Ear care and irrigation with water: an update

Ear care is just one of the many aspects of every day practice nursing, and for many, one of the most common procedures undertaken. But the last published guidance is more than 10 years old: here we bring a preview of the update currently underway

It was in March 2002 that the Action on ENT steering board produced a guidance document to assist practitioners in the community in performing ear care.¹ There had been no national guidelines in place for ear irrigation with water, and this document aimed to address that issue for the benefit of patient care and safety. This guideline is currently being updated with the assistance of the author and the Primary Ear Care Centre (PECC), and the current updates will be discussed here.

The initial aim of the guidance document was to suggest a basic standard for ear care. As a result, it introduced information regarding basic ear anatomy and physiology, examination advice and suggestions for performing ear care in the community. The hope was to reduce the number of complications post irrigation with water. Understanding the basic anatomy and physiology of the ear is important in order to be able to assess, diagnose and offer appropriate treatment options. One of the recommendations was that practitioners should attend an ear care course, such as those facilitated by the PECC (http://www.earcarecentre.com/), to ensure they had the clinical knowledge to underpin the most appropriate treatment options.

It is estimated that between 2% and 4% of people suffer from wax impaction: its removal is the most frequent ENT procedure carried out in the UK.² Wax is usually removed by irrigation with water, and the procedure is most frequently performed by the practice nurse. Although approximately two million people in England and Wales have their ears irrigated with water every year,3 not every practice nurse in a surgery might carry out the procedure frequently. It can prove difficult to keep up to date with new information regarding contraindications to irrigation with water. Reasons why irrigation with water should not be carried out with specific patient signs and symptoms are listed in Table 1, and situations where caution should be exercised are given in Table 2.

To aid the practice nurse the author has devised a checklist, to reinforce their ear care and irrigation with water competence and confidence. (see illustration above)

SOFTENING PRIOR TO REMOVAL

There is no conclusive research regarding the best method of softening wax prior to removal. The Cochrane review5 of ‘softening’ ear drops concluded that ‘water and saline drops appear to be as good as more costly commercial products’. Within the author’s own practice, irrigation is started in the ear where there appears to be harder wax and left to run for 10 seconds. The water is then left in the ear canal to soften the wax while irrigation is commenced on the other side. If the wax is hard in both ears then the patient is asked to sit outside the treatment room for 15 minutes (time often depends on patient workload!) while the wax is softened. This has hugely reduced the time it takes to remove all the wax from the ear canal.

There is also no research advocating that patients should be advised to use a softening preparation for a period of time before attending wax removal appointments. When a liquid is inserted into the ear canal, the wax can expand, increasing uncomfortable symptoms. If the hearing is reduced or vertigo occurs as a result of the expanded wax, there could be concern over patient safety and the nurse’s practice of ear care called into question. I find that olive oil inserted into the ear canal on the night before and the morning of the appointment lubricates the canal aiding the wax removal process. A spray dispenser is easier to use than drops, and can improve compliance.

OPPORTUNISTIC EXAMINATION

Due to the significant symptoms of wax impaction and potential co-morbidity of symptoms, I would encourage nurses to carry out routine examinations opportunistically, for example, in general health assessments. It is incorrect to consider that wax ‘just’ causes blocked ears. It has been shown to cause tinnitus, vertigo, discharge, pain, hearing loss and otitis externa.⁶ Saana and colleagues7 also found that wax impaction can adversely affect the mental health of patients with schizophrenia. Depending on how much wax there is in the ear canal there can be a 5 to 40 decibel hearing loss.⁸ While it is universally recognised that hearing decreases with age, the problem can be compounded when wax obstructs the ear canal: suddenly an acceptable level of reduced hearing deteriorates to cause significant hearing loss. Hearing loss can lead to miscommunication, social withdrawal, confusion, depression and reduction in functional status.⁹

A practice nurse who understands how wax is produced, why it can become problematic and the symptoms it causes will be able to advise the patient on how to take care of their ears. Many adults insert some form of implement – such as cotton buds – in their ears, but there is a link between wax impaction, external ear infections and cotton bud usage.^10,11 The ear is self-cleaning and ‘fiddling’ with the ears can interfere with this process.

It is important to keep the ears dry, by preventing or protecting them from the entry of water, and to avoid anything that causes irritation to the ears or skin around the ears.¹² This is particularly important if the person suffers from itchy ears. Cotton wool and petroleum jelly offer effective protection. Some practitioners advocate the occasional use of oil to improve the lubrication and condition of the skin in the ear canal.¹³ This will hopefully reduce the likelihood of wax impaction and itchy ears.

CONCLUSION

Wax should be removed before the symptoms of vertigo, tinnitus, discharge, pain, blocked ears, hearing loss and otitis externa occur. The removal of the wax can be managed safely following the guidelines by the nurse trained in ear care thereby improving patient comfort, safety and even quality of life.

REFERENCES

1. Harkin H, for the Action on ENT steering board. PECC Guidance document in ear care, 2007. http://www.earcarecentre.com/HealthProfessionals/Protocols.aspx?id=8

2. Guest JF, Greener MJ, Robinson AC et al. Impacted cerumen : composition,production,epidemiology and management. QJM 2004;97:477-88.

3. Clegg A, Loveman E, Gospodarevskaya E, et al. Ear wax removal interventions: a systematic review and economic evaluation. British Journal of General Practice 2011; Oct 61(591):e680-3.

4. Richard M, Rosenfeld SR, Schwartz C, et al Clinical Practice Guideline: Acute Otitis Externa, Executive Summary. Otolaryngology-Head and Neck Surgery 2014; 150: 161

5. Burton MJ, Doree C ear drops for the removal of ear wax (the Cochrane collaboration). The Cochrane library 2009 issue 1. John Wiley and son.

6. Roland P, Smith T, Schwartz S et al Clinical practice guideline: cerumen impaction. Otolaryngology-Head and Neck Surgery 2008;139,S1-S21.

7. Saana E, Eila S, Kaisia J, et al. Cerumen impaction in patients with schizophrenia. Clinical Schizophr Related Psychoses 2013; 27:1-10

8. Roeser RJ, Ballachanda BB. Physiology, pathophysiology and anthropology/epidemiology of human ear canal secretions. Journal of American Academy of Audiology 1997:391-400.

9. Demers K. Hearing screening. Journal of Gerontological Nursing 2001;Nov. 27(11): 8-9.

10. Kalantan K.A, Abdughani H, Al-Taweel A.A. et al Use of cotton tipped swab and cerumen impaction. Indian Journal of Otology 1999;5:27-31.

11. Hobson Jand abuse of cotton buds. Journal of Royal Society of edicine.2005;98(8):360-361.

12. Osguthorpe,JD.;Nielson, DR. (2006) Otitis externa:review and clinical update. American Family Physician. Nov 1;74(9):1510-1516.

13. Rodgers, R. (2003) Ear problems and solutions. Practice Nurse. 25(8):59-63.