6/04/2019

EAR
IRRIGATION [Most] Everything you need to 
know to do it safely.
Chris Helms, PhD RN MSN ANP‐NP FACNP

4 April 2019  |  APNA National Conference
Adelaide, South Australia
BridgingHealth.com.au | @nursehelms

Outline
Purpose

Clinical Governance

History and Examination

Differential Diagnosis

Approaches to Management

Procedure

Red Flags and When to Refer

sli.do #EAR

BridgingHealth.com.au BridgingHealth.com.au
|         @nursehelms | @nursehelms

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Why is this Needed?

• Cerumen impaction is common
• Supplements APNA Module
• Not usually a part of our basic training
• Feedback: Nurse-led clinics
• Concerns over scope of practice
• Uncertainty RE: NMBA expectations
• NOT a replacement for VET 10630NAT
• ? Appropriate level of education

Ear syringing is a skill that almost anyone can learn.  
Knowledge informing that skill is key to safely, effectively and 
efficiently performing it.

Litigation

19% 43% 26% 26%

Procedural Claims Poor Technique Faulty Equipment Excessive Pressure

Up to 19% of general Of those claims, most were Was the second most Was also the second most
practice procedural claims. due to poor technique; common cause of claims; and common cause of claims.
(Price, 1997) (Bird, 2008)

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5%

Failure to Exam
Not a scope of practice thing.
A small proportion were because no one
Simply a negligence thing.
bothered to look in the ear. (Bird, 2008)

Complications…
• Failure to remove;
• Otitis externa;
• Perforation of eardrum;
• Damage to external auditory canal;
• Pain, vertigo and otitis media. (Bird, 2008)

• “Minor” complications are approximately 1:1000

• e.g. Perforation, Laceration, Infection, Hearing Loss
• “Major” complications are approximately 1:10,000
• e.g. Malignant Otitis Exeterna

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Malignant External Otitis

(Ford & Courteney-Harris, 1990)

• Risk: Diabetics (90%), actively immunocompromised

+/- age 60
• Pain+++Temp+++
• Pus draining from ear (Pseudomonas > Staph)
• Necrotic ear canal
• Osteomyelitis of the canal and likely mastoid
• Auricular swelling
• Chondritis: Loss of cartilage structure
• Erysipelas
Image: Osguthorpe & Nielsen, 2006

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Erysipelas
• Superficial form of cellulitis
• Affects upper dermis into the
superficial cutaneous
lymphatics
• “St Anthony’s Fire”

Image: Menner, 2000
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So what?
• There are few clinicians out there that cause harm because of
negligence (5%)
• Most harm: lack of clinical governance and individuals practicing
outside their scope of practice (95%)
• Poor Technique
• Faulty Equipment
• Excessive Pressure

• This presentation is about clinical governance and

supporting scope of practice through education.
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Scope of Practice
[Your] scope of practice 
• Knowledge + skills + experiences = ability may change over time. If 
• Professional vs. a [nurse] decides to 
expand or change their 
scope of practice to 
meet the needs of their 
• Jurisdictional vs. client group, then [you] 
will need to complete 
further postgraduate
• Organisational vs. education and skill 
development to meet 
those needs.
• Individual (NMBA, 2016)

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Clinical Governance
• Describes a systematic approach to
maintaining and improving the quality of
patient care within a clinical care setting,
health program or health system. (DOH, 2012)

• Important to discuss:
• Public protection
• Evidence-informed practitioners
• Term has been relatively absent from the
sli.do #EAR
nursing literature
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Requirement: Policies and Procedures

• Need not be onerous and exhaustive,

but encompassing
• Parameters for practice (e.g.
accreditation, populations, etc.)
• Informed consent and patient checklists
• Equipment and maintenance
• Mechanisms for review and quality
assurance
• Risk management
• Documentation
• Care escalation
APNA : Management of Ear Cerumen

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Is Flexible
Accounts for existing and future
workforce, and recognises the
fluidity of professional boundaries

Is Transparent and Encapsulates Best Practice

Contextualised
Ensures the right care is
Accounts for the delivered at the right time
capabilities of the by the right person.
organisation and
Improves efficiency.

Protects the
Public Reflects and Refines
Keeps the patient at the Ensures there are
centre of care at all regular mechanisms for
times. review and refinement.

