Ear Irrigation

Objectives:
At the end of this lecture, each student will be able to:
1-Define cerumen, cerumen impaction, cerumen obstruction and ear
irrigation.

2-Identify signs and symptoms of cerumen impaction/obstruction.

3-List purposes of ear irrigation.

4-Enumerate contraindications to ear irrigation.

5-Recognize complications of ear irrigation.

6-Identify considerations of ear irrigation.

7-Apply nursing process for ear irrigation patient.

8-Imagine scenario for ear irrigation patient.

Outlines:
1-Definitions of cerumen, cerumen impaction, cerumen obstruction and
ear irrigation.

2-Signs and symptoms of cerumen impaction/obstruction.

3-Purposes of ear irrigation.

4-Contraindications to ear irrigation.

5-Complications of ear irrigation.

6-Considerations of ear irrigation.

7-Nursing process for ear irrigation patient.

8-Scenario for ear irrigation patient.

 Ear Irrigation
Definitions:
Cerumen/Earwax: it is a mixture of desquamated skin and secretions
produced by sebaceous and ceruminous glands located in the lateral
external auditory canal. Cerumen is hydrophobic and antibacterial,
forming a protective layer that helps prevent infection and trauma.

Cerumen impaction: it is an accumulation of cerumen that is associated

with symptoms, prevents the necessary assessment of the ear, or both.

Cerumen obstruction: it is a buildup of cerumen that totally blocks the

ear canal.

N.B.: In case of cerumen impaction or obstruction, the patient needs ear

irrigation.

Ear irrigation: it is a procedure used to remove excess cerumen/ear wax

or certain foreign materials from the ear.
Signs and symptoms of cerumen impaction/obstruction:

Cerumen impaction may result in:

1-Feeling of fullness in the ear.

2-Tinnitus.

3-Ear pain/otalgia.

4-Itching in the ear.

5-Decreased hearing or hearing loss.

6-Sensation of imbalance/vertigo.

Purposes of ear irrigation:

The main purposes are:

A-Remove excess cerumen/ear wax in order to:

1-Improve conduction of sound to the tympanic membrane/eardrum.

2-Allow examination of the external auditory canal and the tympanic

membrane and thus allow correct treatment of the ear.

B-Remove foreign bodies, which are not hygroscopic, from the external
auditory canal.

N.B.: Hygroscopic matter (such as peas and lentils) will absorb the water
and expand, making removal more difficult.

C-Relieve signs and symptoms associated with cerumen accumulation

and/or presence of foreign body.
Contraindications to ear irrigation:
Contraindications to performing ear irrigation include:

1-Hygroscopic foreign bodies.

2-Perforated tympanic membrane.

3-Patent tympanostomy tube.

4-An opening into the mastoid bone.

5-A continued bulge in the eardrum indicates possible pus or fluid in the
middle ear.

6-A history of middle ear disease, inner ear problems (especially vertigo),
ear surgery, radiation in the area or cleft palate; repaired or not.

7-The patient has previously experienced complications following this

procedure in the past.
Complications of ear irrigation:
Irrigation of the ear can lead to:

1-Trauma to the skin covering the external auditory canal.

2-Perforation of the tympanic membrane.

3-Middle ear damage if the tympanic membrane is perforated.

4-Tinnitus.

5-Ear infection.

N.B.: symptoms of complications include sudden pain, ringing in the ear,

loss of the ability to hear, bleeding and/or dizziness.

Considerations of ear irrigation:

1-This procedure is only to be carried out by an experienced healthcare

worker who has received recognized training in ear care and the use of
ear care equipment.

2-An individual assessment should be made of every patient to ensure

that it is appropriate for ear irrigation to be carried out.

3-In a normal healthy ear, the ear canal appears the same color as the skin
and the eardrum is a light gray or pearly white. The eardrum is not
bulging outward and should reflect light.

4-Wax-softening eardrops should be used to soften earwax before ear

irrigation.

5-Ear irrigation is typically a safe and relatively comfortable procedure

and it is usually completed in about 30 minutes or less.

6-Ear irrigation should be done gently with warm sterile water or saline
solution (at 37oC - 38oC or temperature comfortable for the patient).
7-Continuously monitor the temperature of the solution throughout the
procedure.

8-Ear irrigation can be done using syringe, mechanical or electrical

irrigators.

9-The tip of the syringe/irrigator should not pass the outer one-third of the
external ear canal (approximately 8 mm).

