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What lies beneath your ear irrigator jet tips?

Rosemary Rodgers
MA(Ed) PGDip(Ed) MCGI RGN RSCN
Independent Specialist Nurse Consultant
Ear Care Services
Stag Medical Centre
162 Wickersley Road
Rotherham
S60 4JW
E:earcareservices uk@btinternet.com
W:www.earcare servicesuk.com

The electronic ear irrigator is used daily in general practices throughout the UK. A variety of cleaning methods, dependent on the frequency of use of the irrigator and the local infection control policies, are used to clean the now-obsolete reusable jet tips.
It has been shown that otitis externa is one of the problems that occurs following ear irrigation.(1-4) External ear canal infections can be related to many factors, and as professional clinicians it is our duty of care to address and prevent all possible causes of infection resulting from clinical treatments. One of the possible causes relates to recent research directed by Dr David Coates, an independent microbiology consultant.
There is a significant risk that the reusable jet tips (obsolete since September 2002), which deliver the water into the patient's ears during irrigation, are not being cleaned effectively and can remain contaminated with bacteria. Disposable "one-use" ear tips are shown to be the preferred and more suitable option.

External ear infections
The occurrence of otitis externa following ear irrigation has been recorded in many studies, as shown in the papers mentioned above. There are many factors that can cause this problem, and each should be addressed and prevented wherever possible in the nurse's duty of care for the patient. Bacteria can rapidly proliferate in a warm moist environment, such as the ear canal, especially where the skin has been traumatised or the tissue defences compromised in other ways.(5) Hence it is preferable to gently dry the ear meatus following ear irrigation and recognise and treat any potential cause of infection. There is more likely to be evidence of infection occurring where there has been attempted self-cleaning(6) or inflammation caused by the use of some proprietary cerumenolytics(7) before irrigation, including over-the-counter sprays, which maintain a wet environment in the meatus. The patient's general health, skin condition and personal hygiene methods are all relevant factors when considering the probability of otitis externa developing following ear irrigation.
The habit of lying down in the bath with the head under water has been shown to increase the chances of ear infections by reason of the water, containing body bacteria, becoming trapped behind ear wax. It can be difficult to recognise bacterial debris as it can have an appearance of caramel-coloured, soft cerumen or moist keratin debris, and the patient presents with similar symptoms to just having excess ear wax. These are itchiness, blocked, full feeling, tinnitus and discomfort. The inflammation following irrigation may just be attributed to the irrigation process, and an infection may not be recognised. This could necessitate a further doctor visit and a prescription. Bacteria such as Pseudomonas spp can rapidly proliferate in wet conditions,(5) so clearing and drying the ear meatus, recognising any minor inflammation, trauma or infection and providing first-line treatment and advice about future ear care will help prevent the development of major ear problems.

Potential causes of infection
However, another factor to consider in the potential causes of otitis externa following ear irrigation is the introduction of bacteria through the use of the irrigator. The cleaning of the irrigator and the technique used when actually irrigating the ear are also relevant factors. Consider whether you are still irrigating ears "blind", or can you actually see into the ear canal as you irrigate (using a headlight)? Safety in practice increases patient satisfaction, reduces time spent in the practice of ear irrigation and decreases risk of litigation. Consider Continued Professional Development and whether a short refresher course would help.
In the past the reusable ear tips have been cleaned in various ways, including holding under running water, using washing-up liquid or placing them in the reservoir when cleaning the irrigator with a sodium dichloroisocyanurate (NADCC) cleaning and decontaminating product. This information was collected through a surgery survey in September 2004. The reusable jet tips, which used to be sold with the electronic irrigator, have a narrow bore, and air can remain trapped unless properly expelled prior to immersion in NADCC. The manufacturer recognised the potential likelihood of variable cleaning standards by the multitude of users and replaced the original reuseable jet tips with one-use ear tips, which come individually wrapped, in September 2002. However, the obsolete reusable jet tips are still in use in some practices on the grounds of economy and the assumption that there is a sufficient degree of cleanliness.

Testing for cleanliness
Microbiological tests were carried out on 120 reusable jet tips collected from surgeries (selected from the previous survey) across five counties in the UK to determine the hygienic state of jet tips, which were classified by the surgeries as "clean and ready to use".
The purpose of this study was to determine the reliability of the cleaning procedures being used in surgeries by examining the reusable jet tips that had been cleaned in the surgeries and were considered ready to use. Two of the 22 samples (some practices provided many jet tips, so every tip collected from one practice became one sample) had not been cleaned in this manner. The study was also to highlight any hygiene issues with regard to potential risks of cross-infection. It is the duty of clinicians and employers to follow current manufacturer's guidelines in order to ensure a uniform level of cleanliness and eliminate the risk factors.

