NHS Grampian Ear Irrigation Guidelines
Table of ContentsGuidance Document / ………………………………………..………….. / 3
Cerumen Management / ………………………………………..………….. / 4
Guidance for Ear Examination / ………………………………………..………….. / 4
Guidance on Patient Ear Care / ………………………………………………….... / 6
Guidance on the Use of Wax Softeners – Olive Oil / ……………….…….. / 6
Guidance on the Use of Syringes in the Ear / ………………………………… / 8
Reasons for Carrying Out Ear Irrigation Using the Propulse II / ………….. / 9
Reasons When Irrigation Should Not be Carried Out / ………………………. / 9
Equipment Requirements / ………………………………………..………….. / 9
Ear Irrigation Procedure / ………………………………………..………….. / 10
Guidance Notes for Aural Toilet / ………………………………………..………….. / 13
Guidance Notes for Removal of Excessive Wax Using Instrumentation .. / 14
Decontamination Guidelines(as approved by NHS Grampian Infection Control Teams) / ………………………………………..………….. / 15
FAQs / ………………………………………..………….. / 17
Useful Links Relating to Ear Care / ……………………………………………. / 18
Bibliography / ………………………………………..………….. / 19
Appendix 1: 3C Checklist for Ear Irrigation / ……………………….. / 20
Appendix 2: Suggested Ear irrigation Consent Form / ……………….. / 24
Appendix 3: Additional Information on the Propulse III Universal / ……………….. / 25
An ear care website has been developed to support staff in Grampian. As well as information and downloads, there is also a discussion forum, an area for sharing good practice and an opportunity to ask questions.
The website can be found via the NHS Grampian Intranet homepage, click on microsites, then ear irrigation.
NHS Grampian Ear Irrigation Guidelines
Guidance DocumentThis guidance document has been produced to support all disciplines of staff working within NHS Grampian who undertake otoscopy, ear irrigation, aural toilet and manual wax removal. The experienced practitioner should always use their clinical judgement to select the most appropriate procedure and method for ear examination and wax removal.
These recommendations do not replace the need for education, training and supervision in order to develop confidence and competence when performing these procedures safely. If staff are undertaking ear irrigation as a new skill, then they are encouraged to use the 3C Ear Irrigation Observation Checklist[see Appendix 1].
It is no longer acceptable practice to use a chrome, metal, plastic syringe or the Propulse I for ear irrigation in Grampian. Please refer to ‘Guidance on the Use of Syringes in the Ear’ (page 8) for further information.
These guidelines endorse the use of both the Propulse II and Propulse III Universal for ear irrigation in Grampian. Where these guidelines refer to the Propulse II only, it is assumed that the Propulse III Universal is also included.
Please refer to ‘Appendix 3’ for further information on the Propulse III Universal.
Thanks to everyone who have contributed and given feedback during the development of these guidelines. Acknowledgement also to the Primary Ear Care Centre (Rotherham Health Authority) for their guidance in preparing this document.
This document supercedes and replaces all previous Ear Irrigation Guidelines in Grampian.
This document has been compiled by Paul E Murray, Clinical Training Officer, NHS Grampian with input and approval from Clinical Staff, the Lead Nurse Group, the GP Sub-Committee, Infection Control, Risk Management and Mirage Health Group.
This document shall not be copied in part or whole without the express permission of the author or the author’s representative.Cerumen Management
Wax or cerumen is a normal secretion of the ceruminous glands in the outer meatus and is slightly acidic, providing bactericidal qualities.
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 (frequent users of cotton buds, etc) have narrow ear canals, hearing aids, older adults and patients with learning difficulties. A build-up of wax may also occur as a result of anxiety, stress and dietary or hereditary factors.
Wax should only be removed if it is causing symptoms such as dulled hearing, itch, or discomfort.
If wax is removed due to a complaint of hearing loss, ascertain whether good hearing is restored after treatment or if the patient would benefit from a formal assessment by ENT or Audiology.
Guidance for Ear Examination- Prior to the physical examination of the ear, listen to the patient, elicit symptoms and take a careful history. Thorough hand hygiene (soap & water) should be undertaken before the physical examination starts.
- Consent
Explain each step of any procedure or examination and ensure that the patient understands and gives consent. Consent may be given verbally or written depending on local preference [refer to appendix 2 for a suggested ear irrigation consent form].