10-Avoid dropping on the eardrum and never use more than 500 ml of
irrigation solution per ear.
11-the patient must be referred to an ENT specialist in the following
situations:

Perforated tympanic membrane.

Abnormal tissue in the ear canal.
Ear infection.
Prior ear surgery.
Cerumen impaction in the only or better hearing ear.
Pain or bleeding during irrigation.
Failure to remove cerumen after irrigation with 500 ml of irrigation
solution per ear, preceded by wax-softening eardrops.
Persistence of symptoms despite successful removal
of cerumen.
Chronic cerumen impaction.

Nursing process for ear irrigation patient:

I-Assessment:
Assessment of the patient helps to evaluate his/her condition and to detect
any contraindication to ear irrigation procedure. Assessment includes the
following:

1-Assess the patient's history.

2-Check the patient's medications.

3-Check the patient's diagnostic tests.

4-Assess overall condition of the patient.

5-Examine patient's ears with otoscope as follows:

Wash hands and wear disposable gloves & headlight.

Assist the patient to assume the position, which allows a good view.
 Tilt the patient's head slightly toward the opposite shoulder.
Straighten the external auditory canal by gently pulling the auricle
upward and backward.
Turn on the otoscope light and insert the speculum just inside the
opening of the ear.
Check the external auditory canal for redness, swelling, drainage,
cerumen impaction or foreign bodies.
Check the tympanic membrane for bulging, perforation, and color
change.

II-Nursing diagnosis:
Decreased hearing ability related to impaired conduction of sound
to the tympanic membrane secondary to cerumen impaction as
evidenced by improper response to the speaker's questions.
Tinnitus in the ears related to cerumen impaction as evidenced by
patient's complaints.

III-Planning (Expected outcomes):

Expected outcomes following completion of the procedure:

Excess cerumen will be removed.

 Conduction of sound to the tympanic membrane and hearing ability
will be improved.
Tinnitus in the ears will be relieved.
IV-Implementation: (procedure of ear irrigation with syringe):
Steps Rationale
Preparation
1-Prepare yourself:
a,b-To prevent infection transmission.
a-Wash hands.
c-To improve vision during the procedure.
b-Wear personal protective equipment.
c-Wear the headlight.

1-Disposable apron and gloves.

2-Prepare needed equipment.
2-Headlight.
3-Otoscope and suitable size speculum.

4-Waterproof barrier.
5-Two towels.
6-Irrigation syringe with tip.
7-Container of warm sterile water or saline
solution (at 37oC - 38oC or temperature
comfortable for the patient) placed in a pan of
warm water.
8-Container to receive earwax/foreign body.
9-Cotton balls.
 10-Cotton-tipped applicators.
11-Container for dirty instruments.
12-Rubbish bin.
3-Prepare environment:
a-Ensure good lighting. a-To facilitate the procedure.
b-Ensure good ventilation. b,c-To ensure patient comfort.
c-Ensure privacy.
4-Prepare patient: a-To ensure working with the right patient.
a-Identify the patient. b,c-To reassure the patient and gain his/her
b-Introduce yourself to the patient. cooperation.
c-Explain procedure to the patient. d-This is from patient's rights.
d-Take informed consent from the patient or
relative to perform the procedure
The procedure:
5-Place the patient in suitable position (the -To facilitate drainage of irrigation solution.
patient sits up or lies with head tilted
slightly toward side of the ear to be
irrigated).
6-Place towel above waterproof barrier on -To protect the patient's clothes and the bed.
the patient’s shoulder and under the ear to
be irrigated.
7-Ask the patient to hold the container -To receive the irrigating solution
under the same ear.
8-Clean the auricle and meatus of auditory -To avoid entrance of any dirt inside the
canal with moistened cotton-tipped auditory canal during the procedure.
applicators soaked in warm tap water or the
irrigating solution.
9-Check the temperature of the irrigation -To ensure it is warm.
solution.
10-Fill the irrigation syringe with the -Priming the syringe expel the air from it.
solution and prime the syringe. Air forced into the ear canal is noisy and
therefore unpleasant for the patient.
11-Straighten the external auditory canal by
gently pulling the auricle upward and
backward.

12-Direct a steady slow stream of solution -This prevents injury to the tympanic
against the roof of the auditory canal using membrane. Continuous in-and-out flow of
only enough force to remove secretions. Do the irrigating solution helps to prevent
not occlude the auditory canal with the pressure in the canal.
irrigating nozzle.
-Repeat this step and stop the procedure if
there is any sign of complication.

