|
The Patient Group Directions are currently available
to download in Microsoft Word format.
GUIDANCE DOCUMENT IN EAR CARE
In order to reduce litigation in ear irrigation and provide the
patient with effective and safer ear care this document has been
produced by the ‘Action On ENT’ Steering Board (2002)
and revised by the Primary Ear Care Trainers (2007). It provides
the practitioner with guidance in otoscopy, ear irrigation, aural
toilet and manual wax removal
The Document has been endorsed by the Royal College of General
Practitioners, The Royal College of Nursing, The Primary Ear Care
Centre and the Medical Devices Agency
Cerumen Management
Wax or cerumen is a normal secretion of the ceruminous glands
in the outer meatus. It is slightly acidic, giving bactericidal
qualities in both its wet, sticky form (as secreted by Caucasians
and Afro-Caribbeans) or dry, flaky form (as secreted by Orientals).
In addition to epithelial migration, jaw movement assists the movement
of wax to the entrance of the External Auditory Meatus (EAM) where
it emerges on to the skin. A small amount of wax is normally found
in the EAM and its absence may be a sign that dry skin conditions,
infection or excessive cleaning have interfered with the normal
production of wax. It is only when there is an accumulation of
wax that removal may be necessary. A build-up of wax is more likely
to occur in older adults and patients with learning difficulties,
hearing aid users, people who insert implements into the ear or
have a narrow EAM. A build-up of wax may also occur as a result
of anxiety, stress and dietary or hereditary factors. Excessive
wax should be removed before it becomes impacted, which can give
rise to tinnitus, hearing loss, vertigo, pain and discharge. If
wax is removed due to the presenting complaint of hearing loss,
ascertain whether good hearing is restored after treatment or if
the patient would benefit from a formal assessment by the ENT surgeon
or Audiologist. Providing they meet certain criteria stated in
local referral guidelines, older adults with a bilateral hearing
loss can be referred directly to the Audiology Department
The experienced practitioner can use his or her clinical judgement
on the best method for ear examination and wax removal.
These recommendations
have been developed to assist practitioners in gaining experience
and knowledge in the provision of ear care. They do not replace
the need for education, training and supervision in order to
perform these procedures
Guidance for ear examination
A Adult patients
1. Before careful physical examination of the ear, listen to the
patient, elicit symptoms and take a careful history. Explain each
step of any procedure or examination and ensure that the patient
understands and gives consent. Ensure that both you and the patient
are seated comfortably, at the same level, and that privacy is
maintained
2. Examine the pinna, outer meatus and adjacent scalp. Check for
previous surgery incision scars, infection, discharge, swelling
and signs of skin lesions or defects. Identify the largest suitable
speculum that will fit comfortably into the ear and place it on
the otoscope
3. Palpate the tragus in order to identify if the patient has
any pain. Proceed with caution
4. Gently pull the pinna upwards and outwards to straighten the
EAM (directly down and back in children). If there is localized
infection or inflammation this procedure may be painful and examination
may be difficult
5. Hold the otoscope like a pen and rest the small digit on the
patient’s head as a trigger for any unexpected head movement.
Do not move the patient's head when the otoscope is in the ear.
Use the light to observe the direction of the EAM and the tympanic
membrane. There is improved visualisation of the tympanic membrane
by using the left hand for the left ear and the right hand for
the right ear but clinical judgement must be used to assess your
own ability. Insert the speculum gently into the meatus to pass
through the hairs at the entrance to the canal
6. Looking through the otoscope, check the EAM and tympanic membrane.
Adjust your head and the otoscope to view all of the tympanic membrane.
