In order to reduce litigation in ear syringing and provide the patient with effective and safer ear care a consensus document titled 'guidance in ear care' has been produced by the Action On ENT Steering Board. It provides the practitioner guidance in otoscopy, ear irrigation, aural toilet, manual wax removal and microsuction. The guidance document in ear care has been endorsed by the Royal College of General Practitioners, Royal College of Nursing, 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-Caribbean's) 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 ear canal where it comes out on to the skin. A small amount of wax is normally found in the ear canal and its absence may be a sign that dry skin conditions, infection or excessive cleaning has 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 people who insert implements into the ear, have narrow ear canals, hearing aid users, older adults and patients with learning difficulties. A build-up of wax may also occur with anxiety, stress and dietary or hereditary factors. Excessive wax should be removed before it becomes impacted giving 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

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 you have privacy.
   
   
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. Decide on the most appropriate sized speculum that will fit comfortably into the ear and place it on the auriscope.
   
   
3. Gently pull the pinna upwards and outwards to straighten the ear canal. (Directly down and back in children). Localized infection or inflammation will cause this procedure to be painful so do not continue.
   
   
4. Hold the auriscope like a pen and rest the small digit on the patients' head as a trigger for any unexpected head movement. Use the light to observe the direction of the ear canal and the tympanic membrane. There is improved visualisation of the ear drum 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.
   
   
5. Looking through the auriscope check the ear canal and tympanic membrane. Adjust your head and the auriscope 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.
   
   
6. If the patient has had canal wall down mastoid surgery, methodically inspect all parts of the cavity, tympanic membrane or drum remnant by adjusting your head and the auriscope. The mastoid cavity cannot be judged to be completely free of ear disease until the entire cavity and tympanic membrane or drum remnant has been seen.
   
   
7. The normal appearance of the membrane or mastoid cavity varies and can only be learned by practice. Practice will lead to recognition of abnormalities.
   
   
8. Carefully check the condition of the skin in the ear canal as you withdraw the auriscope. 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.
   
   
9. Document what was seen in both ears, the procedure carried out, the condition of the tympanic membrane and external auditory meatus 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.
   

Guidance on the use of syringes in the ear

The metal syringe is obsolescent for use in the ear canal. The syringe design is inherently dangerous. Combined with the danger of the syringe itself and the pressure of water it creates within the ear canal, 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 ear canal rather then wax removal under pressure. The MDA issued Safety Notice SN 9807 in February 1998 that 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. This guidance document recommends that practitioners use an electronic ear irrigator rather than the manual syringe and refer to the procedure as ear irrigation.

The Propulse II irrigator has 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 II 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 denotes 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 evidence promoting this machine as an ear irrigator and 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 ear canal 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 can not be used in rooms where there is no access to water as in 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 ear canal.

GUIDANCE FOR EAR IRRIGATION USING THE
ELECTRONIC IRRIGATOR

This procedure is only to be carried out by a trained doctor, nurse or audiologist.

PRINCIPLES - Irrigating the ear is carried out to: -

• Facilitate the removal of cerumen and foreign bodies which are not hygroscopic, from the external auditory meatus. Hydroscopic 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 they are 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.

Irrigation should not be carried out when: -

1. The patient has previously experienced complications following this procedure in the past.
2. There is a history of a middle ear infection in the last six weeks.
3. 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 dept).
4. The patient has a perforation or there is a history of a mucous discharge in the last year.
5. The patient has a cleft palate (repaired or not).
6. In the presence of acute otitis externa; an oedematous ear canal combined with pain and tenderness of the pinna..

REQUIREMENTS

• Auriscope
• Head mirror and light or head light and spare batteries
• Electronic irrigator
• Jug containing tap water to 40°C
• Noots trough/receiver
• Jobson Horne probe and cotton wool
• Tissues and receivers for dirty swabs and instruments
• Waterproof cape and towel

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. Informed consent should be obtained prior to proceeding.
   
   
2. Examine both ears by first inspecting the pinna, outer meatus (ear canal) and adjacent scalp by direct light. Check for previous surgery incision scars or skin defects, then inspect the external ear with the auriscope.
   
   
3. Check whether the patient has had his ears irrigated previously, or if there are any contraindications why irrigation should not be performed.
   
   
4. Explain the procedure to the patient and ask the patient to sit in an examination chair with their head tilted towards the affected ear. (A child could sit on an adult's knee with the child's head held steady).
   
   
5. Place the protective cape and towel on the patient's shoulder and under the ear to be irrigated. Ask the patient to hold the receiver under the same ear.
   
   
6. Check your headlight is in place and the light is directed down the ear canal. Check that the temperature of the water is approximately 40°C and fill the reservoir of the irrigator. Set the pressure at minimum.
   
   
7. Connect clean jet tip applicator to tubing of machine with firm push/twist action. Push until "click" is felt.
   
   
8. 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 and for you to ensure the temperature of water at the tip is approximately 37°C. The initial flow of water is discarded, thus removing any static water remaining in the tube.
   
   
9. Twist the jet tip so that the water can be aimed along the posterior wall of the ear canal (towards the back of the patient's head).
   
   
10. Gently pull the pinna upwards and outwards to straighten the ear canal. (Directly backwards in children).
    
    
11. Warn the patient that you are about to start irrigating and that the procedure will be stopped if they feel dizzy or have any pain. Place the tip of the nozzle into the ear canal entrance and using foot control direct the stream of water along the roof of the ear canal and towards the posterior canal wall (directed towards the back of the patient's head). If you consider the entrance to the ear canal as a clock face you would direct the water at 11 o'clock on the right ear and 1 o'clock on 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 irrigating procedure.
    
