Policy Type: Clinical
Owner Group: Operations C li
Ear Irrigation Policy
Applicable To: Nursing Staff
Communication Method: Line Manager
Consequence of Non Adherence: Disciplinary
Policy Author/Source: Clinical Policy Co-ordinator
Trust Policy Index Number: 7
Version Number: 2
Approval Body: Originally Approved by the
Clinical Policy and Procedure
Group, EBPCT September
Date Approved: Adopted by BENPCT October
Reviewed: January 2007
Review Date: January 2009
Diversity Statement for Clinical Policies 3
Specific responsibilities and accountability 4
Use of Softeners 6
History Taking 6
Examination of Ear 6
Procedure for Ear Irrigation 7
Procedure for Cleaning Equipment 9
Instillation of Ear Drops 10
Patient Advice and Education 11
Patient Information 15
Ear Irrigation Policy Jan/2007 Page 2 of 20
Diversity Statement for Clinical Policies
This policy endeavours to deliver care in such a way as to treat patients
fairly and respectfully regardless of age, gender, race, ethnicity,
religion/belief, sexual orientation and/or disability.
The care and treatment provided will respect the individuality of each
Birmingham East and North PCT is caring, committed and competent in
its core values and these will be developed to ensure equality and
fairness becomes the working culture.
In line with the PCT’s strategy and plans for race and equality all
clinical policies and protocols are reviewed against the values,
standards and targets contained within the strategy for fairness and
Ear Irrigation Policy Jan/2007 Page 3 of 20
1.1 This policy is intended for registered nurses who are competent in carrying out
safe and effective ear irrigation. It provides the practitioner/nurse with guidelines
in assessment, examination on adult ear irrigation.
1.2 Ear irrigation should only be considered when other conservative
methods of wax removal have failed (e.g. use of softeners,see page 5).
Patients requiring ear irrigation should always receive education and advice,
which may reduce contributory factors 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. CONTRAINDICATIONS TO EAR IRRIGATION
2.1 Irrigation should not be carried out when: -
The patient has previously experienced complications following this procedure in
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 Department).
The patient has a perforation or there is a history of a mucous discharge in the
The patient has a cleft palate (repaired or not).
In the presence of acute otitis externa with pain and tenderness of the pinna.
3. SPECIFIC RESPONSIBILITIES AND ACCOUNTABILITY
3.1 The Trust will ensure the following: -
That all staff has access to a policy on ear care and management.
Appropriate training is available to 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.
3.2 All staff that carry out ear irrigation need to be competent and accountable for
what they do and attend theoretical and practical training in ear care which
includes recognition of ear problems as appropriate and attend update courses
every – (as determined by the PCT). Staff need to ensure the safe use of
equipment provided and follow trust guidance, according to the policy for
electrical safety and the medical devices management policy.
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3.3 Managers have a responsibility to ensure that all the above criteria for
individual’s responsibilities is being met, through appropriate and effective
strategies for the safe use of equipment and that any incidents are managed
effectively according to trust policies. Areas for training needs must be
highlighted and addressed. This can be done through, appraisals or supervision
and a record of competencies kept for audit and standard purposes.
4.1 Qualified nurses undertaking this procedure must have undertaken ear care
training, which includes recognition of ear problems, safe ear care treatment
including instruction and practical assessment on the use of the electronic
irrigator and the Jobson Horne Probe.
4.2 Nurses must be competent and confident that their skills and knowledge are
5.1 Staff need to ensure that equipment is used safely and appropriately according to
the medical devices management policy. Equipment must be stored, cleaned
and checked as specified in the trust guidelines and policy. The checking and
safety of equipment must be recorded and dated for audit and safety purposes,
by the maintenance staff, at the estates department.
5.2 All staff using the electronic ear irrigator in the patient’s home should carry out
the following precautions for their own safety: If in any doubt a suitable safety cut
–out device as approved by the manufacturers should be used.