The ear cannot be judged to be normal until all the areas of the
membrane are viewed: the light reflex, handle of malleus, pars
flaccida, pars tensa and anterior recess. If the ability to view
all of the tympanic membrane is hampered by the presence of wax,
then wax removal will have to be carried out
7. If the patient has had canal wall mastoid surgery, methodically
inspect all parts of the cavity, tympanic membrane, or remaining
tympanic membrane, by adjusting your head and the otoscope. The
mastoid cavity cannot be judged to be completely free of ear disease
until the entire cavity and tympanic membrane, or remaining tympanic
membrane, has been seen
8. The normal appearance of the membrane or mastoid cavity varies
and can only be learned by practice. Practice will lead to recognition
of abnormalities
9. Carefully check the condition of the skin in the EAM as you
withdraw the otoscope. If there is doubt about the patient’s
hearing, an audiological assessment should be made. Providing they
meet certain criteria stated in local referral guidelines, older
adults with a bilateral hearing loss can be referred directly to
the Audiology Department. Patients with a unilateral loss should
be referred to ENT
10. Document what was seen in both ears, the procedure carried
out, the condition of the tympanic membrane and EAM and treatment
given. Findings should be documented, with nurses following the
NMC guidelines on record keeping and accountability. If any abnormality
is found a referral should be made to the ENT Outpatient Department
following local policy
B Children
Irrigation can be carried out on children as long as the child
has no contraindications and is happy to co-operate with the procedure.
The practitioner must ensure irrigation is appropriate and necessary.
It may be advisable to instil olive oil for a longer period of
time in children to avoid the need for irrigation. When carrying
out otoscopy, gently pull the pinna down and backwards to straighten
the EAM
Guidance on equipment used for wax removal
The metal syringe is obsolescent for use in the EAM. The syringe
design is inherently dangerous. Combined with the danger of the
syringe itself and the pressure of water it creates within the
EAM, there is the difficulty of disinfecting the syringe after
each use. The Medical Devices Agency (MDA) also has reservations
about the use of the metal syringe for wax removal. There are issues
around the poor manufacture of some syringes, allowing them to
break and cause injury during use and the pressure of water that
can be exerted manually on the tympanic membrane
Electronic irrigators such as the "Propulse" and the "Otoscillo" allow
irrigation of the EAM rather then wax removal under pressure. The
MDA issued Safety Notice SN 9807 in February 1998 which advised
users that the original Propulse electronic irrigator required
an isolation transformer for electrical safety. Subsequently, the
manufacturer designed and marketed the Propulse II to replace the
original Propulse. Propulse III is now available which is both
mains and battery operated
Please note: This guidance document does not recommend the use
of manual syringes or the Propulse 1, even with an isolation transformer,
but recommends that practitioners should use the Propulse II or
III irrigator and refer to the procedure as ear irrigation
The Propulse II and III irrigator have a pressure-variable control
of minimum/maximum, allowing the flow of water to be easily controlled
by commencing irrigation on the minimum setting. For patient safety,
Propulse has limited the maximum pressure available; this limit
is stated in the user instructions. The Propulse III irrigator
has specific disinfecting guidelines issued with approval from
infection control committees
The only other equivalent device available on the British market
is the German ear irrigator called the Mulimed-Otoscillo irrigating
jet machine. The numbers one to six denote the pressure control
but, as the manufacturer does not state a maximum limit, it is
difficult to assess the maximum pressure developed by the irrigator.
There is no documentation about the safe pressure exerted by the
machine. A further failing is that the design of the irrigator
tip does not offer the preferred direction against the posterior
EAM wall. The manufacturers of the Mulimed-Otoscillo do not recommend
a specific solution to disinfect the irrigating machine. This has
the danger of users using inappropriate solutions and the machine
harbouring infection
The Welch Allyn Ear Wash System is an American irrigator that attaches
to a combined hot and cold water tap. There are problems in the
United Kingdom with attachment to a number of taps found within
the community and hospital setting. It is of comparable price
to both the electronic irrigators but there may be the added
cost of having the tap changed to a suitable model. The system
cannot be used in rooms where there is no access to water, as
in the case of patients confined to a sitting room, within a
nursing home or community setting. It does limit the maximum
amount of water pressure exerted in the ear and controls variation
in the flow of water. If there is an increase/ decrease in the
temperature of water the machine will stop the flow of water
until it is altered. This machine has a suction system, which
returns the discharge and debris away from the ear and can be
used without the flow of water to remove the remaining moisture
from the EAM
GUIDANCE FOR EAR IRRIGATION USING THE
ELECTRONIC IRRIGATOR
This procedure is only to be carried out by a trained doctor,
nurse or audiologist. It may also be carried out by a Healthcare
worker who has received recognised training in ear care and the