    
12. If you have not managed to remove the wax within five minutes of irrigating, it may be worthwhile moving onto 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.
    
    
13. Periodically inspect the ear canal with the auriscope and inspect the solution running into the receiver.
    
    
14. After removal of wax or debris, dry mop excess water from 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.
    
    
15. Examine ear, both meatus and tympanic membrane and treat as required following specific guidelines or refer to doctor if necessary.
    
    
16. Give advice regarding ear care and any relevant information.
    
    
17. Document what was seen in both ears, the procedure carried out, the condition of the tympanic membrane and external auditory meatus 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.
    

NB IRRIGATION SHOULD NEVER CAUSE PAIN. IF THE PATIENT COMPLAINS OF PAIN - STOP IMMEDIATELY.

ALWAYS USE A CLEAN SPECULUM, JET TIP APPLICATOR AND PROBE FOR EACH PATIENT.

It is recommended that you follow the manufacturer guidelines for cleaning and disinfecting 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 or audiologist.

An individual assessment should be made of every patient to ensure that they are appropriate for aural toilet to be carried out.

1. Examine the ear.
   
   
2. Dry mop - Using a Jobson Horne probe and a small piece of fluffed up cotton wool, the size of a postage stamp, applied to the probe. Under direct vision (with headlight or head mirror and light) and pulling the pinna to straighten the canal, clean the ear with a gentle rotary action of the probe. 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. Re-examine the meatus intermittently, using the auriscope, 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 them.
   
   
7. Give advice regarding ear care and any relevant information.
   
   
8. Document what was seen in both ears, the procedure carried out, the condition of the tympanic membrane and external auditory meatus 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.

GUIDANCE FOR REMOVAL OF EXCESSIVE WAX

This procedure is only to be carried out by a trained doctor, nurse or audiologist.

They 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 is this 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 or light 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, so 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 irrigating 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 seen in both ears, the procedure carried out, the condition of the tympanic membrane and external auditory meatus 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.

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 trained doctor, nurse or audiologist who have developed the skill of performing the use of the microscope and suction. The suction generates loud noise and patients sometimes complain of the discomfort of the procedure.

An individual assessment should be made of every patient to ensure that microsuction is appropriate.

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 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 cavity, tympanic membrane or drum remnant by varying the angle of the microscope.
    
    
12. The normal appearance of the 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 seen in both ears, the procedure carried out, the condition of the tympanic membrane and external auditory meatus 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.

Reference List

• Aung,T. ; Mulley.G.P. (2002) Removal of ear wax. British Medical Journal. 325:27
  
  
• Eckhof J A H, de Beck G h. Le Cessie S. Springer M P. (2001) A quasi-randomised controlled trial of water as a quick softening agent of persistent earwax in general practice. British Journal of General Practice August: 635-637
  
  
• Fisher,E.W.;Pfleiderer,A.G. (1992) Assessment of the otoscopic skills of general practitioners and medical students:is there room for improvement?. British Journal of General Practice. Vol. 42:65-67.
  
  
• Price, J. (1997) Problems of ear syringing. Practice Nurse. 14:126-8
  
  
• Ney, D.F. (1993) Cerumen impaction, ear hygiene practices and hearing acuity. Geriatric Nursing. Mar/Apr.:70-73.
  
  

• Rodgers, R. (2001) The National Diploma of the Primary Ear Care Centre booklet

• Rodgers R.W. (2002) Continued education: preventive ear care. Nursing in Practice. March: 71-73 Rodgers R. (2000) Understanding the legalities of ear syringing. Practice Nurse 19(4)166-169

• Roesser,R.J.;Ballanchanda,B.B. (1997) Physiology, pathophysiology, and anthropology/epidemiology of human ear canal secretions. Journal of American Academy of Audiology. Vol. 8:391-400.

• Sharp,J.F.;Wilson,J.A.;Ross,L.;Barr-Hamilton,R.M. (1990) Ear wax removal : a survey of current practice. British Medical Journal. Vol. 301:1251:1252.

• Spiro,S. (1997) A cost effective analysis of ear wax softeners. Nurse Practitioner. Vol. 22(8):28,30-31.

• Wilson,P.L.;Roesser,R.J. (1997) Cerumen management:professional issues and techniques. Journal of American Academy of Audiology. Vol. 8:421-430.

• UKCC (1998) Guidelines for records and record keeping. United Kingdom Central Council for Nursing, Midwifery and Health Visiting. London.

• UKCC (1992) The scope of professional practice. United Kingdom Central Council for Nursing, Midwifery and Health Visiting. London

• Zivic, R.C.;King,S. (1993) Cerumen impaction management for clients of all ages.Nurse Practitioner Vol. 18(3):29,33-36,39.
  

This document has been compiled by Hilary Harkin on behalf of the Action On ENT Steering Board.

Acknowledgments

• Jeremy Davis, Consultant ENT Surgeon Medway Maritime Hospital, Gillingham, Kent, ME7 5NY. 01634 825051
  
  
• Adrian Mann, Senior Medical Device Specialist, Medical Devices Agency, Hannibal House, Elephant and Castle, London SE1 6TQ. 020 7972 8000
  
  
• Gordon Hickish, General Practitioner. Gordon.hickish@lineone.net
  
  
• Primary Ear Care Centre. Kiveton Park Primary care Centre, Chapel Way, Kiveton Park, Sheffield, South Yorkshire S26 6QU. 01909 772746
  
  
• Rosemary Rodgers Consultant Specialist Nurse (ear care), Stag Medical Centre, 162 Wickersley Rd. Rotherham, S. Yorkshire. S60 4JW. 01709 531725

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