Effective Clinical Governance

Documentation (Hayter, 2006)

• Indications for ear irrigation

• Assessment for contraindications
or cautions
• Unusual findings
• Irrigation characteristics
• Cerumen quantity and character
• Pre-post observation of ear/TM
• Symptoms reported
• Whether referral was required

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Next Up:
Developing Your
Scope of Practice
Anatomy and Physiology

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Anatomy:
Inspection

Don’t be freaked out if you 
notice your neighbor looking 
at your ear.
Image: healthlifemedia.com, 2019

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Darwin’s Tubercle

Common Variants
Duplication of lobule Hillocks (Pre‐auricular tubercle)

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Images: Color Atlas of ENT Diagnosis, 2009

Prominent Ears
• Important to note within 6
months of life
• Splinting highly successful,
but not after 12 months
• Otherwise, consider
correcting before school
(4-6 years)

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Images: Color Atlas of ENT Diagnosis, 2009

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Pre-auricular Sinuses

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Images: Color Atlas of ENT Diagnosis, 2009

Pathology: What is it?

Keloid after ear piercing  Melanoma

Basal Cell Carcinoma

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Images: Sand, Brors, Altmeyer, Mann & Bechara, 2008

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Obstructive 
Pseudoscience vs Real CAD

Science Just for fun…

Image: Sand, Brors, Altmeyer, Mann & Bechara, 2008
Image: Otoscopy.hawkelibrary.com, 1984
Carney Syndrome

Image: Color Atlas of ENT Diagnosis, 2009
Images: earmedicine.us, 2011

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Gouty Tophi

Where 
the 
magic 
happens. Image: Pearson Education, 2009

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“Middle Ear
Myoclonus”

Image: Pearson Education, 2009
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Epithelial Skin of External Auditory Canal

• Does not normally desquamate
• Canal about 2.5-3cm long in the adult
• Migrates from centre of TM outwards
• 2mm/month migration aided by talking
and chewing
• 6-12 weeks to reach the orifice of the
canal

Image: Otoscopy.hawkelibrary.com, 1984

sli.do #EAR

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Image: Color Atlas of ENT Diagnosis, 2009

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Otoscopy
Equipment

Specula Insufflation 
Large  Tube: OM
and 
Small
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Image: Heine, 2019 Images: Welch Allyn, 2019

Otoscopy

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Normal Anatomy: Entering the Ear

Just in… A little closer… What most of  If the patient 

us see. tolerates.

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Images: Otoscopy.hawkelibrary.com, 1984

Normal Anatomy: Tympanic Membrane

Pars flaccida
Right Ear

Lateral Process 
of Malleus
Incus

Left Ear Handle of 
Malleus

Umbo

Cone of light

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Images: Geekymedics.com, 2019

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Smallest Bone in the Body: The Stapes

Image: Color Atlas of ENT Diagnosis, 2009
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Next Up:
Developing Your
Scope of Practice
Ear Screening

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Hearing Loss: Rinne and Weber

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Screening for Hearing Loss

Weber • Use a 512Hz fork
Rinne (Central) • Conductive (Outer or Middle Ear)
Normal • Cerumen Impaction
• Otitis Media
(Left)
Normal
• TM Rupture
R Sensorineural 
Loss • Ossification
Hearing
Screening (Right) • Sensorineural (Inner Ear)
L Sensorineural  • Presbycusis
Loss • Space occupying lesion

(Left) • 1st Rinne (Conductive)

Abnormal
Conductive • Normal if air louder than bone
• 2nd Weber (Sensorineural)
(Right) • Abnormal if lateralises
Conductive
• Mixed can exist.
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Brief Intro to Audiometry

• Pure tone testing of frequencies from
500 to 4000 Hz (low to high pitch)
• Normal hearing intensity
• Less than 25-30dB Adult
• Less than 15-20dB Children
• Screening or threshold search 5 years and up
• QUIET ENVIRONMENT
• Start at 1000 Hz (easiest to hear)
• 1000,2000,3000,4000,8000,1000,500, 250Hz
• Greater than 40 dB stimulates the other ear (masking)
• Recording
• Right Circle Image: AFP, 2013
• Left X sli.do #EAR

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Screening for Middle Ear Disease

• Extremely useful for Otitis Media with Effusion
• Can be used to establish patency of tubes
• Don’t use age <7 months

Information from Tympanometry

Basic Pneumatic Otoscopy
1. Type A: Normal (Peaked, Normal Volume)
(Advanced/Best)
2. Type B: AOM/OME (Flat, Low Volume)
3. Type B: Patent Passage (Flat, High Volume)
4. Type C: Eustachian Tube Dysfunction
(Peaked, Negative)

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Tympanometry
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(Novice/Adjunctive)

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Break
Questions?

Go to slido.com EVENT PAGE

Enter event code #EAR

Next Up:
Developing Your
Scope of Practice
Pathology

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The Wonderful World of Earwax

The colour and smell of your cerumen is partly determined by your ethnicity.
(Prokop‐Prigge, Thaler, Wysocki & Preti, 2014)

Apocrine Glands are Responsible

Cerumen and underarm odor produced by
East Asians differ markedly from non-Asians.

