Ear care policy - Lincolnshire Community Health Services

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Ear care policy - Lincolnshire Community Health Services

    Ear Care Guidelines

Reference No:

    Version: 2.0

    Ratified by: NHS Lincolnshire Trust Board

    thDate ratified: 26 November 2010

    Maxine Leggett, Georgina Higgins, Maxine Cumberpatch Name of originator/author:

    and Darren Clawson Name of approving Adult Integrated Clinical Governance and Risk Forum

    committee/responsible individual:

    thDate Approved: 26 November 2010

     stDate issued: 1 April 2010

    stReview date: 1 April 2014

    Target audience: Clinical Staff

    Distributed via: myMail Email


    Lincolnshire Community Health Services

    Ear Care Guidelines

    Version Control Sheet

    Section/Para/Version/Description Version Date Author/Amended by Appendix of Amendments

    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

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    Lincolnshire Community Health Services

    Ear Care Guidelines


i. Version control sheet

    ii. Contents

    iii. Policy statement

    Section Page 1 Background / Rationale 5

     1.1 Objectives 6

     1.2 Documentation 6 2 Objectives of Ear Care 6

     2.1 Principles of Assessment 6 3 Procedures 6

    3.1 Guidelines For Ear Examination 7

     3.2 Guidance for the Use of Ear Drops 8

     3.3 Guidelines and Treatment for Removal of Ear Wax 8

     3.3.1 Guidelines on Equipment Used for Wax Removal 8

     3.3.2 Use of Jobson Horne Probe/ Or Propulse 11/111 9

     3.3.3 Guidance for Procedure for Ear Irrigation Using 9 Electronic Irrigator

     3.3.4 Guidance and Principles for Aural Toilet 12

     3.3.5 Guidance for Removal of Excessive Ear Wax 12 4 Ear Car Competencies 13

     All Competencies Met and Achieved 15

    Appendix 1 Ear Care Guideline Maintenance and Cleaning 16 of Equipment

    Appendix 2 Ear Care Guideline Conditions Practitioners 17 need to be aware of

     References 18

     Diagram of Ear 19

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    Lincolnshire Community Health Services

    Ear Care Guidelines

    Policy Statement

    The purpose of the Ear Care Guidelines is to implement a co-Background

    ordinated and uniform approach to ear car in the community

    Lincolnshire Community Health Services will develop policies to Statement

    fulfil all statutory and organisational requirements. These will

     be comprehensive, formally approved and ratified,

    disseminated through approved channels and implemented.

    Responsibilities Compliance with this guideline will be the responsibility of all

    Lincolnshire Community Health Services Staff.

    Authors of policies are responsible for undertaking appropriate

    consultation during the development of any policy.

    The guidance will be agreed at the Adult Integrated Clinical

    Governance and Risk Forum and ratified by the Clinical

    Effectiveness and Risk Committee.

    Heads of Service and operational managers are responsible for Training

    ensuring staff receive training relevant to their role.

Dissemination Website

    Via myMail Email

    Identified in Lincolnshire Community Health Service staff


    The policy has been developed in line with the NHS Litigation Resource implication

    Authority guidelines to provide a framework for staff within

    LCHS. The guidance requires access to specific disposable

    clinical equipment and medical devices.

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    Ear Care Guidelines

    The contents of this document are based on „Guidance for Ear Care‟ published by Rotherham Primary Ear Care Centre which were developed by the „Action on ENT‟ Steering Board (2002) and

    were revised by the Primary Ear Care trainers Rotherham Primary Ear Care Centre (2008). The

    document „Guidance in Ear Care‟ has been endorsed by the Royal College of General

    Practitioners, The Royal College of Nursing and the Medical Devices Agency. Reference: www.earcarecentre.con


    Ear Wax or excess cerumen is a common problem affecting approximately one third of adults in the UK (Kraszewski, 2008). The Institute of Hearing Research (2009) estimates that over half of people aged 71 80 have some degree of hearing loss and that 55% of people over the age of 60 experience some deafness or are hard of hearing (Royal national Institute for Deaf people, 2008). Nursing literature also identifies that a major cause of hearing impairment is due to impacted cerumen resulting in itchiness, discomfort and earache (Rodgers, 2009; Kraszewski, 2008).