use of ear care equipment. This training is available from Primary
Ear Care Centre trainers
PRINCIPLES – Irrigation of the ear is carried out to: -
? Facilitate the removal of cerumen and foreign bodies, which
are not hygroscopic, from the external auditory meatus. Hygroscopic
matter (such as peas and lentils) will absorb the water and expand,
making removal more difficult
? Remove discharge, keratin or debris from the external auditory
meatus
An individual assessment should be made of every patient to ensure
that it is appropriate for ear irrigation to be carried out
REASONS for using this procedure
In order to: -
? Correctly treat otitis externa where the meatus is obscured
by debris
? Improve conduction of sound to the tympanic membrane when it
is blocked by wax
? Remove debris to allow examination of the external auditory meatus
and the tympanic membrane
? Remove cerumen in order to facilitate hearing aid mould impressions
Irrigation should NOT be carried out when: -
? the patient has previously experienced complications following
this procedure in the past
? there is a history of a middle ear infection in the last six
weeks
? the patient has undergone ANY form of ear surgery (apart from
grommets that have extruded at least 18 months previously and the
patient has been discharged from the ENT Department)
? the patient has a perforation or there is a history of a mucous
discharge in the last year
? the patient has a cleft palate (repaired or not)
? there is evidence of acute otitis externa with pain and tenderness
of the pinna
Precautions:
Tinnitus
Healed Perforation
Dizziness
REQUIREMENTS
• Otoscope
•
Head mirror and light or headlight and spare batteries
•
Electronic irrigator
•
Tap water at 37oC
•
Noots trough/receiver
•
Jobson Horne probe and cotton wool
•
Tissues and receivers for dirty swabs and instruments
•
Disposable waterproof cape and paper towels
•
Disposable apron and gloves
THIS PROCEDURE SHOULD BE CARRIED OUT WITH BOTH PARTICIPANTS SEATED
AND UNDER DIRECT VISION, USING A HEADLIGHT OR HEAD MIRROR AND
LIGHT SOURCE, THROUGHOUT THE PROCEDURE
PROCEDURE
1. Consent should be obtained and documented prior to proceeding
2. Examine both ears by first inspecting the pinna and adjacent
scalp using direct light. Check for previous surgery incision scars
or skin defects, then inspect the EAM with the otoscope
3. Check whether the patient has had his/her ears irrigated previously,
or if there are any contra-indications why irrigation should not
be performed
4. Explain the procedure to the patient and ask the patient to
sit in an examination chair (a child could sit on an adult's knee
with the child's head held steady)
5. Check that the headlight/light source is in place and is working
correctly
6. Place the protective cape and paper towel on the patient’s
shoulder and under the ear to be irrigated. Ask the patient to
hold the receiver under the same ear
7. Check that the temperature of the water is approximately 37?C
and fill the reservoir of the irrigator. Set the pressure at minimum
8. Connect a new jet tip applicator to the tubing of the machine
with a firm ‘push/twist’ action. Push until a "click" is
felt
9. Direct the irrigator tip into the Noots receiver and switch
on the machine for 10-20 seconds in order to circulate the water
through the system and eliminate any trapped air or cold water.
This offers the opportunity for the patient to become accustomed
to the noise of the machine. The initial flow of water is discarded,
thus removing any static water remaining in the tube. Check the
temperature of the water again
10. Twist the jet tip so that the water can be aimed along the
posterior wall of the EAM (towards the back of the patient’s
head)
11. Gently pull the pinna upwards and outwards to straighten the
EAM (directly backwards in children)
12. Warn the patient that you are about to start irrigating and
that the procedure will be stopped if he/she feels dizzy experiences
any pain. Ensure that the light is directed down the EAM. Place
the tip of the nozzle into the EAM entrance and, using the foot
control, direct a stream of water along the roof of the EAM and
towards the posterior wall (directed towards the back of the patient’s
head). If you consider the entrance to the EAM as a clock face,
you would direct the water at 11 o’clock in the right ear
and 1 o’clock in the left ear. Increase the pressure control
gradually if there is difficulty removing the wax. It is advisable
that a maximum of two reservoirs of water is used in any one irrigation
procedure
13. If you have not managed to remove the wax within five minutes
of irrigation, it may be worthwhile moving on to the other ear,
as the introduction of water via the irrigating procedure will
soften the wax and you can retry irrigation after about 15 minutes
14. Periodically inspect the EAM with the otoscope and inspect
the solution running into the receiver
15. After removal of wax or debris, dry mop excess water from
the meatus under direct vision using the Jobson Horne probe and
best quality cotton wool. Stagnation of water and any abrasion
of skin during the procedure predispose to infection. Removing
the water with the cotton wool tipped probe reduces the risk of
infection
16. Examine the ear, both meatus and tympanic membrane, and treat
as required following specific guidelines, or refer to a doctor
if necessary
17. Give advice regarding ear care and any relevant information
18. Document what was observed in both ears, the procedure carried
out, the condition of the tympanic membrane and external auditory
meatus and treatment given. Findings should be documented; nurses
should follow the NMC guidelines on record keeping and accountability.