Becomes darker as it oxidises (Zivic & King, 1993)

Cerumen colour in East Asians is typically

dry and white, whereas in non-Asians is Dry
typically wet and yellowish-brown. (Møller &
Mller, 2012)

An emerging field of research is

Wet
looking at how earwax correlates to
systemic diseases, such as tumours
and metabolic diseases! (Shokry &Filho, 2017)
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Images: Epocrates.com, 2019

Cerumen: It Does a Body Good!-ish

• Protects and moisturises the
external canal
• Low pH Discourages
microbial growth
• Traps and slowly removes
foreign material
• Glands atrophy with age
Drier and migrates slower

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Images: Epocrates.com, 2019

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…Except when it does bad things:

Keratosis obturans:
1. NON‐migratory epithelium 
(desquamation)
2. White keratin plug
3. Hard
4. Adherent to wallhyperaemia
5. PAIN with removal
6. ENT Referral.

sli.do #EAR

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Image: Otoscopy.hawkelibrary.com, 1984

Common Pathology
• Tympanosclerosis
• Exostoses PRIORITY 1
PUS FREE FROM BIRTH TO
• Osteomas
THREE
• Foreign Bodies
• Otitis Externa Excellent resource for Closing the Gap: 
Deadly Ears QLD
• Otitis Media with Effusion
• Acute Otitis Media
• Acute Otitis Media with Perforation
• Chronic Suppurative Otitis Media
sli.do #EAR • Dry Perforations
BridgingHealth.com.au | @nursehelms • Grommets

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Tympanosclerosis

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Exostoses Cold Water

Exposure
Local
Vasconstriction
1. Benign
2. Bilateral
3. Males > Females
4. If grow large enough, can cause ___________ hearing loss
5. Differ from osteomas solitary, unilateral
Stimulation
of Periostium Reactive
of Tympanic Hyperaemia
Bone

Images: Otoscopy.hawkelibrary.com, 1984

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Foreign Bodies: How to Remove?

Irrigation Alligator Forceps Mineral/Olive Oil

CAUTION: Swelling from 
vegetable/plant material! Images: Otoscopy.hawkelibrary.com, 1984

Otitis Externa

Diffuse Swelling
- Pain with manipulation of pinnae, blocked feeling,
draining, itching and hearing loss Images: Otoscopy.hawkelibrary.com, 1984

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Otitis Externa

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Images: Color Atlas of ENT Diagnosis, 2009

Acute Otitis Media vs OM with Effusion

Acute Otitis Media Otitis Media with Effusion Normal

“Pearly grey”

Images: Medicine.uiowa.edu, 2017

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OM with Effusion vs. AOM +/- Perforation

Images: Otoscopy.hawkelibrary.com, 1984

AOM with Perforations

Grommet with AOM Anterior Marginal  20% Central Anterior 

(Unsafe) Perforation Perforation
Images: Otoscopy.hawkelibrary.com, 1984

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Stages

Early AOM ‐ Redness Early AOM – Purulence  Otitis Media with Effusion 

and Bulging ‐ Pain ‐ Painless

Grommets

Images: Otoscopy.hawkelibrary.com, 1984

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Barotrauma

Which is it?

Herniated TM – Air/Pus Level AOM AOM

Prerupture State
Images: Otoscopy.hawkelibrary.com, 1984

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Dry Perforations

Retraction Pockets (Atelectasis)

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Atelectasis Before/After Valsalva

Others

Dried Blood Keratinisation Cholesteatoma 

– More  – Behind TM
pronounced 
when wet!

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Break
Questions?

Go to slido.com EVENT PAGE

Enter event code #EAR

Next Up:
Developing Your
Scope of Practice
Cerumen Removal

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Risk Factors for Impacted Cerumen

(Roland, Smith, Schwartz, Rosenfeld, Ballachanda…Wetmore, 2008)

• 1:10 children & 1:20 adults

• Hearing aids
• Occupations with high exposure to dust and debrischicken or
egg as ear plugs stimulate cerumen production
• Older persons (65% of those aged >65, 57% NH residents)
• Developmentally delayed/disabled (36%)

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Reasons for Removal

• Symptoms:
• Conductive hearing loss
• Cough
• Tinnitis
• Dizziness
• Fullness
• Itchiness
• Mild pain
• Discharge +/- odor
• Audiology appointment
• Unable to examine sli.do #EAR

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Ear Candling
Although it appears to be highly relaxing 
(with a bonfire being lit near your ear)

It’s ineffective and potentially harmful. 

