* This policy is under review and is being updated.

A revised policy will be added shortly *

Ear Irrigation Guidelines

Document Title:

PCT Document Ref

1313/13224
No.:
Local Document Ref
No.:
Date of Approval:
01 March 2010
Approved by:
Clinical Development Forum

Category: Clinical

Sub Category: Nursing and Provider Service

Responsible Director:
Organisational Development
Date of next review:
01 March 2014
Initial Equality Impact
Yes
Screening:

If required, full impact

assessment attached: No

Who should read this:

All clinical staff who undertake ear irrigation

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POLICY AND PROCEDURE FOR EAR IRRIGATION

CONTENTS Page

1.0 INTRODUCTION 3

2.0 SPECIFIC RESPONSIBILITIES AND ACCOUNTABILITY 3

3.0 RESPONSIBILITIES OF PRACTIONERS PERFORMING EAR

IRRIGATION 3

4.0 TRAINING/SKILLS 4

5.0 CONTRAINDICATIONS TO EAR IRRIGATION 4

6.0 USE OF SOFTENERS 4

7.0 GUIDELINES FOR EAR IRRIGATION 5

8.0 WHEN TO IRRIGATE 5

9.0 PREPARATION OF THE PATIENT 5

10.0 EXAMINATION OF THE EAR 5

11.0 EQUIPMENT TO UNDERTAKE EAR IRRIGATION 6

12.0 PROCEDURE FOR EAR IRRIGATION USING THE ELECTRONIC 7-9

IRRIGATOR

13.0 PROPULSE CLEANING GUIDELINES 10

14.0 CLEANING OF NOOTS EAR TANK 10

APPENDIX 1 Patient Information Leaflet 11-12

APPENDIX 2 Competency Checklists 13-14

APPENDIX 3 Patient assessments Checklist 15

REFERENCES 16

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1.0 INTRODUCTION

1.1 These guidelines are intended for practitioners who are competent in
carrying out safe and effective ear irrigation. They provide the practitioner
with guidelines in assessment, examination and ear irrigation in adults

1.2 Ear irrigation should only be considered when other conservative methods
of wax removal have failed (e.g. use of softeners see page 4). Patients
requiring ear irrigation should always receive education and advice, which
may reduce contributory factors for the build up of ear wax and therefore the
need for ear irrigation

1.3 Ear irrigation is undertaken for the purpose of removing wax from the
external auditory meatus where this is thought to be causing a hearing
deficit and/or discomfort, or restricts vision of the tympanic membrane
preventing examination, in the adult patient

2.0 SPECIFIC RESPONSIBILITIES AND ACCOUNTABILITY

2.1 The employer must ensure: -

That all staff have access to the best practice guidelines on ear care and
management.

Appropriate training is available and accessed by staff in order to carry out

these procedures.

To have in place a system that ensures the availability of safe appropriate

equipment to staff for this procedure.

3.0 RESPONSIBILITIES OF PRACTIONERS PERFORMING EAR IRRIGATION

3.1 All staff who carry out ear irrigation need to be competent and accountable
for what they do and attend theoretical and practical training and attend
update courses every 3 years in ear irrigation. This should include
recognition of indications and contraindications to undertaking ear irrigation
and that they are signed off as competent by a mentor in practice before
they undertake the procedure unsupervised. (Appendix 2)

3.2 Before the procedure they must examine the ears, check the history,
discuss complications, and obtain informed consent

3.3 Staff must ensure the safe use of the equipment provided, according to
current best practice guidance and Medical Devices Management policy.

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3.4 Record all findings and treatment in the patient’s records-as per current
Trust record keeping requirements.

3.5 Carry out the procedure as per these guidelines

4.0 TRAINING/SKILLS

4.1 Practitioners undertaking this procedure must have undertaken both

theoretical and practical ear care training to ensure competency (see
Appendix 2), this should include:-

Knowledge of the normal and abnormal anatomy and physiology of the ear

Awareness of the indications, contraindications and complications of ear

irrigation.

The principles of ear care and safe practice when performing ear irrigation

Instruction and practical assessment on the use of the electronic irrigator

and the Jobson Horne Probe.

