VOL: 97, ISSUE: 20, PAGE NO: 40
Geoff Stubbs, RGN, NDN, CMS, is clinical nurse manager, Beechwood Surgery, Thornton, Lancashire
The condition known as Otitis externa is becoming more common as a result of increased foreign travel, the regular use of cotton buds and the increasing popularity of swimming pools. Burke (1989) stated that GPs could expect to see at least 16 new cases a year, but in the first few months of this year the Beechwood Surgery’s aural clinic has received at least one referral a week with this condition.
In many cases O externa is self-inflicted by probing into the ear canal with foreign bodies to relieve itching or in an attempt to remove wax. If the thin epithelial lining is damaged bacterial infections may develop, the most common being Pseudomonas aeruginosa (Browning et al, 1988). O externa may also develop as a result of poor aural care technique or the use of outdated and poorly maintained ear-syringing equipment.
To limit such infections to a minimum, trained practitioners should be offering aural care based on the latest research and using up-to-date equipment. Not everyone has the luxury of an electronic ear syringe, but nurses should make the best and safest use of what is available.
Many practice nurses, district nurses and GPs currently use a chrome syringe to perform ear syringing and have no protocols or guidelines on its correct care and maintenance. It is often the only ear-syringing equipment supplied by many GPs and health authorities, who may not be aware of the dangers. Yet they need only look at the compensation claims made by patients when things go wrong - including perforation of the eardrum, damage to the external auditory canal, pain, infection and deafness - to recognise the importance of carrying out this routine procedure correctly.
A review by the Medical Defence Union of claims involving general practice procedures which were settled over a five-year period revealed that ear syringing accounted for 19% of the total, and in 56% of the claims the practice nurse performed the syringing (Price, 1997). Patients were harmed as a result of poor technique, faulty equipment, the exertion of excess pressure and failure to examine the ear canal. The use of a metal ear syringe was implicated in 92% of the cases under review, compared with 8% involving an electronic ear syringe (Price, 1997).
Keeping it clean
If nurses have no alternative but to use an outdated and potentially dangerous chrome syringe they must be aware of the process necessary to disinfect it and maintain it in good working order. The following steps should be taken:
1. Dismantle the syringe into its three parts: barrel, plunger and nozzle;
2. Wash in hot soapy water to remove any trace of ear wax or lubricant from the barrel and rinse in clean water;
3. Lay the pieces individually on a tray and place them in an autoclave. This is the most satisfactory way to sterilise a chrome syringe. The time cycle will vary from machine to machine so nurses must refer to the manufacturer’s instructions. Remember that after the completion of the cycle the syringe will be too hot to handle and must be left to cool;
4. Remove from the autoclave and dry thoroughly. If time permits allow the syringe to be left to dry in the autoclave;
5. Store in a suitable container until next required;
6. Replace the nozzle. These vary in size and shape. Whenever possible nurses should use nozzles with rounded tips. Only when the external meatus is very narrow should a straight tip be used - but with extreme care.
It is the responsibility of the nurse using the syringe to reassemble it before use. It will be necessary to lubricate the barrel for ease of movement. A tube of petroleum jelly should be available for this purpose. Squeeze a small amount of jelly onto a tissue and replace the cap. Apply the jelly sparingly to the plunger, reassemble the syringe and check that you have optimum movement within the barrel. Holding the empty syringe, manoeuvre the plunger up and down to ensure smooth flow.
Unless nurses perform only the occasional ear syringing, it is impractical and unnecessary to autoclave the entire syringe between patients. The only part of the syringe that should come into contact with the patient is the nozzle so a supply of clean nozzles should be available. These should be changed after each patient, and between the syringing of each ear if examination reveals any sign of infection.
The barrel will be contaminated only if the operator withdraws the plunger while the syringe is in contact with the patient or water discharged from the ear canal. If contamination does occur the whole syringe must be disinfected as described opposite.
If for any reason only one nozzle is available it can be disinfected between patients as follows:
- Remove the nozzle from the syringe;
- Wash well in hot soapy water to remove wax and debris;
- Dry well;
- Immerse in a 70% industrial spirit solution (methylated spirit) for 10 minutes (RCN, 2000);
- Dry well, allowing all trace of spirit to evaporate;
- Reattach to the syringe;
- Proceed with next treatment.
It must be remembered that ear syringing is a clean but not sterile procedure. However, no less care should be taken in the maintenance of equipment.
It is not usually necessary to wear gloves when undertaking ear care, but as with any other clinical procedure adequate and correct handwashing and drying is essential.
All ear syringing must be performed under direct vision. The nurse and patient should be sitting at the same level with the nurse able to view the ear canal with the aid of a suitable light source, such as a headlight.
Practitioners should be reminded when not to irrigate ears:
- Where there is a history of ear problems, such as tympanic membrane perforation;
- Where there is a recent history of otalgia, or a recent/current middle-ear infection;
- If the patient has experienced difficulties as a result of a similar procedure in the past;
- If the patient has a healed perforation. In some cases irrigation may be acceptable, but it must be performed with extreme care as the healed area is more susceptible to rupture;
- If grommets are in place;
- NEVER irrigate mastoid cavities. Mastoidectomy is performed to control potentially hazardous chronic ear disease, usually cholesteatoma. One can never be sure exactly which type of operation has been performed - cortical, modified or radical.
In the extreme this may involve the clearance of diseased mastoid air cells, the ossicles (except the footplate of the stapes) and all the tympanic membrane. This creates a single, large mastoid cavity. The thickness of the bone is reduced, which may allow infection to spread intracranially and cause extra-dural abscess, subdural abscess, meningitis or brain abscess.
The importance of training
Nurses must have received correct instruction in aural care before attempting to syringe an ear. Unfortunately, many carry out procedures for which they have received no formal training. A survey by the Primary Ear Care Centre in Rotherham, Yorkshire, showed that 85% of nurses attending courses between April and August 1999 had never been trained in ear syringing or had learnt to do so through a ‘see one, do one’ process.
All nurses performing ear syringing are personally accountable under The Scope of Professional Practice (UKCC, 1992). If they have not received adequate training, are not competent or have not been recently updated they may be seen to be negligent in the eyes of the law. Most primary care nurses syringe ears regularly, although they may not update their ear-syringing skills regularly (Cater and Hawthorn, 1988). Any such practitioner who has not received any formal training in aural care or requires updating should attend a recognised course.
The Primary Ear Care Centre in Rotherham offers recognised courses run by licensed trainers around the country. It can be contacted c/o Stag Medical Centre, 162 Wickersley Road, Rotherham S60 4JW.