The Primary Ear Care Centre

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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

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

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

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

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

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

An individual assessment should be made of every patient to ensure that it is appropriate for ear irrigation to be carried out

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

• 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

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)

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

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

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

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

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

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

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