5.0 CONTRAINDICATIONS TO EAR IRRIGATION

5.1 Irrigation should not be carried out when the patient:

 Has had a recent history of otalgia, or displays signs of a middle ear

infection
 Has a past history of tympanic membrane perforation or there is a history of
a mucous discharge in the last year.
 Has recurring otitis externa with pain and tenderness of the pinna.
 Has had previous ear surgery; e.g. mastoidectomy or cleft palate
 Has grommets in place or history of recurrent grommet insertions
 Has had untoward experiences following this procedure in the past;
 Has permanent hearing loss in one ear.
 The patient cannot keep still for the procedure
 The patient lacks capacity to agree to the procedure

6.0 USE OF SOFTENERS

6.1 Prior to ear irrigation it is recommended that a softener is used 7 days prior
to ear syringing. Current studies recommend olive oil as the safest, most
suitable pre-irrigation treatment. Ranges of commercial softeners are
available but may cause inflammation or irritation of the meatal skin (see
British National Formulary); however, their advantages over simpler methods
continue to be debated. Nut based oils should not be used where nut
allergies are suspected.

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6.2 Patients should be given advice on how to correctly use olive oil ear drops to
soften the wax prior to irrigation. (Appendix 1)

7.0 GUIDELINES FOR EAR IRRIGATION

7.1 Aim: To facilitate the safe removal of cerumen (ear wax) from the external
auditory meatus.

8.0 WHEN TO IRRIGATE

8.1 Irrigation should only be undertaken if:-

8.2 Alternative methods to remove ear wax have failed i.e. with use of a
cerumen softener to facilitate the ears natural cleaning mechanisms.

8.3 The patient history and examination reveal no contraindications to

undertaking the procedure; refer to patient assessment checklist
(Appendix 1)

8.4 Following examination of the ear there is wax occluding a healthy eardrum
and the patient is experiencing difficulty in hearing

8.5 The ear wax is soft enough to be removed easily by irrigation.

9.0 PREPARATION OF THE PATIENT

9.1 Take a comprehensive history to determine if there are any

contraindications to undertaking ear irrigation.

9.2 Check whether the patient has had his/her ears irrigated before.

9.3 Use the patient assessment checklist to identify if the patient requires the
procedure. (Appendix 3)

9.4 Explain the procedure to the patient.

9.5 Obtain informed consent adhering to the PCT Consent policy and document
in the patient’s record that consent has been given. If the person lacks
capacity to consent, the procedure can still go ahead if it is in the person’s
best interests and the appropriate steps have been taken to assess this and
document it. Please refer to the Trust Consent policy and the Mental
Capacity Act Code of Practice.

10. EXAMINATION OF THE EAR

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10.1 Sit the patient in a chair appropriate for the procedure with the ear to be
examined facing the practitioner, who should be sitting at the same height
as the patient in order to view the ear canal fully. Inform the patient to keep
still during the procedure and advise them to report any discomfort
experienced immediately.

10.2 Examine the external ear to check for previous surgery.

10.3 Hold the otoscope like a pen and rest the small digit on the patient’s head
as a trigger for any unexpected head movement

10.4 Insert the speculum gently into the meatus to pass through the hairs at the
entrance to the canal, and using gentle movements of the otoscope
examine the walls of the canal, which are sensitive and fragile

10.5 Use the light to observe the direction of the ear canal and locate the
tympanic membrane. There is improved visualisation of the eardrum 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. It may not be
possible to visualise the tympanic membrane if excess wax is present.

11.0 EQUIPMENT REQUIRED TO UNDERTAKE EAR IRRIGATION

 Waterproof cape and/or absorbent clean towel

 Otoscope with a number of different sized disposable speculae.

 Use as large a size speculum as possible that is comfortable for the patient,
this will give a better view.

 Headlight

 Propulse/NG irrigator (ensuring that it is used appropriately and serviced to

the agreed standard) with disposable single use tips

 Access to warm water 37- 40 degrees centigrade

 Noots receiver

 Thermometer to test water temperature

 Protective goggles/apron/non sterile gloves

 Jobson Horne Probe and cotton wool

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12. PROCEDURE FOR EAR IRRIGATION USING THE ELECTRONIC IRRIGATOR

ACTION RATIONALE

1 Ensure equipment has been cleaned To prevent cross infection

and disinfected as per
manufacturers instructions prior to use

2 Perform aural assessment and aural To maximise safety.

examination To identify clinical need.
IF YOU SUSPECT ANY To rule out any contra-indications
CONTRAINDICATIONS
- REFER BACK TO
THE PATIENT’S DOCTOR
3 Explain procedure to patient, and Patient to understand procedure.
obtain informed consent (as per Patient is aware of any possible side
PCT consent policy) effects of pain/dizziness and can inform
Explain the need for the patient to the nurse if this occurs immediately
inform the nurse of any adverse effects
during the procedure
4 Ask the patient to sit in a comfortable To enable ease of access for the
upright position on a chair which procedure and patient comfort
supports their back.
The practitioner should sit at the same To ensure good view of ear canal during
height as the patient the procedure