(Because there’s a fire dripping hot wax into 
your ear. and it doesn’t actually remove 
anything but the wax from the candle itself.)

sli.do #EAR

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Removal: Cotton Swabs

WARNING: DO NOT INSERT INTO 
EAR CANAL.  IF USED TO CLEAN 
EARS, STROKE SWAB GENTLY 
AROUND THE OUTER SURFACE OF 
THE EAR ONLY.

Expert opinion recommends 
against the use of swabs to 
remove cerumen, although the 
evidence against this is sparse.
(Roland, Smith, Schwartz, Rosenfeld, Ballachanda…Wetmore, 
2008)

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Cerumenolytics Alone (Aaron, Cooper, Warner & Burton, 2018)

• Cochran Review of 10 studies looking at oil-based (e.g.

olive or almond), water-based (e.g. docusate, 3%
hydrogen peroxide) saline or plain water, and no
treatment
• Risk of doing nothing (1:20) vs risks with drops (1:5)
• Using any cerumenolytic is better than nothing
• Suggestion of minimum of 5 days’ therapy
• Seem to work better in children

Options from my experience
3% Hydrogen Peroxide 1‐2ml/ear
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2‐3 gtts BD Olive Oil (filtered and unflavoured)
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Techniques that have been

tried over the past 100+
years…
Pay close 
attention…

NOT recommended unless there is NO other option 
as risks generally outweigh benefits.

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(Sharp, Wilson, Ross & Barr‐Hamilton, 
1990)

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Ear Syringing Products: Mechanical

Image: NJ Phillips, 2019

Image: MirageHealthGroup.com, 2019

sli.do #EAR

BridgingHealth.com.au | @nursehelms Image: Guardian, 2019

Cautions and Contraindications (Bird, 2008; Hayter, 2016;

• Perforation of the ear drum • Stenosis (trapped H2O)

• Ear Infections within last 6 • Exostoses (trapped H2O)
weeks • Discharge in last 12 months
• Presence of a grommet • Anticoagulation use
• History of ear surgery (atrophy) • Diabetes
• Uncooperative (children) • Immunocompromise
• Only hearing ear • Active dizziness or tinnitis
• Facial trauma
• Cleft palate (with or w/o sli.do #EAR

surgery) BridgingHealth.com.au | @nursehelms

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Irrigation and Earwax Can Cause:

• Vertigo (Semicircular Canals 
• Nausea and Vomiting (Semicircular 
Canals)
• Cranial Nerve V
• Trigemenial
• Tinnitis
• Cranial Nerve VII
• Facial
• Sensory Changes
• Cranial Nerve VIII
• Acoustic Changes
• Cranial Nerve IX
• Glossopharyngeal
• Coughing
• Cranial Nerve X
• Vagus sli.do #EAR
• TM/Posterior Wall
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• Fainting Image: Pearson Education, 2009

General Approach
• Ensure clinical governance and • STOP irrigation if:
agreed clinical training • Pain
framework • Dizzy
• Explain and gain consent • Ringing
• Bleeding
• Sitting down and comfortable • Nausea or vomiting
• Assess with otoscopy and • Coughing*
consider: • Abnormal discharge or smell
• Rinne and Weber • Equipment concerns
• Ensure water is at body • DRY the canal with wick or
temperature cotton swab afterwards
• Reassess
• Educate
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• Document

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10 Steps to Mitigate Risk

1. Think twice: presence of wax in itself is not a problem.
2. Only attempt syringing if symptomatic.
3. Informed consent (1:1000 have a ’minor’ complication)
4. 15 minutes pre-procedure softening*
5. Use a mechanical device that controls pressure.
6. Use warm (37°C) water - never more than 500ml/ear (Stevenson, 2010)
7. Consider ENT referral for suctioning or sterile saline for diabetics,
actively immunocompromised or age >60.
8. Always perform a pre/post examination.
9. Always provide appropriate f/u education and instruction.
10. Use modifiable templates to DOCUMENT EVERYTHING.
sli.do #EAR

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What if Symptoms of Impaction Don’t

Resolve?
• Consider alternative diagnoses:
• Sensorineural hearing loss
• Otosclerosis
• Otitis Media
• Medication ototoxicity
• Head and neck tumours
• TMJ syndrome
• URTIs
• Eustachian Tube Dysfunction
• Skin Disorders
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Any questions?

Go to slido.com EVENT PAGE

Enter event code #EAR

Thank You!
Chris Helms, Nurse Practitioner
E: [email protected]
W: bridginghealth.com.au
T: @nursehelms sli.do #EAR

BridgingHealth.com.au | @nursehelms

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