VOL: 96, ISSUE: 43, PAGE NO: 35
Geoff Stubbs, RGN, NDN, CMS, is clinical nurse manager, Beechwood Surgery, 23 Beechwood Drive, Thornton Cleveleys, Lancashire, FY5 5EJ
The removal of ear wax has been practised since ancient Egyptian times, when suppurating ears would be syringed with olive oil, frankincense and salt.
It is the most common ear, nose and throat procedure performed in general practice and yet there is a distinct lack of medical and nursing education on the subject (Sharp et al, 1990).
Many of the staff who undertake this procedure have received little or no formal training. A survey by the Primary Ear Care Centre in Yorkshire showed that 85% of nurses attending courses between April and August 1999 had never had training in ear-syringing or had merely learnt through observation, without knowing if the method they were shown was safe or correct (Rodgers, 2000).
In 1997 an article in the nursing press posed the question: ‘How safe is your syringing?’ A nurse had been found negligent because she had not updated a clinical skill that she had been using for 10 years (Rodgers, 1997).
To provide safe and effective aural care the practitioner must know the basic anatomy and physiology of the ear to enable them to distinguish the normal from the abnormal. They must have attended an approved training course (for details contact the Primary Ear Care Centre).
The future of aural care
We are moving away from the outdated ‘local rules’ where the patient must first be seen by the GP. Nurse-led aural clinics will in the future provide a superior service to patients, allowing GPs to concentrate on more appropriate referrals. Patients may self-refer to dedicated ear-care clinics where a trained nurse advises, treats and refers to GPs and via GPs to hospital consultants (UKCC, 1994; Advisory Group on Health Technology Assessment, 1992; Fall et al, 1997).
I run clinics at my two practices. Many patients self-refer, others are sent by the GP, practice nurse or health visitor. I work within a strict protocol that has been approved by the GPs. I am also very aware of The Scope of Professional Practice (UKCC, 1992) and Guidelines for Records and Record Keeping (UKCC, 1998). The clinics aim to:
- Promote better ear care and a better understanding of ear care (Sharp et al, 1990);
- Prevent excessive wax build-up by educating patients about the cause;
- Prevent minor ear problems becoming major problems by providing early treatment;
- Encourage patients to seek help sooner rather than later;
- Be easily accessible with well trained staff.
We achieve this by:
- Keeping a register of patients with ‘ear problems’ and aural record notes;
- Examining and treating patients as appropriate, for example aural toilet, syringing or ear dressing. We explain why they have their specific problem, and if possible how to prevent recurrence.
- Offering advice and information leaflets on problems such as itchy ears, discharging ears, blocked ears, hearing loss and hearing aids, tinnitus and Menière’s disease.
- Inviting patients who have had a problem to return every 6-12 months for a check-up.
- Taking regular audits.
The amount of patients having ears syringed at my clinics has reduced by over 40% in 12 months.
The first appointment
It is essential to take a full history before any treatment commences. A history should include:
- What the patient is complaining of, any symptoms and the duration of the condition, plus details of any current treatment;
- Precipitating factors, for example working environment - dust or noise;
- Details of past allergies, childhood problems, ototoxic drugs, deafness, tinnitus and past ENT problems. If possible, examine case notes;
- Any previous ear-syringing and its effects on the patient. Any perforations of the tympanic membrane;
- Whether the patient uses cotton buds or other implements to clean their ears.
Next examine the patient. Start behind the pinna looking for lesions. Examine the outer ear and the ear canal, paying attention to the meatal lining. An auriscope allows you to view all the features inside the ear. A white halogen fibre-optic light is best. Choose the largest speculum that will fit comfortably into the ear canal, to get the best view.
Observe how much wax is present. A little is normal. Two types of secretory glands are located in the outer third of the cartilaginous portion of the human ear canal: sebaceous glands that produce sebum, and modified apocrine glands that produce apocrine sweat. Sebum and apocrine sweat, together with shed epithelial cells, dust and other small foreign bodies, make up earwax (Rosser and Ballachanda, 1997).