5 Drape patient’s neck and shoulders To protect patient’s clothing

with a protective cover
6 Wash hands and put on a plastic To prevent cross infection.
Apron and vinyl gloves. To perform clean procedure.

7 Examine the patient’s ears using the To improve visualisation of the tympanic
otoscope with a disposable membrane.
speculum (largest possible that is
comfortable for the patient).
Hold the otoscope like a pen, grasp the To prevent trauma to ear canal from any
pinna of the ear between the thumb and unexpected head movement
forefinger and gently apply traction to

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the pinna in an upwards and backwards

direction. Inspect the outer ear, pinna,
ear canal, Check for previous surgical incisions,
DO NOT PROCEED IF YOU scar tissue, inflammation, discharge.
SUSPECT ANY To rule out any contraindications
CONTRAINDICATIONS.
IF SO, REFER BACK
TO THE DOCTOR.
8 Follow the setting up procedure for the To ensure equipment is set up correctly
Propulse II, III or NG Ear Irrigator
Ensure good lighting.

9 Fill water reservoir of Propulse To ensure water is at body temperature

machine with warm water (37-40 when it enters the ear canal.
degrees C). Check temperature with a
thermometer. Set pressure at minimum.

ACTION RATIONALE

10 Apply a single use disposable jet tip To avoid cross infection.

applicator to the Propulse/NG irrigator
with a firm push action (push until a
click is felt).
11 Direct irrigation jet tip into receiver and To circulate water through system.
switch on machine. Apply gentle To eliminate trapped air or cold water.
pressure on the foot pump for 10-20 The initial flow of water is discarded thus
seconds removing any static water from the
tubing.
To allow patient to become accustomed
to the noise
Put on headlight and eye protective To protect self from splash back.
goggles
12 Hold upper margin of pinna of ear To straighten the meatus.
firmly but gently with thumb and
forefinger and draw it slightly upwards
and backwards.

13 Ensure good lighting. Warn patient To prevent any trauma or discomfort.

you are about to start irrigation and to To maximize safety.
inform you of any pain or dizziness
immediately so that you can stop the
procedure.

14 If possible, ask patient to hold receiver To collect used water.

under ear, held against neck. To prevent patient becoming wet.

15 Twist the jet tip so that the stream of To obtain maximum effectiveness.
water can be aimed at roof of the
meatus and towards the posterior wall
(towards the back of patient’s head).
Place the jet tip into the external
auditory meatal entrance. Switch on
the machine using foot control. If you
consider the ear canal as a clock face,

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you would direct the water at 11 o’clock

to right ear and 1 o’clock to left ear.

16 Use foot control to manage the stream For ease of dexterity and to enable a
of water along roof of ear canal. steady stream of water to flow all along
Increase the pressure control gradually the floor of the passage into receiver,
if needed carrying with it any wax.

17 Periodically inspect the ear canal with To check on progress and effectiveness
the otoscope and inspect the solution in of the procedure.
receiver.(If you have not managed to
remove all the wax within 5 minutes, it The wax may gradually soften after
may be worthwhile moving on to the contact with irrigation water.
other ear as the introduction of water
via the irrigator will soften the wax and
you can gently retry irrigation after 15
minutes). NB. maximum of 1 reservoir To prevent trauma to the auditory
of water per ear is used in any one meatus
procedure
ACTION RATIONALE

18 After removal of wax, wrap cotton wool To remove water from ear canal.
around Jobson Horne probe and mop
water from the lower end of the ear
canal

19 Examine ear(s), both meatus and
tympanic membranes. Stagnation of
water and any abrasion of the skin
during the procedure predispose the
patient to otitis externa or possible
infection.
To ensure excess water has been
removed and no damage to the ear canal
has occurred.
To visualise the tympanic membrane
once wax has been removed

20 After procedure, ask patient to sit for To prevent patient falling (and give
15 minutes, in case of dizziness. dizziness time to wear off).