If any abnormality is found a referral should be made to the ENT
Outpatient Department following local policy
NB. IRRIGATION SHOULD NEVER CAUSE PAIN. IF THE PATIENT COMPLAINS
OF PAIN - STOP IMMEDIATELY
Always use a sterilised or single use speculum and jobson horne
probe and a single use jet tip applicator for each patient
It is recommended that you follow the manufacturer’s guidelines
and local policy for cleaning, disinfecting and calibrating the
irrigator and its components
GUIDANCE FOR AURAL TOILET
Principles - aural toilet is used to clear the aural meatus of
debris, discharge, soft wax or excess fluid following irrigation
This procedure is only to be carried out by a trained doctor,
nurse, audiologist or healthcare worker with recognised ear care
training
An individual holistic assessment should be made of each patient
to ensure that it is appropriate for aural toilet to be carried
out
1. Examine the ear using an otoscope
2. Under direct vision, dry mop - using an ear mop or Jobson Horne
probe with a small piece of cotton wool applied to the serrated
edge. Clean the EAM with a gentle rotary action. Do not touch the
tympanic membrane
3. Replace the cotton wool directly it becomes soiled. Pay particular
attention to the anterior-inferior recess, which can harbour debris
4. Intermittently re-examine the meatus, using the otoscope, during
cleaning to check for any debris/discharge/crusts which remain
in the meatus at awkward angles
5. Patients who have mastoid cavities should be followed up in
the ENT department unless the nurse, doctor or audiologist has
been specifically trained in this area. The frequency of cleaning
required by the cavity will depend on the individual patient. If
the cavity gets repeatedly infected the patient should be considered
for revision surgery
6. If an infection is present treatment should follow patient
group directives and referral guidelines or as dictated by the
result of a swab culture and sensitivities following the failure
of first line management. If the patient has repeated problems
with the ear, an ENT Surgeon should review the patient
7. Give advice regarding ear care and any relevant information
8. Document what was observed in both ears, the procedure carried
out, the condition of the tympanic membrane and external auditory
meatus and treatment given. Findings should be documented; nurses
should follow the NMC guidelines on record keeping and accountability.
If any abnormality is found a referral should be made to the ENT
Outpatient Department following local policy
GUIDANCE FOR REMOVAL OF EXCESSIVE WAX
This procedure is only to be carried out by a trained doctor,
nurse or audiologist
These notes are to be used as a guide: when the practitioner
has developed their skills they can use their own clinical judgement
on the most appropriate method and instrumentation to remove
wax
1. Examine the ear to discern the type of wax to be removed. Ask
yourself if it is healthy wax or may it be bacterial debris of
wax-like appearance? Is it dry crumbly wax related to Seborrhoeic
Dermatitis? Is it soft, beige wax, in both ears, that can be associated
with high cholesterol?