Wax may be hard or soft - generally pale honey to dark brown in colour. Hard wax will require softening with olive oil for five to seven days before removal. Soft wax may be removed by syringing. Those with experience may be able to remove excess wax by using a Jobson Horne probe.
Examinations and treatments must be under direct vision using a headlight to illuminate the ear canal, with the nurse and patient seated at the same height. If syringing is appropriate, there is a choice of syringe. Most commonly used are the metal ‘Chrome’ syringe and the electronic ‘Propulse’.
It is worth noting that a review by the Medical Defence Union of general practice procedure claims over a five-year period revealed that ear syringing accounted for 19% of the total. The use of a metal aural syringe was implicated in 92% of the cases reviewed, compared with 8% involving the electronic syringe (Price, 1997). On this evidence and from personal experience I prefer the electronic syringe.
Generally, syringing is performed to facilitate removal of excess wax or foreign bodies which are not hydroscopic. This may help improve the conduction of sound. It is also used to remove discharge or debris in cases of otitis externa, where the meatus is blocked and too painful to toilet.
Do not irrigate ears if:
- There has been a recent history of tympanic membrane perforation;
- There is a history of recent otalgia (earache) or middle ear infection;
- The patient has had any untoward experiences following ear irrigation in the past;
- Grommets are in place;
- There is a mastoid cavity.
Where an old perforation has healed, irrigate with care as the area is more susceptible to rupture.
First explain the procedure to the patient and ask their permission to treat. Sit the patient with their head tilted slightly towards the affected ear. Inspect the ear to be syringed with the auriscope. Check your headlight is switched on.
- Fill the Propulse water tank with tap water at 37°C;
- Ask the patient to hold the water reservoir under their ear;
- Gently pull the pinna upwards and backwards to straighten the meatus. Ensure you have a direct view with the headlight (Rodgers, 2000);
- Place the tip of the nozzle into the external auditory meatus entrance. Warn the patient you are about to start and direct the stream of water along the roof of the meatus aiming at the posterior wall (the ‘five to’ and ‘five past’ clock positions). Be aware that if the patient suddenly swallows they may have a perforation. In this case stop syringing and investigate. This patient will need a prophylactic course of antibiotics;
- Increase the water pressure setting as determined by the aural condition. It is advisable that no more than two tanks of water are used in any one procedure;
- Periodically inspect the meatus with the auriscope and inspect the solution in the reservoir;
- After removal of wax or debris, dry mop excess water under direct vision using the Jobson Horne probe and best cotton wool. Static water can contain the pathogen Pseudomonas aeruginosa (Campos et al, 1998; Rodgers, 2000). Any abrasion of the skin during the procedure predisposes to otitis externa;
- Inspect the tympanic membrane - find the lateral process of the handle of malleus, then look round in a clockwise or anticlockwise direction. Check for retraction pockets, especially posteriorly in the Pars Flaccida. Check any old healed perforations. Examine the ear canal for any signs of otitis externa and discuss preventive treatment.
Syringing may cause discomfort but should never cause pain.
Educate patients about management of their ears. Instillation of olive oil - one drop weekly to the affected ear(s) helps reduce the build up of excess wax. Advise them to keep their ears dry.
Discuss any hearing problems and advise. Offer an annual preventive ear check and give patients an advice leaflet. Finally, document the care you have provided. This must include:
- What the patient complained of;
- Your findings - history and examination;
- The treatment you gave;
- The reasons for your treatment and any follow up you have recommended.
This documentation should be placed in the patient’s records. Should any future aural care be required your findings and treatment will be important. Also, should anything go wrong it will be easier to remember your patient in court.
- For further information please write to Geoff Stubbs at the above address or contact: The Primary Ear Care Centre, c/o Stag Medical Centre, 162 Wickersley Road, Rotherham, S60 4JW