21 Document in nursing notes:- To record all findings and treatment

- Which ear was irrigated. according to PCT guidelines on
- If eardrum visualised and its condition. Accountability and Record Keeping.
- Condition of ear after procedure.

22 Give patient advice on ear care and Patient is well informed.

Patient Information leaflet (appendix 1)
23 Dispose of any disposable equipment To prevent cross infection
Clean and disinfect propulse/NG
machine as per PCT protocol.

24 NB If wax cannot be removed easily

ask patient to re-instil drops and return
for further irrigation in 1 week
NB Irrigation of ears may cause
discomfort but should never cause
pain.

STOP immediately if:

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• patient complains of pain

• water comes down the nose If the tympanic membrane has perforated
• patient swallows excessively the patient may need antibiotic
• bleeding occurs. treatment.
If you suspect the tympanic
membrane has perforated REPORT
TO GP

Instruct patient to contact their GP if To keep the patient informed about

they feel unwell following the ear possible adverse effects and who to
irrigation procedure contact in an emergency

13. PROPULSE CLEANING GUIDLINES

13.1 Place one Precept cleaning tablet into the reservoir and fill with warm water
to the 5OOml mark.

13.2 Once Precept tablet has dissolved, run the Propulse for a few seconds to
allow the solution to fill the pump and flexible tubing.

13.3 Leave to stand for 10 minutes.

13.4 Ensure that the cleaning and disinfection solution is not left in the unit for
more than 10 minutes.

13.5 Flush the unit through with cool boiled water/ sterile water and dry
thoroughly.

13.6 Always follow manufacturers’ guidelines regarding use of the equipment.

Annual servicing by Medical Equipment Services is the minimum
requirement.

14. CLEANING OF NOOTS EAR TANK

14.1 Clean with detergent solution

14.2 Rinse under hot water.

14.3 Dry thoroughly

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APPENDIX 1

PATIENT INFORMATION LEAFLET

EAR CARE
Ear Wax is a normal secretion that protects the lining of the ear.

Ear irrigation is one way of removing excessive amounts of earwax.

The only reason for carrying out ear irrigation is when hearing is reduced due to
wax impacted on the eardrum.

Regular or routine irrigation is not recommended.

For patients with identified wax impaction the first line of management is the use of
olive oil drops which will soften the wax preventing the need for ear irrigation.

INSTILLATION OF EAR DROPS

1 To soften wax, insert the olive oil drops/spray twice a day for at least 7
days
2 Lie down on your side with the affected ear uppermost

3 Pull the top of the ear backwards and upwards and instil 2 or 3 drops of

oil (at room temperature) into the ear canal and massage the ear, this

enables the oil to run down the ear canal.

4 Stay lying down for 5 minutes and then wipe away any excess oil.
5 Do not leave cotton wool at the entrance to the ear
6 Repeat the procedure with the opposite ear if necessary.

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7 Some patients may need to use an ear softener for more than seven
days to remove excessive wax build up; regular use may prevent the
need to have your ears irrigated.

If you do not succeed in removing the excess wax by the above methods you
should consult a nurse to have your ears examined to assess the need for
ear irrigation

PATIENT ADVICE AFTER EAR IRRIGATION

The ear canal may be vulnerable to an ear infection after irrigation due to the
removal of all the protective ear wax.

Keep the ear(s) dry for 5 days following ear irrigation until the protective ear wax
has returned to normal.

In the unlikely event that you develop pain, dizziness, reduced hearing or
discharge from the ear after ear irrigation, consult with your nurse/doctor

REMEMBER some ear wax is normal as it protects the ear. Wax is normally shed
naturally by the ears.

Some common causes of impacted wax are:

Using cotton buds, matchsticks and hair clips to try to clean out the ear canals is
one of the most common causes of impacted wax. It causes the wax to be forced
down the canal and form a hard dry plug against the eardrum. Matchsticks and hair
clips can inflict considerable damage to the skin lining of the canal.

Hearing aid moulds can also interfere with the ears natural ability to shed dead
skin and wax.

To prevent the build up of excessive wax it may be helpful to instil olive oil 2 – 3
times a week.