    Wax or cerumen is a normal secretion of the ceruminous glands in the outer meatus. It is slightly acidic, giving bactericidal qualities in both its wet, and sticky form, (as secreted by Caucasians and Afro-Caribbean‟s) or dry, flaky form (as secreted by Orientals). In addition to epithelial migration, jaw movement assists the movement of wax to the entrance of the External Auditory Meatus (EAM) where it emerges on to the skin. A small amount of wax is normally found in the EAM and its absence may be a sign that dry skin conditions, infection or excessive cleaning have 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 older adults and patient with learning difficulties, hearing aid users, people who insert implements into the ear or have a narrow EAM. A build-up of wax may also occur as a result of anxiety, stress and dietary or hereditary factors. Excessive wax should be removed before it becomes impacted, which can give rise to tinnitus, hearing loss, vertigo, pain and discharge. If it is removed due to the presenting complaint of hearing loss, ascertain whether good hearing is restored after treatment or if the patient would benefit from a formal assessment by the ENT surgeon or Audiologist. Older adults with a bilateral hearing loss can be referred back to the GP for assessment and possible referral to the Audiology Department (Rotherham primary Ear Care Centre, 2008)

    Although the ear has natural mechanisms for the removal of ear wax, it is recognised that contributory factors may be present; and as a result certain people do experience problems with the accumulated wax. Despite non invasive interventions being carried out first there are occasions when ear irrigation is required.

    Ear irrigation is an invasive procedure with the potential to cause discomfort or injury (Cook 1998 in Kirklees) and therefore must only be considered when other conservative methods of wax removal have failed (e.g. the use of softeners).

    Risk associated with irrigation include tympanic membrane perforation and otitis externa.

    These guidelines only relate to ear irrigation for the purpose of cerumen (wax) removal. Metal syringes should never be used as their use is obsolete due to the dangers attached to this type of equipment. Propulse 11 or Propulse 111 is the equipment of choice. Safety precautions are essential when using electronic irrigators. Propulse irrigators should be serviced annually. (MDA 1998)

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    A review by the Medical Defence Union of General Practitioners looked at claims settled over a five year period and revealed that ear syringing accounted for 19% of the total claims (Price, 1997) with poor technique, faulty equipment, excess pressure and failure to examine as the four main reasons for this.


    Audit revealed the need to standardise practice by issuing guidelines for best practice and to provide training and updates for all nurses providing ear care. Therefore these guidelines are aimed at community staff to support their clinical practice in the provision of ear care to patients in their own home.

    The experienced practitioner should use his/her clinical judgement on the best method of ear examination and wax removal.

    These guidelines have been developed to assist practitioners in gaining knowledge and experience in the provision of ear care. They do not replace the need for education, training and supervision in order to perform these procedures.

    Practitioners undertaking ear care in the community must therefore have attended Ear Care Training and be deemed competent by a practitioner experienced in ear care and who has attended the relevant training. Competencies which must be completed after attending the Ear Care Training can be found in section 7.0.

    Professionals are individually accountable for their professional practice (NMC, 2008) and professionals using these guidelines should have their competency reviewed on annual basis via their KSF performance review.


    Full consent, history and assessment must be documented using the Ear Care Template on System One. This can be found in the Clinical Tree under Templates and Regular Contacts.


    ; To provide an opportunity to educate patients in good ear care

    ; Improve conduction of sound where the impacted wax is believed to be the cause of

    hearing deficit

    ; To enable the proper functioning of a hearing aid ( excessive wax causes both feedback,

    i.e. whistling and poor sound quality)

    ; Where the wax is considered to be the source of discomfort

    ; To prevent further wax impaction occurring by providing patient advice and education


    Before any intervention is initiated a through assessment and examination of the patient‟s ear history should take place. The ear care checklist is a guide for staff to support them in the assessment process.

    On assessment if wax is the cause of the patients hearing loss and discomfort initiate the use of a softening agent for 5-7 days to soften the wax.