If verbal consent is given, then it is important for the Health Professional to record that this has been asked and given in the patient’s notes.
- Ensure that both you and the patient have privacy and are seated comfortably at the same level. 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 size of speculum that will fit comfortably into the ear and place it on the auriscope.
- Gently pull the pinna upwards and outwards to straighten the ear canal (directly down and back in children). Localised infection or inflammation will cause this procedure to be painful, so if this is present do not continue!
- Hold the auriscope like a pen and rest your small finger on the patient's head as a trigger against 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.
- Looking through the auriscope, check the ear canal and tympanic membrane. The ear cannot be judged to be normal until all the areas of the membrane are viewed. 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.
- If the patient has had canal wall mastoid surgery, methodically inspect all parts of the cavity and tympanic membrane 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 has been seen.
- The normal appearance of the membrane or mastoid cavity varies and can only be learned by practice. Practice will lead to recognition of any abnormalities.
- Carefully check the condition of the skin in the ear canal as you withdraw the auriscope. If there is any doubt about the patient's hearing an audiological assessment should be made. Thorough hand hygiene (soap & water) should again be undertaken before going to complete any documentation.
- Document what was seen in both ears, the procedure carried out, the condition of the tympanic membrane and external auditory meatus and any treatment given.
- Findings should be documented, following your Professional Body’s recommendations on record keeping and accountability. If any abnormality is found, a referral should be made to the ENT Outpatient Department following local procedures.
Earwax forms a protective coating of the skin in the ear canal. Small amounts are made all the time and the quantity of earwax produced varies greatly from person to person.
The ear canal is usually self-cleaning. Patients should be discouraged from putting any implement into their ear as this can damage the delicate ear lining and increase the likelihood of ear infection, itchiness and problems with the build-up of wax.
Remember wax is not formed in the deep part of the ear canal near the eardrum, but only in the outer part of the canal. When a patient has wax blocked up against the eardrum it is often because they have been probing their ears with cotton buds, pen tops, match sticks, paper clips, Kirby grips or the end of their pencil!
Patients shouldn’t put anything into their ears!
Patients should also be encouraged to maintain the health and well-being of their ears by keeping their ears dry during showering or bathing, as it may be their shampoo or soap that is irritating the skin. Patients should also ensure that they dry their ears using a towel or dry tissue afterwards.
Guidance on the Use of Wax Softeners – Olive OilDespite there being a vast array of wax softeners available, olive oil is the current oil of choice. These NHS Grampian guidelinesrecommend the use of olive oil as it is effective, cheap and readily available from Pharmacists in a glass dropper bottle that has been specifically designed for applying into the ear.
Maintenance Use
Evidence and practical experience show that where patients suffer from excessive wax, the insertion of 1 to 2 drops of olive oil on a regular basis (e.g. weekly, depending on the Health Professional’s clinical judgement and the hardness of the wax) may help the ear clean itself, thus reducing or eliminating the need for regular ear irrigation.
Guidance on the Use of Wax Softeners – Olive Oil/ continuedOther Oils In Use
It is impossible to give a complete and definitive guide to all the ear softening oils available to patients, however some of the more commonly used oils include:
Almond Oil – should be avoided due to the risk of anaphylaxis caused by nut allergy.
Sodium Bicarbonate – can be effective, but tends to dry the ear, which is unhelpful in older patients.
‘Over-the-counter’ products such as Cerumol or Otex are also not recommended routinely as they are generally more expensive and have no clear clinical advantage over olive oil. Their side-effects can also include local irritation to the ear lining which can further compound the patient’s ear problems.
For further information on these drugs visit the BNF website at:
Patient Advice Prior To Ear Irrigation
Insert 1 to 2drops of olive oil into the ear(s) requiring wax softening, every morning and evening commencing at least 3-7 days prior to treatment. The olive oil should be administered at 370. Patients can heat the oil to this temperature by placing the closed glass dropper bottle containing the oil into a cup of warm water for two minutes or by allowing it to come up to room temperature.
The patient should always test a drop of the oil on their hand to ensure that it is not too hot, before placing it in their ear and it may be easier for someone else to put the oil drops in.
