache, irritability, mood changes, depression and weight gain

H. Ear wax Dissolving Agents

Hearing loss can also be caused due to blockage of ear canal by ear wax. It is thought to be secreted by our body to protect the inner structures of ear. However, if it is not removed regularly, it gets accumulated in the canal and can lead to conductive hearing loss. It should be noted that ear wax should never be removed at home using a hair pin, cap of a pen and other such objects. It should only be removed by a doctor under hospital setting. Annual removal of ear wax is enough to maintain normal hearing.

If a person has blocked ear canal due to ear wax, ear drops are prescribed to him for softening the wax to facilitate its easy removal. The ear drops prescribed under such situation contain the following ingredients:

  • Mineral oil
  • hydrogen peroxide
  • Carbamide peroxide
  • Baby oil
  • Glycerin

b. Treatment of Sensorineural Hearing Loss

This is a type of hearing loss that cannot be treated with the help of medicines. If the condition is mild to moderate, hearing aids might provide some help.

A. Hearing Aid

Hearing aids are electronic devices that run on batteries and improve hearing abilities. They are small in size and can be worn easily in or behind the ear. They help in making the sounds louder which can be heard by the person having hearing difficulty. These are the parts of electronic hearing aids:

  • Microphone: It picks up the sound from the surrounding.
  • Amplifier: This makes the sound louder.
  • Receiver: It is used for sending amplified sounds into the ear.

It should be noted that only 1 in 5 people can benefit from hearing aids. Generally, these are prescribed to people with damaged inner ear or auditory nerve that sends impulses to the brain.

After consulting with a doctor, a patient can get a hearing aid after getting examined by an ENT specialist and an audiologist. People should refrain from ordering a hearing aid through mail-order. If a person suffers from hearing loss in both the ears, it would be nice to wear hearing aids in both ears.

Hearing aids can be divided into two categories:

1. Analog Hearing Aids

These are the devices that increase the loudness of continuous sound waves and amplify all sounds in a similar fashion. Some of these devices have programmable chips that allow the user to adjust the amplification process according to the environment he is in. [1] These devises convert sound waves converted into electrical signals and amplify them. They are economical, and the volume can be controlled with the help of simple controls.
These devices are increasingly becoming less common.

2. Digital Hearing Aid

They have all the elements of analog hearing aids but differ in the mechanism of operation. Sound waves are converted into digital signals by these devices and are exactly duplicated. There are computer chips present inside that analyze speech and other sounds. They also offer more flexible services and can transmit sound that meet the needs of the user. [2]

There are mainly 3 styles of hearing aids, based on the size, placement and how efficiently they enhance the loudness of the sound. They are:

  • Behind-the-ear (BTE) hearing aids: have their entire body contained in a small plastic case that is put behind the ear. These are generally used for treating mild to rare hearing loss. They are generally bigger in size and are very powerful.[3]
  • Open-fit hearing aids or ‘Mini’ BTE or ‘on-the-ear hearing aids are: placed behind the ear and a narrow tube transmits the sound inside the ear canal. The difference between open fit and behind the ear hearing aids is that they are more open, smaller in size and feel less plugged up.
  • In-the-ear (ITE) hearing aids: are extremely small in size so that it can easily fit inside the outer ear. Telecoil, a small magnetic coil is also placed in the device for facilitating telephonic communication. However, they are not used for children because their outer ear is still in the growing phase.
  • In-the-canal (ITC) and completely-in-the-canal (CIC) hearing aids are: placed in extremely small cases that fit partly or completely inside the ear canal. They offer a better cosmetic and hearing advantage. They usually suggested to people with mild to moderate hearing loss.

B. Hearing Implants

Hearing implants are used when hearing aids become ineffective. By using a surgical procedure these electronic devices are placed inside the skull of a person. They are of following types:

  • Cochlear implants: are used when the auditory nerve is functioning properly there is extensive damage to the inner ear. These do not amplify the sound, rather perform the function of damaged ear parts. This automatically makes hearing normal. It is used by people who are suffering from moderate to profound hearing impairment in one or both ears, have no benefit from using hearing aids and score less than 65% in the sentence recognition tests performed by doctor.

Cochlear implants comprise of a microphone like device that collects sounds and converts it into electrical signals, that are transmitted directly to the brain through the auditory nerve.

  • Bone-Anchored Hearing Aids (BAHA): are surgically placed devices that help people who have hearing difficulties. These devices help in transmitting sound waves through the bone and stimulate the cochlea. These systems bypass the outer and middle ears. As soon as the sound waves reach cochlea and stimulate it, the information gets converted into neural signals and is transmitted to the brain. These implants go inside the bone behind the ear.
  • Middle-ear implants are suggested to people who have mild to moderate conductive, sensorineural or mixed types of hearing loss. It is a more recent invention that offers an alternative for the conventional hearing aids. These devices are a boon for people having ear mound allergies, outer ear infections, narrow, collapsed or closed ear canals, skin problems in ears and malformed ears.

The device has two parts, an external part and a surgically implanted inner part. There is a receiver that is placed below the skin for picking up sound signals. The implanted processor is connected to one of the bones of the middle ear or is attached adjacent to the membrane of cochlea. It improves hearing abilities by increasing the movement of the natural hearing pathway. They have an advantage of being completely hidden and can be used even while swimming or bathing.

  • Auditory brainstem implants are prescribed to people with profound sensorineural hearing loss, in which the person has near total loss of hearing. It has two parts, an external part that picks up sound frequencies and an internal part that is surgically placed inside the skull. The picked-up sound vibrations are converted into electrical signals. But unlike cochlear implants, they do not transmit signals to the cochlea. Instead the signals are directly transmitted to the brain. These implants are more effective as they can be used even if a person has a problem in his auditory nerves.

OTC Drug List

Only conductive hearing loss can be treated with the help of medicines. For sensorineural hearing loss, hearing aids and implants are the only treatment options available along with surgery.

Following are some of the medicines which can be used for managing conductive hearing loss arising from otitis media or otitis externa:

Name of the Country

OTC Drug(s) Available

Argentina

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

Australia

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

Austria

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Ear wax dissolving ear drops

Canada

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Ear wax dissolving ear drops

China

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

Croatia

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Ear wax dissolving ear drops

Czech Republic

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

Denmark

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Ear wax dissolving ear drops

France

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Ear wax dissolving ear drops

Germany

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

Greece

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

Hungary

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

India

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Ear wax dissolving ear drops

Ireland

Acetylsalicylic acid (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Ear wax dissolving ear drops

Italy

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

Japan

Aspirin (oral)

Acetaminophen (oral)Argentina

Ibuprofen (oral)

Ear wax dissolving ear drops

Mexico

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

Philippines

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Ear wax dissolving ear drops

Russia

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

Singapore

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Ear wax dissolving ear drops

South Africa

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

South Korea

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

Spain

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

Switzerland

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

The Netherlands

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Diclofenac (oral)

Ear wax dissolving ear drops

UK

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Ear wax dissolving ear drops

USA

Aspirin (oral)

Acetaminophen (oral)

Ibuprofen (oral)

Ear wax dissolving ear drops