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    3.1: GUIDELINES FOR EAR EXAMINATION (Ear Care Centre, 2008)

    Adult Patient:

    1. Before careful physical examination of the ear, listen to the patient, elicit symptoms and

    take a careful history. Explain each step of any procedure or examination and ensure that

    the patient understands and gives consent. Ensure that both you and the patient are

    seated comfortably, at the same level, and that privacy is maintained.

    2. Examine the pinna, outer meatus and adjacent scalp. Check for previous surgery incision

    scars, infection, discharge, swelling and signs of skin lesions or defects. Identify the

    largest suitable disposable speculum that will fit comfortably into the ear and place it on the


    3. Palpate the tragus in order to identify if the patient has any pain. Proceed with caution.

    4. Gently pull the pinna upwards and outwards to straighten the EAM (directly down and back

    in children). If there is localized infection or inflammation this procedure may be painful

    and examination may be difficult.

    5. Hold the otoscope like a pen and rest the small digit on the patient‟s head as a trigger for

    any unexpected head movement. Do not move the patient‟s head when the otoscope is in

    the ear. Use the light to observe the direction of the EAM and the tympanic membrane.

    There is improved visualisation of the tympanic membrane 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.

    6. Looking through the otoscope, check the EAM and tympanic membrane. Adjust your head

    and the otoscope to view all the tympanic membrane. The ear cannot be judged to be

    normal until all the areas of the membrane are viewed: the light reflex, handle of malleus,

    pars flaccida, pars tensa and anterior recess. 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


    7. If the patient has had canal wall mastoid surgery, methodically inspect all parts of the

    cavity, tympanic membrane, or remaining tympanic membrane, by adjusting your head the

    otoscope. The mastoid cavity cannot be judged to be completely free of ear disease until

    the entire cavity and tympanic membrane, or remaining tympanic membrane has been


    8. The normal appearance of the membrane or mastoid cavity varies and can only be learned

    by practice. Practice will lead to recognition of abnormalities.

    9. Carefully check the condition of the skin in the EAM as you withdraw the otoscope. If there

    is doubt about the patient‟s hearing, an audiological assessment should be made.

    Providing they meet certain criteria stated in local referral guidelines, older adults with a

    bilateral hearing loss can be referred to the General Practitioner (G.P) so that they may be

    considered for referral to the Audiology Department. Patients with a unilateral loss should

    be referred to ENT by the GP.

    10. Document what was seen in both ears, the procedure carried out, the condition of the

    tympanic membrane and External Auditory meatus and treatment given. Findings should

    be documented, with nurses following the NMC guidelines on record keeping and

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    accountability. If any abnormality is found a referral should be made to the ENT Outpatient

    Department following local policy.


    It is recommended to soften the wax using olive oil. Droppers can be purchased separately at local chemists by the patient / carer and should be advised that they individual use. The rationale is that olive oil is less of an irritant on sensitive skin. It also acts as a moisturiser and is cost effective when compared with other softeners some of which can be irritant. Nurse prescribers are able to prescribe olive oil if necessary from the nurse prescribers formulary. (BNF, 2010; Nurse Prescribers Formulary for Community Practitioners, 2009-2011). The administration for 7 days is the minimum recommended. On no account should olive oil be heated. EAROL Olive

    oil spray is now available with instructions for use.

    Information to provide to patients in respect of olive oil ear drop administration; hands must be decontaminated prior to any patient contact and after the procedure is complete.

    I. Lie down on your side with the affected ear uppermost

    II. Drop 2 to 3 drops of oil, at room temperature into the ear massage tragus and pull pinna

    backwards and upwards. This enables the oil to run into the ear canal

    III. Stay lying down for 5 minutes then get up, wipe away any excess oil. DO NOT leave

    cotton wool at the entrance of the ear

    After using softening agent for a minimum of 7 days reassessment of the patients ears is required before any further intervention is planned.



    The metal syringe is obsolescent for use in the External Auditory Meatus. The syringe design is inherently dangerous. Combined with the danger of the syringe itself and the pressure of water it creates with EAM, there is the difficulty of disinfecting the syringe after each use. The Medical Devices Agency (MDA, 1998) also has reservations about the use of the metal syringe for wax removal hence they should not be used. There are issues 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.

