|

PATIENT GROUP DIRECTIONS
The Patient Group Directions are currently
available to download in Microsoft Word format.
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)
|