2. Hard, crusty wax can often be gently manoeuvred out of the
meatus with a ring probe, using a head mirror and external light
source or headlight for illumination. Experienced practitioners
may prefer to use a wax hook or forceps. If this treatment becomes
painful, do not continue as the meatal lining quickly becomes traumatised,
risking infection. Instruct the patient according to your clinical
judgement. A possible treatment could be to use olive oil or sodium
bicarbonate inserted correctly for up to 1 week. The patient can
then return for irrigation or further instrumentation. Excessive
soft wax or crumbly wax and debris can be wiped out with cotton
wool wound onto a Jobson Horne probe (using aural toilet guidelines)
or irrigated
3. Cerumenolytic ear drops can be used to break up hard wax but
patients may develop meatal irritation from the astringent qualities
of these agents. This is particularly the case with older adults
or people who suffer with dermatology conditions or recurrent otitis
externa
4. If a perforation is suspected behind the wax, advise the patient
to use olive oil in very small amounts, but to stop using it if
they experience any pain
5. Give advice regarding ear care and any relevant information
6. Document what was observed in both ears, the procedure carried
out, the condition of the tympanic membrane and external auditory
meatus and treatment given. Findings should be documented; nurses
should follow the NMC guidelines on record keeping and accountability.
If any abnormality is found a referral should be made to the ENT
Outpatient Department following local policy
GUIDANCE FOR MICROSUCTION
PRINCIPLES - Use of the microscope and suction is carried out
to: -
•
Remove cerumen and hygroscopic foreign bodies in patients who
are not appropriate for ear irrigation
•
Remove discharge, keratin or debris from the external auditory
meatus or mastoid cavity
This procedure is only to be carried out by a doctor, nurse or
audiologist who has trained in the use of the microscope and
suction. An individual assessment should be made of every patient
to ensure that microsuction is appropriate. The suction generates
loud noise and patients sometimes complain of the discomfort
of the procedure
PROCEDURE
1. Before careful physical examination of the ear listen to the
patient, elicit symptoms and take a careful history. Explain
each step of any procedure of examination and assure yourself
that the patient understands and gives consent
2. Check whether the patient has had microsuction previously, explain
the nature of the noise and that they can ask for a rest if they
experience any vertigo (if this should occur ask the patient to
focus their eyes on a fixed object until the feeling subsides)
3. Adjust the magnification, eye piece and angle of the microscope
to the appropriate position. Request that the patient position
themselves comfortably on the examination couch or chair
4. First examine the pinna, outer meatus and adjacent scalp by
direct light and check for incision scars and observe for skin
defects
5. Gently pull the pinna upwards and outwards (in infants downwards
and backwards) to straighten out the meatus. Remember that the
skin lining the deeper meatus is very delicate and sensitive
6. Direct the microscope down into the ear. Insert the speculum
gently into the EAM/cavity - use the largest size speculum that
will fit comfortably into the ear
7. Carefully check the cavity, tympanic membrane or drum remnant.
Decide the size of suction tip most appropriate for the procedure
and attach it to the suction tubing
8. Turn the suction machine on, maintaining the pressure between
80 to 120mm Hg (18 to 20 cm H2O). Apply the suction tip to the
areas requiring debris removal. Use an appropriate solution to
wash through the suction tubing when it becomes blocked
9. Avoid touching the wall of the meatus, cavity or drum/ drum
remnant. By only touching the debris, most pain can be avoided
10. The ear cannot be judged to be completely free of ear disease
until the entire cavity and tympanic membrane or drum remnant has
been seen. You may need to ask the patient to move his head e.g.
lean head towards the opposite shoulder to be able to see more
clearly into the roof of the meatus and posterior aspect of the
cavity
11. Methodically inspect all parts of the EAM/cavity, tympanic
membrane or drum remnant by varying the angle of the microscope
12. The normal appearance of the EAM/cavity varies and can only
be learned by practice. Practice will lead to recognition of abnormalities
13. Carefully check the condition of the external auditory meatus
as you withdraw the speculum
14. Advice should be given to the patient as appropriate
15. Document what was observed in both ears, the procedure carried
out, the condition of the tympanic membrane and external auditory
meatus and treatment given. Findings should be documented; nurses
should follow the NMC guidelines on record keeping and accountability.
If any abnormality is found a referral should be made to the ENT
Outpatient Department following local policy
This document has been compiled by Hilary Harkin and The Primary
Ear Care Centre on behalf of the Action On ENT Steering Board and
revised (January 2007) by The Primary Ear Care Centre nurses and
licensed trainers
Acknowledgments
•
Jeremy Davis, Consultant ENT Surgeon
•
Adrian Mann
•
Gordon Hickish
•
The Primary Ear Care Centre
•
Mrs Rosemary Rodgers
Revised February 2008
Download
These Guidelines (printer friendly)
|