    Electronic irrigators such as the “Propulse” and the “Otoscillo” allow irrigation of the EAM rather then wax removal under pressure. The Medical Device Agency issued Safety Notice SN 9807 in 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. Propulse III is now available which is both mains and battery operated.

Please note: This guidance document does not recommend the use of manual syringes or the

    Propulse I, even with an isolation transformer, but recommends that practitioners should use the Propulse II or III irrigator and refer to the procedure as ear irrigation.

    The Propulse II and III irrigator have a pressure-variable control of minimum/maximum, allowing the flow of water to be easily controlled by commencing irrigation on the minimum setting. For patient safety, Propulse has limited the maximum pressure available; this limit is stated in the user instructions. The Propulse III irrigator has specific disinfecting guidelines issued with approval from infection control committees and must be decontaminated between patients. Refer to manufacturers guidance. (Mirage 2006).

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    Use disposable Jet Tips and disposable Otoscope ear pieces, disposable Jobson Horne Probes and Henkle forceps when undertaking any treatments.


    If wax is soft and at the edge of the external auditory meatus it can be removed using a Jobson Horne probe or irrigation using the Propulse 11 or the new Propulse 111.

Criteria for Patient inclusion;

    ; When the patient has excess wax obscuring the tympanic membrane which needs to be

    removed for diagnostic circumstances;

    ; Where the patient has wax confirmed by an examination by a GP or registered nurse;

    ; Where the patient has given consent to the procedure and has had the potential

    complications of ear wax removal explained to them. This should be documented in the

    patient‟s records;

    ; Each patient should have an individual risk assessment carried out to ensure they meet

    the criteria for inclusion and identify risks that would exclude them from the procedure;

    ; The risk assessment should include an assessment of the safest environment to carry out

    the procedure.

Criteria for Exclusion

    ; The patient has previously experienced complications following this procedure in the past;

    ; There is a history of a middle ear infection in the last six weeks;

    ; 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


    ; The patient has a perforation or there is a history of a mucous discharge in the last year;

    ; The patient has a cleft palate (repaired or not);

    ; There is evidence of acute otitis extena with pain and tenderness of the pinna.



    Healed Perforation




    This procedure is only to be carried out by a trained doctor, nurse or audiologist. It may also be carried out by a healthcare worker who has received recognised training in ear care and the use of ear care equipment. This training is available from the Professional Development Team hosted by LCHS and requested via Lincolnshire Learning Academy. Training reporting function carried out by E-systems team and managers to access the training records of individual staff through „ESR Manager self-service‟.

PRINCIPLES Irrigation of 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, making removal more difficult;

    ; Remove discharge, keratin or debris from the external auditory meatus.

    An individual assessment should be made of every patient to ensure that it is appropriate for ear irrigation to be carried out.

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REASONS for using this procedure

In order to:-

    ; Correctly treat otitis externa where the meatus is obscured by debris;

    ; Improve conduction of sound to the tympanic membrane when it is blocked by wax;

    ; Remove debris to allow examination of the external auditory meatus and the tympanic


    ; Remove cerumen in order to facilitate hearing aid mould impressions.

Irrigation should NOT be carried out when:-

    ; The patient has previously experienced complications following this procedure in the past;

    ; There is a history of a middle ear infection in the last six weeks;

    ; 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


    ; The patient has a perforation or there is a history of a mucous discharge in the last year;

    ; The patient has a cleft palate (repaired or not);

    ; There is evidence of acute otitis externa with pain and tenderness of the pinna.



    Healed Perforation



    ; Otoscope / disposable tips

    ; Head mirror and light or headlight and spare batteries

    ; Electronic irrigator (Propulse II or III)

    ; Tap water at 37ºC

    ; Noots trough/receiver

    ; Jobson Horne probe and cotton wool

    ; Tissues and receivers for dirty swabs and instruments

    ; Disposable waterproof cape and paper towels

    ; Disposable apron and gloves



    Prior to any contact with the patient hands must be decontaminated and appropriate personal protective equipment applied.

1. Consent should be obtained and documented prior to proceeding;

    2. Examine both ears by first inspecting the pinna and adjacent scalp using direct light. Check

    for previous surgery incision scars or skin defects, then inspect the EAM with the otoscope;

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