5.2.1 Visually checking that the condition of the socket outlet that they are plugging
their equipment into is safe, and that cracked or damaged socket outlets should
5.2.2 Each time they use any electrical equipment they should check for damage to the
lead and ensure the flex is covered securely with none of the flex cords showing.
If damage is found it should be reported to Estates department.
5.2.3 Ensure the equipment has a portable appliance test label attached and that it is
not out of date. It is the team’s responsibility to ensure the equipment is tested
annually. (In the case of new equipment this is tested prior to sale and should be
tested within the first year). There is some flexibility in the Portable Appliance
Testing as it is not possible to test every piece of equipment on the due date.
This date can go over by 2 to 3 months without concern, as long as the user
carries out the visual checks, and the equipment is seen to be in good condition.
If the appliance testing date has expired past the extra 2-3 months staff must not
use the equipment and arrange for Estates to carry out the appropriate
maintenance and testing.
5.2.4 Staff must not change the fuse in the plug head as an incorrect fuse fitted by an
unauthorised person can endanger users.
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6. USE OF SOFTENERS
6.1 Prior to ear irrigation a softener should be used for a duration of between 3-7
days, depending on the condition of the wax . Firstly it is necessary to determine
whether the ear is occluded by wax or any other matter, i.e. infected debris or
foreign body. Secondly the nurse must identify the type of wax present as if
normal, soft wax is present, this can be irrigated without the need for softeners.
However, if hard wax is present and is located deep in the ear canal, then a
softener should be used prior to irrigation. 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.
7. HISTORY TAKING
7.1 Explain each step of any procedure or examination and ensure that the patient
understands and gives consent. Prior to examination of the ear obtain a careful
history using the ear irrigation flow chart (see appendix 1)
Ear Irrigation Policy Jan/2007 Page 6 of 20
8. PROCEDURE FOR THE EXAMINATION OF THE EAR
8.1 The Nurse should refer to the ear irrigation flow chart (appendix 1) as part of the
8.2 Ensure that both you and the patient are seated comfortably at the same level if
possible and that you have privacy.
8.3 Examine the pinna, outer meatus and adjacent scalp. Check for previous surgery
incision scars, infection, discharge, swelling and signs of skin lesions or defects.
Decide on the most appropriate size of speculum that will fit comfortably in the
ear and place it on the auroscope.
8.4 Gently pull the pinna upwards and backwards to straighten the ear canal.
Localized infection or inflammation will cause this procedure to be painful, if this
is present, do not continue.
8.5 Hold the auroscope like a pen and rest the small digit on the patient’s head as a
trigger for any unexpected head movement. Use the light to observe the
direction of the ear canal and 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. Insert the speculum gently into the meatus to pass through the hairs at
the entrance to the canal, and using gentle movements of the auroscope and the
patient’s head, examine the walls of the canal, which are sensitive and fragile.
8.6 Identify any of the following: -
Wax in the canal, this can range from black or dark brown and solid to yellow
and sticky to white and flaky (mainly seen in oriental people). However, white
and flaky debris may be due to an excess keratin signifying an external ear
Inflammation in the canal – the canal could be red, swollen and tender, or
pale and moist. The nurse should also identify if an odour is present, or if
there is a discharge which may be creamy or have the apprearance of
The normal eardrum – the colour is normally pearly light grey, shiny and
Other visible abnormalities.
8.7 Document what was seen in both ears, this should be in accordance with the
NMC guidelines on record keeping and the trust policy.
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9. PROCEDURE FOR EAR IRRIGATION USING THE ELECTRONIC
9.1 EQUIPMENT REQUIRED
Head light, spare batteries and spare bulb
Propulse Electronic irrigator
Jug containing tap water to 40°C approximately (warm to finger touch)
Jobson Horne probe and cotton wool
Tissues and receivers for dirty swabs and instruments
Disposable waterproof and absorbent covering Apron & gloves
9.2 IRRIGATION PROCEDURE
9.2.1 Informed consent should be obtained prior to proceeding. The patient should be
informed of the risks of the procedure i.e. trauma, minor infection, chronic
infection, acute and chronic tinnitus, perforation of eardrum and deafness, to
enable them to give consent.