Contact your G.P, practice nurse or district nurse if you have any questions:

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Appendix 2
ASSESSMENT OF COMPETENCE

Aural nursing assessment and the use of the Propulse II Electronic Ear
Irrigation equipment to remove ear wax.

Name: Locality:

Aim:
To safely undertake clinical examination of the ears before considering whether to
proceed with ear irrigation
To perform ear irrigation competently
Objectives:
The practitioner will be able to;
Demonstrate competency and safety in performing aural assessment and
performing aural examination.
Demonstrate an awareness of the potential complications/ precautions of ear
irrigation.
Have a clear understanding of the principles of ear care, utilising safe practice in
performing ear irrigation.
(high level risk of harm to patient due to poor technique employed)
Understand the principles of decontamination of equipment and use of disposable
products
Requirements prior to undertaking this procedure fro patients:

Training: attendance at a theoretical and practical training session.

Self-directed study of guidelines on ear assessment and irrigation.

Assessment: in the workplace using the criteria overleaf.

Those acting as trainers/mentors in clinical practice must be clinicians who

are competent in the procedure and undertake the procedure regularly
It ids expected that the nurse will have sufficient knowledge of the:

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 Need to provide the patient with information and obtaining informed

consent
 Anatomy and physiology of the auditory system and ability to
recognise normal and abnormal appearances of the ear and ear
drum
 Guidelines and protocol for ear irrigation
 Rationale for carrying out ear irrigation, the contraindications for
irrigation and potential risks involved.

I certify that the above-named Registered health Care Practitioner has

completed the theoretical assessment which is covered above:

Name of Trainer: Date:

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Clinical Practical Skill Checklist

Performance Criteria: Performed

The practitioner will: Safely (√)
1. Assess patient competently, Following the Ear Care Guidelines,
complete an aural assessment, aural history and clinical examination.
2. Give patient appropriate advice and self-help measures to prevent
build up of earwax or to soften the wax.
3. Obtain and document informed consent from the named patient,
according to PCT guidelines.
4. Demonstrate knowledge of the auditory system and an ability to
recognise normal and abnormal appearances of the ear and eardrum
5. Demonstrate an understanding of the rationale for carrying out ear
irrigation, the contraindications and the potential risks involved.
6. Demonstrate the appropriate cleaning, disinfection and servicing
measures for the equipment used.
7. Demonstrate safe and effective ear irrigation, using the appropriate
equipment
8. Demonstrate safe care of the patient during the procedure
9. Provide patient with advice and self-help measures, after the
procedure.
10. Demonstrate safe and accurate record keeping, according to NMC
guidelines
I confirm that the Registered Healthcare Practitioner named overleaf has
completed the practical assessment competently.

Signed: Date:

Print Name: Designation:

Mentors Comments

Declaration
I confirm that I have had theoretical and practical instruction on how to safely and
competently perform the ear syringing procedure I acknowledge that it is my
responsibility to maintain and update my knowledge and skills relating to this
competency.

Signed: Date:

Print Name: Designation

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Appendix 3

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References

British National Formulary. (2007) Removal of ear wax. BNF 54. Section 12.1.
British Medical Association and Royal Pharmaceutical Society of Great Britain.
Also available at www.bnf.org

Burton MJ, Doree CJ. ( 2007) Ear drops for the removal of ear wax. In: The
Cochrane Library, Issue 2, Wiley, Chichester, UK.

Hand C, Harvey I. (2004) The effectiveness of topical preparations for the

treatment of earwax: a systematic review. British Journal of General Practice;
54: 862-867.

Harkin H. (2007) Ear irrigation. In Lucas J (ed) New Practice Nurse. Churchill
Livingstone, London, 154 -158.

Kraszewski S. (2008) Safe and effective ear irrigation. Nursing Standard, 22, 43
p45 – 48.

Mental Capacity Act (2005) Department of Health, London. Available online at

http://www.opsi.gov.uk/acts/acts2005/ukpga_20050009_en_1

Primary Ear Care Centre (2002) Department of Health ‘Action On ENT’.

Steering Board: The Guidance accessed October 2010 at
www.earcarecentre.com/protocols.htm

Somerville G. (2002) The most effective products available to facilitate ear

syringing. British Journal of Community Nursing, 7: 94 -101.

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