Discussion
The study demonstrated the magnitude of microorganisms on the tips that had not been cleaned, showing that the jet tips are a great risk of infection for patients if used without correct cleaning. These samples were found to be contaminated with E Coli, Staphylococcus spp, Pseudomonas spp, and fungus and yeast organisms. However, five of the samples that were cleaned and ready for use were also found to be contaminated with these bacteria, fungus and yeast microorganisms. Half of all the samples were contaminated with fungus and yeast microorganisms. Eighty-six percent of the ear irrigator jet tip samples showed some contamination, while 11% of these samples contained high-enough levels of contamination to present a clear infection control concern. As the culture plates were only incubated aerobically, it can be anticipated that microorganisms requiring other atmospheres for growth, such as anaerobic bacteria, could also be present on the jet tips.
The jet tips' necessary hollow cannula style of design, with a radius curve and a very narrow terminal lumen (orifice), makes them hard to clean effectively. Repeated cleaning and disinfection may result in micro-etching of the inner surface, which will promote adherence of organic material. Some of the jet tips sent for testing were discoloured with age and showed signs of wear.
It was expected that, as the surgeries knew their ear tips were being sent to the laboratory for inclusion in microbiological tests, the majority of them would have been cleaned carefully before collection, except for the samples where it was stated that cleaning had not taken place. Therefore it is surprising to find that many of the pooled samples remained contaminated after cleaning. Previously recommended methods of cleaning the reusable ear tips had to be followed carefully to be effective. NADCC solutions rapidly lose strength after preparation so must be prepared fresh each day. They are inactivated by organic matter, so the reusable jet tips had to be scrupulously cleaned before immersion. To achieve disinfection, 100% contact between the tip surface and the disinfectant was required. Hence if any air bubbles remained in the lumen of the tip then disinfection of the inner surface was incomplete. Drying of the tips after the disinfection process was extremely important. If just one or two bacteria survive the disinfection process, they can multiply overnight into millions of new bacteria in a warm moist environment.(5)
Following Dr Coates' research, which supports the manufacturer's decision of 2002 to use only the disposable one-use ear tips, the guidelines previously laid down for cleaning the reuseable jet tips are no longer relevant. This research shows the majority of cleaning has been inadequate or variable, compromising the level of hygiene in the procedure.(8) As the standard of hygiene varies enormously, only the disposable one-use ear tip should now be used with the machine according to the present guidelines.

Conclusion
In the nurse's duty of care for the patient, factors leading to possible causes for infection should be identified and prevented wherever possible. Ear irrigation may be an insignificant procedure in the course of nursing practice and not included in the GP contract targets. However, no patient should have to suffer otitis externa following ear irrigation. By following the NHS Ear Care Guidance Document and evidence-based practice, using a recognition and prevention process of care, ear infections following irrigation should be a problem of the past.
The infection risks highlighted in this article, you may think, may not have referred to your practice in the past. However, having read the evidence, you may now harbour a doubt about past practice, which will hopefully result in safer future practice.

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References

  1. Sharp JF, Wilson JA, Ross L, Barr-Hamilton RM. Ear wax removal: a survey of current practice. BMJ 1990;302:1251-3.
  2. Grossan M. Cerumen removal - current challenges. Ear Nose Throat J 1998;77(7):541-6, 548.
  3. Roeser RJ, Ballachanda. Physiology, pathophysiology and anthropology/epidemiology of human earcanal secretions. J Am Acad Audiol 1997;8:391-400.
  4. Browning G. Ear, nose and throat disorders - ear wax. Clin Evid 2005;14:1-3.
  5. Todar K. Todar's online textbook of bacteriology/Pseudomonas aeruginosa. Wisconsin: University of Wisconsin-Madison; 2004.
  6. Hooper M. Aural hygiene and the use of cotton swabs. Nurs Stand 1991;6(12):38-9.
  7. BMJ Publishing Group, Royal Pharmaceutical Society of Great Britain, RCPCH Publications. British National Formulary 2004;47:524-5.
  8. Coates D. Microbiological tests on the obsolete re-useable Jet Tips for the Propulse ear irrigator. Unpublished study. Information from Propulse manufacturer. 2004.

Resource
ENT Nursing
W:www.entnursing.com