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Ear irrigation: minimising the risks

Nurses must always work within their own competence. In the area of ear care there is an increased need for nurses to be fully trained in all aspects of ear health to ensure that not only is the patient protected from harm, but also that the nurse is protected from litigation

Helen E Lewis
RM BMid(Hons) RN(Adult BSc(Hons)
Practice nurse
Newport, South Wales

Excessive amounts of cerumen in the external auditory canal is probably one of the most common otologial problems faced by primary care nurses.(1) Patients will often present with pain in the ear and loss of hearing. The occlusion of the tympanic membrane, which under normal circumstances vibrates freely when hit by sound, reduces the hearing capacity of the individual and is often described by the patient as a muffled sound in the affected ear.
The most common form of cerumen removal is through ear irrigation using warm water to remove the cerumen off the tympanic membrane and restore hearing. However, this high-risk procedure has in the past been undertaken by untrained nurses in more of a "see one do one" approach.(2,3) This has led to an increased incidence of litigation against clinicians.
To enable nurses to work within the sphere of safety and within their own competence level as detailed in the NMC Code of Professional Conduct,(4) it is essential that they understand the examination process, identification of the normal tympanic membrane and alternative methods of cerumen removal.
Anatomy and physiology
It is worthwhile recapping on this aspect of ear irrigation. It is all too easy to allow our basic physiological knowledge to slip into the background due to the amount of ear syringing taking place across the country - 40,000 ear irrigations are completed by practice nurses in the UK each week.(5) This section is not to patronise but simply to focus practice nurses' knowledge on the anatomy and physiology of the ear.
The ear is divided into three sections: external, middle and inner ear. The external ear is made up of the pinna, external auditory canal (EAC) and tympanic membrane. The pinna is a flap of elastic cartilage shaped like the flared end of a trumpet and covered with skin. It is attached to the head by ligaments and muscle. The external auditory canal is approximately 2.5 cm long. It is slightly S-shaped in adults but in children it is slightly shorter and straighter and lies in the temporal bone of the skull and acts as a channel for sound waves to travel from the pinna to the tympanic membrane. The tympanic membrane is a thin semitransparent membrane that separates the outer and middle ear. It is covered by an epidermal layer and lined with simple cuboidal epithelium. Collagen, elastic fibres and fibroblasts are found between these epithelial layers. The ceruminous glands, specialised sweat glands, can be found in the lateral third part of the ear canal.(6)
The middle ear is a small air-filled cavity which is separated from the external ear by the tympanic membrane and the inner ear by a minute bony partition containing the oval and round window - two small membrane covered openings. Connected by synovial joints and spanning the middle ear are the three smallest bones of the body, the auditory ossicles. The bones, named after their shapes are the malleus (hammer) incus (anvil) and stapes (stirrups) respectively. The "handle" of the malleus is attached to the inner aspect of the tympanic membrane. The head of the malleus articulates with the incus, the middle bone of the three, which in turn articulates with the head of the stapes. The base of the stapes fits into the oval window. Directly below the oval window is the round window, which is protected by a secondary tympanic membrane.
The eustachian tube is made up of both hyaline cartilage and bone is located in the anterior wall of the middle ear and connects to the nasopharynx. Under normal circumstances it is closed at its pharyngeal end. During swallowing or yawning it will open to allow air to pass either into or out of the middle ear, equalising the pressure. If the pressure is balanced the tympanic membrane vibrates freely as sound hits it. However, an imbalance of pressure can cause intense pain, hearing impairment, ringing in the ears and vertigo. The eustachian tube is also the route whereby pathogens may travel from the nose and throat to the middle ear causing acute otitis media.(6)
The inner ear, also called the labyrinth due to its complicated series of canals, contains the organs of both hearing and equilibrium. It consists of two main divisions: the bony labyrinth and the membranous labyrinth. The bony labyrinth is a series of cavities within the temporal bone divided into three areas:

  • The semicircular canals.
  • The vestibule, both of which contain receptors for equilibrium.
  • The cochlea, which contains receptors for hearing.

The bony labyrinth is lined with periosteum containing perilymph, a fluid similar in form to that of cerebrospinal fluid. Perilymph surrounds the membranous labyrinth, a series of sacs and tubes inside the bony labyrinth and having the same general form. The membranous labyrinth is lined with epithelium and contains endolymph. This fluid contains unusually high levels of potassium ions which play a central role in the generation of auditory signals.(7)
It is essential that practice nurses have an understanding of all parts of the ear so they can conduct an examination that is both holistic and comprehensive. This will enable the correct diagnosis and plan of care developing, thereby protecting not only the patients but also the nurse.

