This site is intended for health professionals only

Continued education: preventive ear care

Rosemary W Rodgers
MA(Ed) PG DipEd RGN RSCN
Director
The Primary Ear Care Centre
Rotherham Health Authority
South Yorkshire

The ear canal is the only skin-lined cul-de-sac in the body. If you consider that the ear has self-cleaning properties and was designed with protection of hearing in mind, understanding what is seen through an auriscope is the most important skill a clinician can acquire to enable prevention of ear problems.
Earwax can provide several important clues about a person, and syringing the ear without consideration of this can mean the loss of evidence which could provide information for future prevention.(1)
What is the role of the patient in ear care? Nurses should always listen to their patients - they often have clues regarding the best way to move forward, and they also provide an interesting perspective on medical care. What they reveal, through audit and their difficulties experienced with clinical care, can pose questions for future audit and research and help us understand whether our endeavours in prevention of ear problems through patient education are accepted or ignored.

Patients own the service and help us teach others
The Primary Ear Care Centre carries out regular audits to learn patients' views about ear care services and treatments. The centre aims to maintain a high- quality service and is willing to change practice where necessary.
The Friends of Ear Care support group was established following many enquiries from grateful patients about how they can help others to have an ear care service. Through this group, patients are able to participate in nurse study days and learn more about ear problems and how to eliminate them. The "Friends" also help with ear care exhibitions in their local supermarkets and they design patient education leaflets to help people understand how to care better for their ears.
Because they had ear problems in the past they understand the mistakes they made and recognise how they previously misunderstood the problems. The group feel that they are now well placed to write education leaflets for other people which can then be assessed by medical and nursing staff.
 
Ear care audits
There are 41 practices in Rotherham with a trained nurse in ear care on their staff. In the 1997 patient audit only 27 of these practices took part in the ear care audits. Each participating nurse gave a questionnaire to the next 10 patients who attended for ear care. A total of 212 questionnaires were returned.
Our 1997 audit showed that the majority of people (63%) visit clinics for earwax problems (see Table 1). Patients thought that the advice given by the nurse was generally excellent (48%) or good (43%), with just 6% saying it was adequate and nobody thinking it was poor.

[[NIP04_table1_71]]

Only 6% of patients with earwax problems said that they had their ears syringed frequently. The majority of nurses now use the Propulse electric syringe, and this was shown in the survey - 87% of those whose ears had been syringed on the day said that the electric syringe had been used. The majority (92%) of patients who had experienced conventional and electric syringes said that they found the electric syringe more comfortable.
As the quality of treatment and patient education improve, the attendance for ear care decreases (by 16% in 1998 audit). When the service started the hospital referral rate increased, as longstanding diseased ears were discovered.
After 11 years of offering clinics run by nurses with ear training we now very rarely see severe cases of acute or chronic otitis externa or long-term occlusion by wax. Patients are more ear aware and attend as soon as they feel discomfort. Earwax problems exist, but regular patient preventive visits to clinic enable the problem to be resolved in five-minute appointments. Very rarely does earwax totally occlude the ear canal, and prescriptions for ear drops are seldom required. The majority of patients appreciate the service.
In 1998 the patient audit followed up preference for syringing or instrumentation when removing the wax, and whether the procedure caused any discomfort.  Patients were also asked whether they had ever had their ears syringed for any reason other than earwax and whether they had ever experienced deafness through their earwax problem in the past. Finally they were asked how they managed their ear problem now.
The aim of this audit was to find out whether we should expect a further drop in attendance for ear care. This audit also reflected the changes in patients' personal ear care.
A total of 130 questionnaires were returned, and they showed that 102 people had had their ears syringed at some time in their life. However, 57 (56%) of these had not had their ears syringed within the last three years, and 29 (28%) had had their ears syringed for reasons other than earwax, including infection, foreign bodies and hearing loss. This may indicate that even with patient education there is still a belief that syringing is the treatment to improve hearing.(2) Only 16 (16%) had had their ears syringed for earwax removal in the past three years, which shows a change in previous practice.
Twelve per cent of respondents (12 people) had experienced problems with ear syringing, such as ringing in the ears, severe dizziness, the patient fainted, syringing caused itchiness, damage to the eardrum, ear infection afterwards, or the patient did not like water in their ears. People expressed discomfort with syringing: four (4%) said it was painful, and 32 (31%) described the discomfort as mild pain.
In a more recent audit, 36% of respondents (47 people) had earwax removed by using instruments and a headlight. Only five people had suction treatment, and one complained of vertigo following this procedure. The patients all said that the instrumentation had not caused any problems - 21% experienced mild pain, and the rest experienced no pain.
People accept the removal of earwax as an alternative to waiting for blockage and having the ear syringed. There were more complaints of discomfort with syringing than there were following instrumentation. This may be related to poor nurse technique in the past, or the use of the chrome syringe.
Earwax had caused deafness in the past for 61% of respondents.
So how do they deal with their ear problems now?