9.2.2 Examine both ears by following the ear examination procedure. Check to see if
the ears still require irrigation, the olive oil may have removed the wax.
9.2.3 Check whether the patient has had their ears irrigated previously, or if there are
any contra-indications why irrigation should not be performed. Wash hands prior
to procedure. Explain the procedure to the patient and ask the patient to sit in
chair with their head tilted towards the affected ear so that the nurse is still able
to see into the ear canal.
9.2.4 Place the protective cape and the absorbent covering on the patient’s shoulder
and under the ear to be irrigated. Ask the patient to hold the noots receiver on
the neck approximately two centimetres below the ear.
9.2.5 Check that the headlight is in place and the light is directed down the ear canal.
Fill the reservoir of the irrigator with water that is approximately 40C by finger
touch and testing it on the patient’s ear lobe. Set the pressure at minimum.
9.2.6 Connect a clean jet applicator or a disposable one to the tubing of the machine
until a firm ‘push/twist’ action. Push until a “click” is felt.
9.2.7 Warn the patient that you are about to start irrigating and ask them to alert you if
they become dizzy or experience any pain, so that the procedure can be
discontinued immediately. Direct the irrigator tip into the Noots receiver and
switch on the machine for 10-20 seconds in order to circulate the water through
the system and eliminate any trapped air or cold water. Discard some water onto
the nurses own small finger to confirm that the water is at the right temperature
prior to commencing the procedure. This offers the opportunity for the patient to
Ear Irrigation Policy Jan/2007 Page 8 of 20
become accustomed to the noise of the machine. Demonstrate the gentleness of
the water jet on their fingers before irrigating.
9.2.8 Twist the jet tip so that the water outlet is aimed at the posterior wall of the ear
canal (towards the back of the patient’s head) at the entrance of the meatus).
9.2.9 Gently pull the pinna upwards and backwards to straighten the ear canal.
9.2.10 Warn the patient that you are about to start irrigating. Place the tip of the nozzle
into the ear canal entrance and using foot control direct the stream of water
towards the posterior canal wall (directed towards the back of the patient’s head).
If you consider the entrance to the ear canal as a clock face, you would direct the
water at 11 o’clock in the right ear and 1 o’clock in the left ear. Always start with
two short applications of water to determine if the patient is sensing water in the
nose or throat, which signifies a perforated tympanic membrane. The procedure
can ten be terminated and medical advice sought. However, if the patient does
not experience such problems, the procedure may be continued. Increase the
pressure control gradually if there is difficulty-removing wax. It is advisable that a
maximum of two reservoirs of water is used in any one irrigating procedure.
9.2.11 If you have not managed to remove the ear wax within five minutes of irrigating, it
may be worthwhile moving onto the other ear (if both ears are required to be
irrigated) as the introduction of water via the irrigating procedure will soften the
wax and you can retry ear irrigation after about 15 minutes.
9.2.12 Periodically inspect the ear canal with the auroscope and inspect the solution
running into the receiver.
9.2.13 After removal of earwax or debris, dry mop excess water from the meatus under
direct vision using the Jobson Horne probe and best quality cotton wool.
Stagnation of water and any abrasion of skin during the procedure or by previous
attemps at self clearing the ears can predispose to infection. Removing the water
with the cotton wool and tipped probe reduces the risk of infection.
9.2.14 Give advice regarding ear care and any relevant information and provide leaflet.
9.2.15 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, following the NMC guidelines on record
keeping. If any abnormality is found a referral should be made to the GP.
IRRIGATION SHOULD NEVER CAUSE PAIN. IF THE PATIENT COMPLAINS OF
PAIN – STOP IMMEDIATLEY.