Patient Advice Following Ear Irrigation
The ear canal may be vulnerable to ear infection after irrigation. This is caused by removal of all the wax, which has inherent protective properties for the ear canal.
Until the ear produces more wax to protect the canal, patients should be encouraged to keep the ear(s) that have been irrigated dry from the entry of water for a minimum of four or five days after the procedure. This would include activities such as showering, bathing or swimming.
In the unlikely event that patients develop pain, dizziness, reduced hearing or discharge from the ear after the procedure, then they should be encouraged to return and consult with their nurse or doctor.
Guidance on the Use of Syringes in the EarMetal and plastic syringes are now obsolete for use in the ear canal.
Manual syringes are inherently dangerous due to a combination of the design, the pressure of water it creates within the ear canal and the difficulty of disinfecting the syringe after each use.
The Medicines and Healthcare Products Regulatory Agency (formerly the Medical Devices Agency) also has reservations about the use of the metal syringe for wax removal. They expressed concerns 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.
More information can be found at their website:
Electronic irrigators such as the "Propulse” allow irrigation of the ear canal rather then wax removal under pressure. The Medicines and Healthcare Products Regulatory Agency issued Safety Notice SN 9807in 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 and from February 2005, the Propulse III Universal. This guidance document recommends that practitioners use an electronic ear irrigator rather than the manual syringe and refers to the procedure as ear irrigation. The Propulse II and III irrigators have variable pressure control of minimum-maximum, allowing the flow of water to be easily controlled by commencing irrigation on the minimum setting.
The use of the Propulse II or Propulse III Universal are the preferred irrigation methods for all staff in NHS Grampian.
Mirage will offer a part exchange to staff when upgrading from a Propulse I. For more information telephone: 0845 130 5440.
It is also recommended that only disposable ‘one use’ jet tips should be used. On no account should ‘one use’ items be reused or reprocessed. These disposable one use jet tips can be ordered directly from Central Stores.
Product Code:FP00389 / Description:Tip Jet Disposal for Propulse II (Pack = 100) / Price:
£42.00
A complete range of accessories and replacement parts are also available from Mirage by contacting 0845 130 5440 or go to and click on ‘Medical’.
Immediate queries can be sent to:
Reasons for Carrying Out Ear Irrigation Using the Propulse IIThis procedure is only to be carried out by a competent doctor, registered nurse, audiologist or by a learner who is being closely supervised by one of the above.
Irrigating 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, thus making removal more difficult.
Remove discharge, keratin or debris from the external auditory meatus.
Correctly treat otitis externa where the meatus is obscured by debris.
An individual assessment should be made of every patient to ensure that it is appropriate for ear irrigation to be carried out.
Reasons When Irrigation Should Not be Carried OutThe patient has previously experienced complications following this procedure.
Six-week history of middle ear infection.
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).
Twelve month history of perforation or mucous discharge.
The patient has a cleft palate (repaired or not).
In the presence of acute otitis externa with pain and tenderness of the pinna.
Equipment RequirementsAuriscope
Disposable ‘one use’ jet tip
Noots trough
Non-sterile/ non-powdered gloves / Jobson Horne probe
Cotton wool
Head mirror and light or head light
Disposable waterproof cape or towel
Propulse II or Propulse III Universal electronic irrigator with water heated to 40°C
Staff may also wish to wear safety glasses during the procedure
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.
Ear Irrigation Procedure / 1 of 3Procedure /
Rationale
- Check reason and source for referral.
Although in reality, patients tend to self-refer!
- Check whether the patient has had their ears irrigated previously, or if there are any contraindications why irrigation should not be performed.
Consent and information are legal requirements and ensures the practitioner and patient understands the procedure fully.
- Thorough hand hygiene (soap & water) should be undertaken before the physical examination starts then put on non-sterile/ non-powdered gloves.
A child could sit on an adult’s knee with the child’s head held steady. / Refer to the ‘Guidelines for Hand Hygiene’ document issued by the Infection Control Committee (2002) for further information.
The patients ear should be in the practitioner’s direct line of vision with the practitioner as close to the ear as possible.
A sudden movement by the patient (particularly when it’s a child) could cause injury to the ear.
- Examine both ears with the auriscope and record findings. These findings will determine whether the patient does or does not require ear irrigation. If the clinical decision is not to irrigate, then this should be explained to the patient and documented.