History and examination
In order to reduce the litigation surrounding ear irrigation due to either poor procedure or poor diagnosis the Guidance Document in Ear Care was produced by the "Action on ENT" Steering Board in 2002,(8) and has recently been revised by the Primary Ear Care Trainers.(9) The document gives a clear step-by-step guide to ear examination that should be routinely followed by all nurses and is detailed in Box 1 below. The document has also been endorsed by the Royal College of General Practitioners, the Royal College of Nursing, the Primary Ear Care Centre and the Medical Devices Agency. It is worth mentioning that the guidance states that both the nurse and the patient should be seated during the examination to aid comfort and visualisation of the tympanic membrane. It is also important that each step of the procedure is explained to the patient in order that consent can be obtained. Rodgers suggests that should the patient complain about a problem in one ear, then the other ear should be examined first to develop a baseline for comparison.(2)
Previous medical history is an important aspect of the consultation for a proper diagnosis to be made and a suitable plan of care developed maintaining safe practice ethics. It is important that the patient is questioned regarding precipitating factors, previous medical problems which ended in surgery, current treatment and family history (if any) of deafness.(10)

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The normal tympanic membrane
The Guidance Document in Ear Care suggests that the ear cannot be judged as normal until the entire tympanic membrane has been visualised.(9) These include:

  • Handle of the malleus.
  • Pars tensa.
  • Pars flaccida.
  • Light reflex.
  • Anterior recess.

The handle of the malleus can be viewed where the malleus bone is in contact with the tympanic membrane. It is generally central to the tympanic membrane and is viewed at 10 o'clock in the left ear and 2 o'clock in the right as the membrane is viewed with an auroscope.
The pars tensa is located in the bottom quadrant of the tympanic membrane and should be intact while the pars flaccida is located in the upper part of the tympanic membrane but is not easily visible with the auroscope.
The tympanic membrane as previously described is a semiopaque membrane;(6) when the light from the auroscope shines upon it a reflection of the light is visible. This is often referred to as the light reflex and is visualised in the lower quadrant of the membrane on the same side as the handle of malleus.
The anterior recess is a slitlike space on the tympanic membrane between the anterior malleolar fold and the membrane itself.(7) The healthy tympanic membrane is a grey pink in colour but as Kaufman suggests recognition of abnormalities is only learnt over time and practice in examination.(10) However, visualisation of the tympanic membrane is only possible if there is no occlusion with cerumen in the first place.

Ear wax
Cerumen (or ear wax) is a greasy sticky material made up of oil and sweat secreted from the ceruminous glands located in the subcutaneous layer, deep to the sebaceous glands. It is the combination of these secretions that helps to maintain the health of the ears. It is an antifungal and antibacterial which acts as a filter to protect the tympanic membrane (eardrum). The consistency of the cerumen will also prevent the entry of foreign bodies into the ear canal.(7) The normal processes that occur in the external ear canal in order to clean and renew the lining of the ear canal take approximately two weeks. The skin is moved up from the tympanic membrane to the external ear which means that the lining of the ear is continually being renewed. Therefore while some patients consider that their ears should be routinely cleared of ear wax, this is not necessarily the case. It is also important to stress that under no circumstances should anything be used to artificially clear the ear canal, such as matches cotton buds or fingers!
Occasionally the cerumen can build up in the ear canal - patients who wear ear plugs, hearing aids, work in a dusty or dirty environments or have narrow ear canals may find these are the cause of the wax build-up. Patients wearing hearing aids may find that the ear mould that sits low down in the ear canal has a direct link with a build-up of wax and will often present themselves complaining that they can hear a high-pitched whistle coming from their hearing aid. Tinnitus has also been described as a whistle in the ear, or a hissing, ringing or buzzing in the ears, and therefore it is important that the clinician checks that the patient does or does not wear a hearing aid. Harkin suggests that some individuals produce more cerumen due to anxiety and dry skin conditions. Impaction in the over-60 age group may be as high as 34%,(11) and this may be due to increased usage of hearing aids in this age group which prevents the cerumen from being excreted from the external auditory canal in the normal process. If excessive amounts of cerumen are found the patient should be advised to use olive oil drops in order to soften the wax and help the ear clean itself thereby reducing the need for ear irrigation.(10)
Notwithstanding the advice above on olive oil drops, in order to promote self-cleaning of the ear, ear irrigation remains the most common technique for the removal of cerumen within general practice.(11) Under no circumstances should metal syringes be employed to remove the excess cerumen; they are, as suggested by Rodgers, heavy, unwieldy and difficult to control, and may also be associated with an increase in perforation of the tympanic membrane due to the pressure they exert during the removal process.(3) However, it should be kept in mind that using an electric ear irrigator is not without its drawbacks and careful preparation and maintenance must be paramount. The patient should be advised of any possible complications arising from ear irrigation,(1) before the commencement of ear irrigation, such as:

  • Tinnitus and dizziness.
  • Trauma.
  • Otitis externa (external ear infection).
  • Perforation of the tympanic membrane.