  • 58% still have earwax problems.
  • 36% still have itchy ears.
  • 63% now manage their ear problem by attending for regular checks.
  • 5% believe they still need regular syringing.
  • 8% still wait until their ear feels blocked.
  • 5% say their ears are no longer a problem.
  • 6% had various ideas for self-removal, or used regular olive oil and no longer required help.
  • 12% did not reply to this question.

Why there are so many syringing problems
In reviewing many papers on ear syringing it is difficult to find an illustration demonstrating a correct way to hold the syringe.(4) In the illustrations the clinicians do not seem to be looking at what they are doing; and if they are, the syringe is held at the wrong angle, or the water is aimed directly at the tympanic membrane, or there is no light to illuminate the meatus.
There are other procedures involving irrigation of skin with fluid where the clinician observes the task in action: consider a debris-filled leg ulcer. When irrigating an ear, it is common practice to examine the ear before and at times between carrying out the procedure, but infrequently during the whole procedure. By using a headlight the nurse can observe the moving wax while syringing so it can be lifted out of the ear canal sooner, thus minimising the risk of complications such as perforation, otitis externa, vertigo and cardiac arrest.(2)
A pool of water is never left in a leg ulcer wound: the excess is usually removed before dressing. Yet an ear canal may be left with a pool of water at the base of the tympanic membrane if the clinician has not been trained to dry the whole ear canal. A headlight is used to illuminate the meatus while gently mopping the water out with a Jobson Horne wool carrier (1mm wide end) correctly wound with a small amount of cotton wool. It is necessary to see past the instrument when the cotton wool has been applied in order to view the area being dried or cleaned.
It is possible that an ear infection postsyringing could be caused by the remaining static water in the meatus together with minor trauma caused by previous attempts at self- cleaning. Another reason could be the cleanliness of the syringing equipment. Local minor studies showed that flush samples from some ear syringes grew Pseudomonas aeruginosa and coliform.
In April 2001, Dr David Coates performed microbiological tests to evaluate the effectiveness of sodium dichloroisocyanurate (NaDCC) for decontamination of the Propulse 2 electronic ear syringe (study not yet  published; information available through personal communication).
The aim of this article is to encourage clinicians to reflect on their previous practice and better understand the reasons behind the correct syringing procedure mentioned above. They would then possibly be able to identify learning needs, which in turn would improve practice, save on time, discomfort and prescribing costs.(5)

