WHEN EXCESS CERUMEN is found in adults' ear canals, nurses who work in many different healthcare settings may need to perform ear irrigations. If performed incorrectly, ear irrigations can lead to adverse events such as infection and tympanic membrane perforation.

Our organization recognized that it needed to follow a consistent process to decrease the risk of harm and enhance patient safety. We researched techniques and equipment, then instituted training and education to ensure safe, consistent practice. Besides sharing our process, this article reviews what we discovered, including information about contraindications, techniques and equipment, and safety tips when performing manual ear irrigations in adults.

Getting started

Gundersen Health System in La Crosse, Wis., is a healthcare system consisting of a central hospital and clinic, four affiliate hospitals, and 29 regional clinics covering 19 counties in three states and handling 5,000 to 7,000 clinic appointments daily. Our organization identified a lack of consistent education, training, and resources for ear irrigations. New employees with varying degrees of experience and education about ear irrigations were being trained by RNs and medical assistants (MAs) (see Defining terms), who also had varying levels of skill and practical experience. This led to RNs and MAs following different procedures throughout the organization. The nursing council was asked to clarify the ear irrigation duties for RNs and MAs, develop a consistent process, and identify educational resources for staff.

First, we performed a literature search. In 2008, the American Academy of Otolaryngology-Head and Neck Surgery Foundation published a medical clinical practice guideline with recommendations for cerumen impaction.1 (These guidelines are currently being revised; see http://www.entnet.org/node/334 for more information.) Although several articles about the medical guideline were published in nursing journals, a literature search failed to identify an evidence-based, step-by-step nursing process for manual ear irrigations and competency information.

Looking into the ear canal

Cerumen, or earwax, is a normal ear canal product composed of epithelial cells, sebaceous and ceruminous gland secretions, and hair.2,3 Its function is to protect and clean the ear canal, and it may also have some bactericidal properties.2 The usual course of cerumen evacuation is a natural migration process in which cerumen moves from the tympanic membrane to the external canal aided by jaw movement.3,4

When the normal evacuation process is hindered, cerumen may accumulate in the ear canal, making visualizing the canal difficult or impossible. Cerumen accumulation can be asymptomatic, but it can also cause problems such as impaction, hearing loss, pain, dizziness, and tinnitus.1,4-6 When excess cerumen is asymptomatic and the tympanic membrane doesn't need to be visualized, the cerumen may clear without any intervention;1 however, removal should be considered for patients who can't express symptoms, such as those who are cognitively impaired,2 or who are symptomatic.

Removing cerumen

Therapeutic options for removing excess cerumen include using:

* cerumenolytics: most often over-the-counter preparations made with mineral oil or hydrogen peroxide2,6

* manual removal: with an instrument

* irrigation: with a large syringe or mechanical jet irrigators.6,7

A literature review of water- and oil-based cerumenolytics found that no specific cerumenolytic preparation was superior to the others,1,8 and that using any cerumenolytic is better than no intervention.2,6 Before using a cerumenolytic, patients should be assessed for a history of infection, perforations, or surgery. Cerumenolytic solutions can cause adverse events such as allergic reactions, earache, dizziness, and otitis externa.6

Manually removing cerumen using various instruments such as forceps requires adequate visualization, training, experience, and a cooperative patient.4,5 When using instrumentation to remove cerumen, the RN or MA must know the anatomy of the ear and be competent in using an otoscope, headlamp, or binocular microscope.1 Tympanic membrane perforation and external auditory canal trauma causing pain, bleeding, or laceration are potential adverse events associated with this method.4,5

In many facilities, nurses are allowed to remove cerumen using spoons or probes with loops; however, due to the high level of experience and training needed to competently remove cerumen in this manner, our organization chose to exclude instrumentation from both the MA and RN competency.

Mechanical jet irrigators consist of a reservoir for the irrigation solution, a handle with a tip that directs a steady pressurized stream of fluid into the ear canal, and a foot pedal to regulate fluid flow. Newer generations of mechanical jet irrigators feature a pressure control switch that allows the operator to determine the amount of force or pressure with which the device delivers the fluid.7 Mechanical jet irrigators have drawbacks-for instance, reusable tips are difficult to clean-but disposable tips can be costly. Some manufacturers' instructions for cleaning the device are complicated. Finally, the device needs to be plugged in or adequately charged, limiting portability.9 Our organization chose not to use mechanical irrigators because of these limitations.

After considering the other available options, our organization chose manual flushing, commonly referred to as ear washing, ear syringing, or ear irrigation. With this method, the practitioner uses a syringe to introduce fluid into the canal to remove cerumen. Metal syringes and tips can be used to perform ear irrigations, but sterilizing and disinfecting this equipment is difficult so our organization chose to use disposable 60-mL syringes and tips. The flexible tip we chose regulates the pressure of the solution exiting the syringe and helps prevent ear canal trauma and perforation. The soft rubber tip is cost-effective and latex-free, fits catheter tip syringes, and has wide wings that prevent deep insertion into the ear canal.

