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Ear irrigation guideline

Purpose

  • Correctly treat otitis externa where the meatus is obscured by debris
  • Improve conduction of sound to the tympanic membrane (TM) when it is blocked by wax
  • Remove discharge, keratin, or debris to allow examination of the external auditory meatus (EAM) and the TM
  • Remove wax in order to facilitate hearing aid mould impressions
  • Facilitate the removal of wax and foreign bodies, which are not hygroscopic, from the EAM
  • Hygroscopic matter (such as peas and lentils) will absorb the water and expand, making removal more difficult

Scope

  • This procedure is only to be carried out by an experienced healthcare worker who has received recognised training in ear care and the use of ear care equipment. This training is available UK-wide 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
  • Irrigation should NOT be carried out if:
    • the patient has previously experienced complications following this procedure in the past
    • there is a history of a middle ear infection in the last 6 weeks
    • the patient has undergone ANY form of ear surgery (apart from grommets that have extruded at least 18 months previously and it is documented subsequently that the TM is intact)
    • the patient has a perforation
    • there is a history of a mucus discharge in the past 12 months
    • there is evidence of acute otitis externa with pain and tenderness of the pinna

This list is not exhaustive and the practitioner must use his or her own judgement for each individual.

  • Precautions (ear irrigation should be carried out on a low setting):
    • tinnitus
    • healed perforation
    • dizziness
    • patient taking anti-coagulants
    • the patient has a cleft palate (repaired or not)

Children

  • Irrigation can be carried out on children as long as the child has no contraindications and is happy to cooperate 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

  • Equipment Requirements:
    • otoscope
    • head mirror and light or headlight and spare batteries
    • electronic irrigator*
    • tap water at 37o C or temperature comfortable for the patient avoiding cool water
    • noots trough/receiver
    • Jobson Horne probe/carbon curette or an appropriate cotton wool carrier and good quality 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
  • The patient presenting complaints and the result of the initial examination should be documented. Valid consent should be obtained and documented prior to proceeding
  • Examine both ears by first inspecting the pinna and adjacent scalp using direct light. Check for previous surgery incision scars or skin defects, and then inspect the EAM with the otoscope
  • Check whether the patient has had his/her ears irrigated previously, or if there are any contraindications why irrigation should not be performed
  • 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)
  • Check that the headlight/light source is in place and is working correctly
  • 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
  • Check that the temperature of the water is approximately 37o C and fill the reservoir of the irrigator. Set the pressure at minimum
  • Connect a new tip applicator to the tubing of the machine with a firm 'push/twist' action. Push until a 'click' is felt
  • 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
  • Twist the tip so that the water can be aimed along the posterior wall of the EAM (towards the back of the patient's head)
  • Gently pull the pinna upwards and outwards to straighten the EAM (directly backwards in children)
  • Warn the patient that you are about to start irrigating and that the procedure will be stopped if he/she feels dizzy and/or 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 (direct towards the back of the patient's head). Increase the pressure control gradually if there is difficulty removing the wax. It is advisable that a maximum of one reservoir of water per ear is used in any one irrigation procedure
  • There is evidence to suggest that leaving water in the canal for 15 minutes will increase the chance of success. You may find it beneficial to instil water into both ears (if both require irrigation with water) and return to the procedure after a rest of 15 minutes
  • Periodically inspect the EAM with the otoscope and inspect the solution running into the receiver
  • After removal of wax or debris, dry mop excess water from the meatus under direct vision using the Jobson Horne probe/carbon curette or an appropriate cotton wool carrier and good 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
  • Examine the ear, both meatus and TM, and treat as required following specific guidelines, or refer to a doctor if necessary
  • Give advice regarding ear care and any relevant information. Advise the patient to return if ear starts to discharge or become painful. If the presenting complaint was hearing loss and the hearing doesn't improve following wax removal advise patient to seek further advice as per local policy
  • Document what was observed in both ears, the procedure carried out, the condition of the TM and EAM, and treatment given. Findings should be documented, nurses following the Nursing and Midwifery Council (NMC) guidelines on record keeping and accountability. If any abnormality is found a referral should be made to the Ear, Nose, and Throat (ENT) Outpatient Department following local policy
  • It is recommended that you follow the manufacturer's guidelines and local policy for cleaning, disinfecting, and calibrating the irrigator and its components

NB Irrigation should never cause pain. If the patient complains of pain, stop immediately.

Risk Factors

  • Potential complications following procedure:
    • trauma
    • infection
    • dizziness
    • tinnitus

* 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, III, NG, or G5 irrigators and refer to the procedure as ear irrigation. The Propulse II, III, NG, and G5 irrigators have a pressure-variable control, allowing the flow of water to be easily controlled by commencing irrigation on the minimum setting. For patient safety, the manufacturer has limited the maximum pressure available: this limit is stated in the user instructions. The Propulse III, NG, and G5 irrigators have specific disinfecting guidelines issued.

full guideline available from…
Rotherham Primary Ear Care Centre and Audiology Services, The Rotherham NHS Foundation Trust, Rotherham Community Health Centre, Greasborough Road, Rotherham, S60 1RY
www.earcarecentre.com/HealthProfessionals/Protocols.aspx?id=8

The Rotherham NHS Foundation Trust. Ear Irrigation Guideline
First included: March 2016.