Another lesson to be learnt from patient discussions: over-the-counter eardrops
What is put into an ear canal and why? And how does this affect the skin lining?
If doctors, nurses and patients are asked the question, "What eardrops do you recommend?", they will give totally different answers. Patients often mention products they have seen on the television, or eardrops that they know are for ears "so they must be OK". How effective are these eardrops that patients ask for at the pharmacy?
The British National Formulary states: "Some proprietary preparations containing organic solvents can cause irritation of meatal skin and, in most cases, the simple remedies … are just as effective and less likely to cause irritation."
Contraindications to the use of over-the-counter eardrops include a perforated tympanic membrane, previous otitis externa, and other skin disorders, including seborrhoeic dermatitis. It is usually impossible to identify a perforation or potential otitis externa behind a wax-occluded auditory meatus, while the possible action of these drops on thinning skin caused by steroid medication or the ageing process must also be borne in mind.
People often put extra drops in to make sure the wax will come out, and nurses frequently report the inflamed skin in ears that have been treated with drops containing organic solvents.
Research to show the effectiveness of eardrops has been carried out using cerumen samples in test tubes, but this does not account for patient feelings when an eardrop is instilled with the sole purpose of wax removal and they experience discomfort in the ear canal and a burning sensation in the throat because they have a perforation behind the wax.
Certain substances are advertised as breaking up wax, but do we require the wax to be broken up? The main purpose of cerumenolytics is to soften and lubricate the wax ready for removal without having an adverse effect on the skin-lined cul-de-sac. Drops that are advertised as breaking up wax are less likely to irritate the skin, but patients have experienced pain as the residue of wax becomes small and solid, falls down toward the eardrum and causes pain.
Sodium bicarbonate drops are very effective, but the alkaline properties dry the skin and can cause cracking and/or irritation, especially if there is a history of otitis externa or dry itchy skin.
The Primary Ear Care Centre and Friends of Ear Care recommend olive oil because even if the oil penetrates a perforation and enters the eustachian tube and the nasopharynx, the patient will not experience the same burning pain and discomfort as with other drops, and lubricating the skin with oil is, in most cases, beneficial. We have found only four people in the UK who have adverse reactions to oil. This figure has been obtained by asking every group of nurses taught whether they know any patients who are sensitive to oil.
Beware of nut allergy if nut oils are used. Some proprietary preparations contain arachis oil, which is peanut-based.
A recent paper shows the benefits of using water as a quick softening agent for persistent earwax in general practice.(6) However, it is a commonly known fact among nursing staff that if there is difficulty syringing an ear, leave the ear wet while treating the other ear and on returning to complete treatment for the first ear the wax is more easily removed. They have successfully used the water method in New Zealand for many years.

Conclusion
This article has given new views of the ear canal and may help clinicians reflect on other ways to treat ears. The opinions of patients show that patient education helps prevent canal blockage, and the different ways that patients can help improve ear health services have been demonstrated.
These views are only of value when the comments are put into action. We will help with any identified ear care learning needs and will send information. If you are unable to find the information you require on our website, then please send an SAE with your request.

References

  1. Roeser RJ, Ballachanda BB. Physiology, pathophysiology and anthropology/epidemiology of human ear canal secretions. J Am Acad Audiol 1997;8:391-400.
  2. Sharp JF, Wilson JA, Ross L, Barr-Hamilton RM. Ear wax removal: a survey of current practice. BMJ 1990;301:1251-3.
  3. Price J. Problems of ear syringing. Practice Nurse 1997;14(2):126-8.
  4. Booth L. Ear syringing. Practice Nurse 1998;16(9):580-1.
  5. Fall M, Walters S, Read S, et al. An evaluation of a nurse-led ear care ­service in primary care: benefits and costs. Br J Gen Pract 1997;47:699-703.
  6. Eckhof JAH, de Boek GH, le Cessie S, Springer MP. A quasi-randomised controlled trial of water as a quick ­softening agent of persistent earwax in general practice. Br J Gen Pract 2001;51:6357.
  7. British National Formulary 36.12.1.3 Removal of ear wax. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 1998.

Resources
The Primary Ear Care Centre
Rotherham Health Authority
162 Wickersley Rd
Rotherham
South Yorkshire S60 4JW
W:www,earcarecentre.com

Information
Research on effective decontamination of the electronic syringe completed by:Dr David Coates
Q Laboratories Ltd
Quayside Navigation Way
Ashton-on-Ribble
Preston
Lancashire