ALWAYS USE A CLEAN SPECULUM, JET TIP APPLICATOR AND PROBE FOR
Ear Irrigation Policy Jan/2007 Page 9 of 20
It is recommended that you follow the manufacturer guidelines for cleaning and
disinfecting the irrigator and its components.
10. CLEANING GUIDELINES – PROPULSE EAR IRRIGATOR
10.1 Warning: Please follow COSHH regulations when using Sodium
(COSHH guidelines come with the product, follow manufacturers
guidelines) PROPULSE Stage 1 – Each day before use the Propulse
must be disinfected using a solution of Sodium Dichloroisocyanurate
10.2 Suggested use of 1 x 0.5g (500g) HAZ MINI/PRESEPT/SANICHLOR
tablets in 500mls of cold water or 2 tablets in a litre of water to get a
solution which provides 1000 parts (NaDCC) per million (0.1%).
10.3 Fill the water tank with NaDCC solution.
10.4 Run the Propulse for a few seconds to allow the solution to fill the
pump and flexible tubing.
10.5 Leave to stand for 10 minutes. Empty the water tank; rinse the system
through with tap water before use.
10.6 Stage 2 – At the end of the day (or end of ear irrigation session),
disinfect the Propulse for 10 minutes using the NaDCC solution.
10.7 Rinse the machine by running STERILE WATER through and dry it
prior to leaving it overnight.
10.8 After each individual patient treatment, items of equipment should be
disinfected as follows: -
10.9 Jet Tip Applicator or disposable type
Remove from the tubing and place in a detergent solution (dilute washing
up liquid) to remove wax.
Wash under hot water to remove debris.
Soak for 10 minutes in the NaDCC solution prepared as stage 1.
Rinse and dry thoroughly.
10.10 Speculum for auriscope
Same procedure as for jet tip applicators.
Ear Irrigation Policy Jan/2007 Page 10 of 20
10.11 Jobson Horne Probe
Place in detergent solution to remove wax.
Rinse under hot water
Soak in industrial spirit (70%) for 10 minutes then allow to dry
ALWAYS USE A CLEAN SPECULUM JET TIP APPLICATOR AND PROBE FOR
10.12 Noots Ear Tank
Clean with detergent solution.
Rinse under hot water. Dry thoroughly.
10.13 Any NaDCC solution and industrial spirit prepared for disinfecting
equipment must be discarded at the end of each session/day.
Following cleaning ALL equipment must be stored dry.
10.14 Industrial spirit is a flammable solution and must be stored in a metal
cupboard or metal drawer. No more than 1 bottle in use and one bottle
spare to be kept at any base.
10.15 HAZ MINI/PRESEPTS/SANICHLOR tablets, sterile water and industrial
spirit (70%) may be obtained from pharmacy. These items should be
on your computerised pharmacy request form.
11. INSTILLATION OF EAR DROPS
Explain and discuss the procedure with the patient, and gain consent.
All drops for installation should be prescribed according to the drug
administration policy, and the nurse prescribing guidelines.
Drops should be at room temperature.
Ask the seated patient to tilt their head towards the shoulder with the ear to be
treated uppermost. (If possible the patient should lie on their side).
Pull the pinna (outer ear) backwards and upwards to straighten the meatus.
Drop 2 or 3 drops into the ear canal and massage the tragus just in front of the
Request the patient to remain in the same position for 5 minutes and wipe away
any excess drops.
Ear Irrigation Policy Jan/2007 Page 11 of 20
Repeat the procedure with the opposite ear if necessary.
12 PATIENT ADVICE AND EDUCATION
12.1 The patient should be advised with regard to:
The normal function of the ear – show the patient a diagram of the ear to explain
its self-cleaning properties and the reason for the prohibition of cotton buds and
Wax being normal and its protective qualities.
Keeping ears dry.
Regular ear wax checks to try and avoid the need for irrigation especially in the
following patients: -
- Frequent wax blockage may be caused by a too narrow ear canal that
easily becomes obstructed.