Patient history tips

Before performing ear irrigation, obtain a healthcare provider's order (if an organizational requirement) and a comprehensive patient health history. Also check for any contraindications to the procedure. (See Ear irrigation: Contraindications and precautions.) Failure to identify contraindications can lead to inappropriate irrigations, sometimes resulting in suboptimal care or harm.1 For example, ear irrigations aren't advised for patients with a history of ear surgery or previous tympanic membrane perforation; these patients should be referred to an otolaryngologist instead.7

Also consider the frequency of the patient's ear irrigations. Frequent irrigations can increase cerumen production, leading to a cycle of irrigation, increased cerumen production, irrigation, more cerumen production, and so forth.10 To prevent or break such a cycle, the provider may suggest observation or have the patient use a cerumenolytic agent at home as the best course of action.8

Staff training and education

To decrease the potential for adverse events, staff must have appropriate education, adequate training, and demonstrated competency to perform manual ear irritations. Our organization developed an online educational module that RNs and MAs complete at their own pace. Once the module is finished, the staff member practices ear irrigations on a manikin and then demonstrates competency with a nurse educator or other proficient person. A competency checklist has been developed to assess skill adequacy.

Don't overlook key elements of the competency. For example, the ear canal should be straightened for easier irrigation. For an adult, grasp the upper ear and gently pull it superiorly and posteriorly (upward and out) to straighten the canal.7,10,11 Proper temperature and amount of irrigation fluid are important factors for patient safety. The water should be between 37.0[degrees] and 40.5[degrees] C (98.6[degrees] and 104.9[degrees] F) to decrease dizziness and prevent a caloric response.4,11,12 To decrease the potential for irritation, edema, infection, and perforation, use no more than 500 mL of fluid per ear.13-15

Pretreat the ear with 2 to 4 drops of warm water and wait 15 minutes for the cerumen to soften. This method is more effective than irrigation alone.1,4,10 Point the syringe tip superiorly and posteriorly toward the upper back of the canal wall.11,16 This technique bounces the water off the upper canal wall and behind the cerumen, sending the cerumen down and out the canal. Use a gentle squirting motion to help prevent tympanic membrane injury or perforation.

To prevent perforation, the nurse must also know when to stop irrigating. If the patient complains of pain, dizziness, or tinnitus, or if cerumen remains after 500 mL of fluid has been instilled, notify the healthcare provider.2,4,12 These may be signs and symptoms of perforation or other complications that require further intervention or referral to an otolaryngologist.

Essential documentation

Finally, document this information:

* indications for ear irrigation

* assessment for contraindications

* type, temperature, and amount of irrigation solution used

* amount and characteristics of cerumen removed

* observation of the ear canal before and after irrigation

* any symptoms reported by the patient

* whether referral was required

* any unusual findings. For example, staff in our organization have reported finding unexpected items such as an artificial nail, a hearing aid battery, a pea, an eraser, and popcorn kernels in patients' ear canals.

Safety issues

Patient safety can be ensured at several points during a patient visit. The first opportunity is before ear irrigation. A thorough history and assessment by the healthcare provider can identify contraindications and appropriateness of ear irrigation.

Second, only appropriately trained, knowledgeable, and competent staff should perform ear irrigations. Third, use disposable equipment to eliminate the possibility of contaminating a patient's ear with particles.9 After cleaning, particles have been found in reusable tips.

Fourth, visualize and document the state of the tympanic membrane and ear canal after ear irrigation to help identify any complications. Key points in the competency checklist were developed to help clinicians ensure patient safety.

Positive results

During the first 6 months of implementation, more than 600 RNs and MAs completed ear irrigation education, practiced the procedure on manikins, and demonstrated ear irrigation competency. Response to training was positive.

Hurdles overcome

Barriers must be overcome to change and standardize a procedure in a large organization. Providers wondered why the change was needed. Providers, RNs, and MAs needed evidence to support guidelines on pretreatment, range of water temperature, limitation of water volume, and assessment after ear irrigation. A "frequently asked question" sheet was developed to answer these questions and help staff understand the new process.

Before implementing this program, a formal reporting process for procedural complications wasn't in place, and few complications were being reported. Whether complications were underreported due to a lack of process or weren't occurring at all couldn't be determined. A formal documentation process for adverse reactions or complications is now provided to staff through online education, but we have no baseline data for comparison.

Going with the flow

Standardizing ear irrigations defined a clear list of duties and competency in which patients are appropriately assessed for contraindications, decreasing the potential for harm. Using the tools discussed here, RNs and MAs in our organization now perform ear irrigations confidently, safely, and effectively.

Defining terms

* Caloric response: a response of the semicircular canals in the ear to cold or warm water that can produce dizziness, nausea, vomiting, or falling.17

* Cerumen: a normal substance in the ear canal made up of sebaceous and ceruminous gland secretions, epithelial cells, and hair.2,3

* Cerumen impaction: a buildup of cerumen in the ear canal that prevents assessment of the ear canal or causes symptoms.1

* Cerumen obstruction: a buildup of cerumen that completely blocks the ear canal.1

* Medical assistant (MA): According to the American Association of Medical Assistants, an MA is a health professional who works alongside a physician or other health professional, usually in the clinic setting. Many organizations require that MAs be certified.18

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