13-When irrigation is complete, place a -To absorb excess solution as gravity allows
cotton ball loosely in auditory meatus and the solution in the canal to escape from the
have patient lie on side of irrigated ear on a ear.
towel.
14-Clean the auricle and meatus of auditory -To remove any dirt, prevent infection and
canal with moistened cotton-tipped promote patient comfort.
applicators soaked in warm tap water or the
irrigating solution then dry them with dry
ones.
15-Examine patient's irrigated ear with -To evaluate the result of the procedure and
otoscope. detect any complication.
-Perform the procedure for the other ear if
needed.
Post procedure:
16-Assess overall condition of the patient -To determine any complications.

17-Put patient in suitable and comfortable -To maintain patient health & comfort.
position.

18-Discard disposable supplies/equipment -To prevent cross infection and environmental

in appropriate containers and clean reusable contamination.
equipment.
19-Remove gloves and wash hands. -To prevent cross infection and environmental
contamination.
20-Document in patient's file: -To facilitate continuity of care among health
a-Date & time of procedure. care team and to treat any abnormality.
b-Patient’s tolerance of procedure.
c-Characteristics of discharge.
d-Assessment findings and any
complications.
V-Evaluation:
Following completion of the procedure:
Excess cerumen was removed.
Conduction of sound to the tympanic membrane and hearing ability
were improved.
Tinnitus in the ears was relieved.

Scenario for ear irrigation patient:

Mr. Hani is 30 years old. He was suffering from itching and feeling of
fullness in the ears. He entered the hospital today and was diagnosed with
cerumen impaction. The ENT nurse made ear irrigation for him. During
the procedure he complained of dizziness, pain and bleeding from the ear
that was irrigated.

According to the previous scenario, mention two nursing diagnoses

for that patient and make nursing care plans for them.

The answer

Nursing diagnoses:

Bleeding from the ear related to trauma to the auditory canal as

evidenced by pain and blood coming from the ear that was irrigated.
High risk for falling related to dizziness.
Nursing care plans:

Assessment Nursing Expected Nursing interventions Rationale Evaluation

diagnosis outcomes
Subjective Bleeding After applying -Stop ear irrigation procedure. -To prevent further After applying
data from the nursing trauma and bleeding. nursing
(symptoms): ear related interventions: -Call ENT specialist -To deal with the interventions:
-Reports of to trauma Trauma to immediately. situation. Trauma to
pain in the to the the -Assess ear with otoscope. -To know the the
ear during ear auditory auditory characteristics and auditory
irrigation. canal as canal will extent of trauma and canal was
evidenced be healed bleeding. healed
Objective by pain properly. -Place sterile cotton gently in -To absorb blood properly.
data (signs): and blood Bleeding the outer ear canal then cover coming from the ear Bleeding
-blood coming from the the outside of the ear with a and help in stopping of from the
coming from from the ear will be sterile dressing shaped to the bleeding. ear was
the ear that ear that stopped. contour of the ear, and tape it stopped.
was irrigated. was loosely in place.
-Facial irrigated.
-Assess and record the -To know the extent of
grimace.
characteristics of pain and pain.
-Guarding.
nonverbal pain cues such as
-Protective
changes in vital signs,
behavior.
emotions and behavior.
-Reassure the patient and -To reduce fear and
encourage pain management pain sensation.
techniques (such as deep-
breathing exercises).
-Administer medications as -To promote healing of
indicated and as prescribed. trauma and control
bleeding & pain.
Assessment Nursing Expected Nursing Rationale Evaluation
diagnosis outcomes interventions
-Assess vital High risk After -Stop ear irrigation -To control dizziness. After applying
signs. for falling applying procedure. nursing
-Assess level related to nursing interventions:
-Call ENT specialist -To deal with the
of dizziness. interventions: Dizziness
immediately. situation.
consciousness. Dizziness was
-Place the patient -To reduce dizziness
-Assess will be relieved.
in bed and raise sensation and ensure
surrounding relieved. Falling was
the side rails. the patient safety.
environment. Falling prevented.
-Assess vital signs -To evaluate the patient
will be
and level of condition.
prevented
consciousness.
.
-Assess and remove -To reduce risk of
any obstacles from falling.
surrounding
environment.
-When the patient -Sudden changes in body
wants to come out of position can cause
bed, help him to sit orthostatic hypotension
on the edge of bed and further dizziness.
for minutes then
stand and walk
slowly with
assistance.
-Administer -To relieve dizziness and
medications as prevent falling.
indicated and as
prescribed.