However reduction in complications attributed to ear irrigation can be reduced and has been endorsed by a number of primary care authors by following the Guidance Document in Ear Care and attending a certified training course.
A full history should be sought prior to any ear irrigation procedure being undertaken as this will highlight any contraindications to the procedure being completed. The Guidance Document in Ear Care (Primary Care Trainers 2007) clearly states the contraindications to ear irrigation, which include:

  • The patient has previously experienced complications following this procedure in the past.
  • History of middle ear infection in the previous six weeks.
  • Any form of ear surgery.
  • Perforation of the tympanic membrane.
  • Cleft lip and palate (repaired or not).
  • Evidence on examination of acute otitis externa with pain and tenderness to the pinna.

While the Guidance Document in Ear Care is very comprehensive and is clearly updated on a regular basis it is no replacement for a certified training course. It should also be recommended that clinicians carrying out this procedure should attend regular update sessions in order to comply with the NMC Code of Professional Conduct in which it states that nurses are responsible for updating their own knowledge and skills.(4)

Patient education
To prevent the build-up of cerumen, patient education must form part of the consultation process in how to care for the ears. Coopey suggests that patient education leaflets should be given and discussed during the consultation,(3) which may reduce the need for future irrigation. Stubbs advises that using one drop of olive oil per week will help maintain a healthy ear by encouraging self-cleaning.(12) It is imperative to the success of education that patients are told about the ill-effects and potential damage they are doing by inserting objects into their ears in an attempt to clean them, such as cotton buds, which can damage the delicate lining of the canal.(1) Patient advice leaflets are particularly useful in this regard and can be downloaded, free of charge, from the Primary Ear Care website (www.earcentre.com).

Conclusion
Education for both clinicians and patients is ultimately the single greatest advantage to increasing an understanding into ear health and care and reduces the chances of minor ear problems developing into major ones.(2) Before undertaking such responsibilities nurses have a duty to themselves and their patients to be guided by the Code of Professional Practice by attending a certified course and ensuring that they have access to an experienced mentor. There is an increased need for nurses to be fully trained in all aspects of ear health and become evidence-based practitioners to ensure that they are protected from litigation and their patients are protected from harm.

References

  1. Harkin H. A nurse led ear care clinic - sharing knowledge and improving patient care. Br J Nurs 2005;14:250-4.
  2. Rodgers R. Primary ear care treatments. Practice Nurse 2003;25(9):69-73.
  3. Coopey S. Ear syringing - a case for clinical governance. J Commun Nurs 2001;15:20-2.
  4. Nursing and Midwifery Council. The NMC code of professional conduct: standards for conduct, performance and ethics. London: NMC; 2004.
  5. Dinsdale RC, Roland PS, Manning SC, Meyerhoff WL. Catastrophic otologic injury from oral jet irrigation of the external auditory meatus. Laryngoscope 1991;101:75-8.
  6. Waugh A, Grant A. In: Ross and Wilson Anatomy and Physiology in Health and Illness. 9th ed. Edinburgh: Churchill Livingstone; 2004.
  7. Tortora G, Grabowski S. Principles of anatomy and physiology. 10th ed. London: Wiley; 2003.
  8. Action on ENT. Guidance document in ear care. 2002.
  9. Primary Care Trainers. Guidance document in ear care. 2007. Available from: http://www.earcarecentre.com (accessed on 6th January 2008).
  10. Kaufman G. Ear problems: care and prevention. Practice Nurse 1998;15:338-42.
  11. Lewis-Cullinan C, Janken J. Effect on cerum removal on the hearing ability of geriatric patients. J Adv Nurs 1990;15:595-600.
  12. Stubbs G. Ear syringing and aural care. Nurs Times 2000;96(43):35-7.

Your comments (terms and conditions apply):

"As stated in this article, the management to reduce the need for repeated irrigation is weekly drops of olive oil. However, the GP surgery where I currently work does not agree with ear irrigation as a firstline treatment and we prescribe sodium bicarbonate for three weeks. The patient is then advised
to return if still experiencing problems after this time. It is only then if the tympanic membrane is not visible and a plug of wax is apparent that ear irrigation will be performed. I think ear irrigation is used too often as the easy option, alternatives should be tried as initial management. Ear syringing after all should be performed with caution." - Maria Hazelwood