- Wax contains a high concentration of fatty acids and a change of diet may
reduce the incidence of blocked ears, especially in patients with high lipid
If too little wax, patient may complain of itchy ears this is common in the elderly.
The use of olive oil, once weekly may help the natural process - if indicated
(provide patient with information)
Ear Irrigation Policy Jan/2007 Page 12 of 20
Birmingham Specialist Community Health NHS Trust (2001). Policy for Electrical Safety.
Birmingham Specialist Community Health NHS Trust (2001). Guidelines for clinical
Birmingham Specialist Community Health NHS Trust (2001) Medical Devices
Birmingham Specialist Community Health NHS Trust (2001) Admission of Medical by
Registered Nurses Policy
Harkin H (2003) Ear Care 2 Irrigation New Practice Nurse
Harkin H (2003) Guideline Document in Ear Care compiled by Primary Ear Care Centre
on behalf of the Action on ENT Steering Board.
North Birmingham Community Health NHS Trust (1998) Adult Ear Syringing Guidelines.
NMC (2002) guidelines for records and record keeping
Primary Ear Care Centre (2001) Cleaning Guidelines
Palm Training Ltd (2003) Ear Syringing course handbook.
Ear Irrigation Policy Jan/2007 Page 13 of 20
Patient Name:……………………………….. D.O.B:…………………………
Ear Irrigation Flow Chart
SUBJECTIVE DATA: HISTORY Right Ear Right Ear Left Ear Left Ear
YES NO YES NO
Surgery on tympanic membrane or
other ear surgery
History of impaction
History of injury or foreign body
Use of ceruminolytic agents/olive oil
Previous ear irrigation
OBJECTIVE DATA: EXAMINATION
Tympanic membrane visible
Land marks identified
Tympanic membrane perforated
Amount and colour
Signature …………………………….. Date ……………………
Ear Irrigation Policy Jan/2007 Page 14 of 20
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The normal ear has self-cleaning properties, and wax is normal and
has protective qualities
Do not use cotton buds or cotton wool
Keep ears dry, after showering and swimming.
Have your ears checked regularly to avoid the need for ear irrigation: -
- Frequent wax blockage may be caused by a narrow ear
canal that easily becomes obstructed.
- Wax contains a high concentration of fatty acids and a change
of diet may reduce the incidence of blocked ears especially if
your blood cholesterol is high.
If your ears become itchy it may be because of too little wax, see the
GP or Nurse for advice.
Use ear drops or olive oil once weekly it may help the natural process
if indicated (refer to instructions for how to use ear drops)
Ear Irrigation Policy Jan/2007 Page 17 of 20
HOW TO USE EAR DROPS
INSTALLATION OF EAR DROPS
Preparation for wax removal – or to encourage normal expulsion of wax from
the outer ear.
WHEN USING OLIVE OIL
Apply olive oil as directed by your Doctor or Nurse.
Most patients find that applying drops 1-2 times daily for 3-4 days prior to a
consultation for wax removal is helpful. Your nurse or doctor may suggest
using olive oil once every week as a preventative treatment.
1. Lie down on your side with the affected ear uppermost.
2. Pull the pinna (outer ear) backwards and upwards
(See diagram below). Drop 2 or 3 drops of oil, at
room temperature into the ear canal and massage
the tragus just in front of the ear.
3. Remain lying down for 5 minutes and then wipe
any excess oil. DO NOT leave cotton wool at the
entrance to the ear.
4. Repeat the procedure with opposite ear if
Ear Irrigation Policy Jan/2007 Page 18 of 20
WHEN USING ANTIBIOTIC / ANTI- INFLAMMATORY EAR DROPS
(Only when prescribed)
1. Hold the head to one side with affected ear
2. Pull the pinna (outer ear) backwards and upwards
(see diagram below). Drop 2 or 3 drops of oil, at
room temperature into the ear canal and massage
the tragus just in front of the ear.
3. Return the head to the upright position and wipe
away any excess drops.
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