Download Ear Care Guidelines - Southern Health NHS Foundation Trust

SH CP 196
Ear Care Guidelines
Version: 1
Summary:
Keywords:
Target Audience:
These guidelines are to ensure the provision of evidence based practice, which
will ensure that all patients who are require ear care receive the best quality of
evidence based care, minimising risk and potential adverse effects and
maximising quality of life.
Aural toilet, cerumen, ear care, ear examination, ear syringing, ear irrigation,
ear wax, wax softening, wax removal,
Next Review Date:
This guideline extends to cover those people who are registered with General
Practitioners within the geographical Boundaries of Southern Health
Foundation Trust (SHFT) and the responsibilities of those staff providing such
service.
June 2018
Approved &
Ratified by:
Quality Improvement and Development
Virtual Policy Group
Date issued:
June 2016
Author:
Mandy Lyons, Clinical Trainer
Director:
Lesley Stevens, Medical Director
Date of meeting:
April 2016
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Version Control
Change Record
Date
Author
Version
Page
Reason for Change
Reviewers/contributors
Name
Position
Version Reviewed &
Date
Steve Coopey
Head of Clinical Development Bands 5 and Above
V1 - 2016
Sharon Guy
Lead Clinical Trainer
V1 - 2016
Wendy Eastman
GP Development lead
V1 - 2016
Theresa Lewis
Lead Nurse Infection Prevention & Control
V1 - 2016
Marie Corner
Medical Device Lead
V1 - 2016
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Contents
Section
1.
Title
Introduction
Page
4
2.
Who does this policy apply to?
4
3.
Definitions
4
4.
Duties and responsibilities
6
5.
Main policy content
6
6.
Training requirements
10
7.
Monitoring compliance
10
8.
Policy review
11
9.
Associated trust documents
11
10.
Supporting references
11
APPENDICES
A1
Training needs analysis
12
A2
Ear care nursing record
13
A3
Procedure for Ear Examination (Otoscopy)
16
A4
Guidance for wax softening
18
A5
Procedure for Aural Toilet
19
A6
Procedure for Ear Irrigation
21
A7
Cleaning guidelines for an Electronic Irrigator
24
A8
Referral guidelines
28
A9
Ear Care Patient Information Leaflet
32
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Ear Care Guidelines
1.
Introduction
1.1
The purpose of this guideline is to support staff to provide safe, effective ear care to adults, either
in a clinic or domiciliary setting, in line with best current evidence base. It aims to reduce litigation
risk in ear irrigation and to provide the patient with a positive experience of ear care.
1.2
This document provides guidance on the following subjects
 Cerumen management
 History taking and assessment
 Ear examination
 Softening agents
 Aural toilet/ removal by instrumentation
 Ear irrigation
 Patient referral and advice
 Documentation
1.3
The ‘Ear Care Guidance Document’ (revised in 2014) by The Rotherham Primary Ear Care
Centre’ is the nationally recognised protocol for ear care. It is endorsed by The Royal College of
General Practitioners, The Royal College of Nursing, and the Medical Devices Agency, and has
been recognised as the key evidence base for this guideline.
1.4
Every year in the UK, over two million people have problems with earwax and need it removed.
Complications of syringing are a common cause of complaints and litigation in primary care.
A study examining ear syringing in UK general practice estimated that the rate of complications
requiring specialist referral was about in 1/1000 ears syringed. These complications included
perforation, canal lacerations, and failure of wax removal. Otitis externa may also complicate ear
syringing.
2.
Who does this policy apply to?
This guideline is intended for all members of staff employed by Southern Health NHS Foundation
Trust who are required to undertake ear care. This includes registered nurses in all aspects of ear
care, and any Bands 3 and 4 who have undergone specific training and been assessed as
competent to undertake ear assessment and examination and give advice regarding
management options and the administration of ear drops as appropriate.
3.
Definitions and abbreviations
3.1
Areas of tympanic membrane - Pars flaccida, Pars tensa, Anterior recess, Light reflex
Handle of malleus
3.2
Audiology - field of health care that deals with hearing and balance disorders
3.3
Aural Toilet (also known as Dry mopping) - a procedure used to clear the External auditory
meatus of debris, discharge, soft wax or excess fluid following irrigation, using cotton wool.
3.4
Aural speculum - A funnel shaped piece of plastic on a light source (otoscope) that is inserted
into the auditory canal of the ear, allowing the examiner to look at the ear canal and ear drum.
3.5
Cerumen (Ear wax) - a normal wax-like substance that protects the ear canal
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3.6
Cerumenolytics - agents that soften hardened cerumen (earwax) and make it easier for it to be
removed from the ear.
3.7
Crocodile forceps- instrument used in ear care
3.8
Ear Nose and Throat (ENT) - the area of medicine that deals with disorders and conditions of
the ear, nose, and throat
3.9
Ear irrigation ( formerly known as ear syringing) - a routine procedure used to remove excess
earwax, or foreign materials from the ear
3.10
External auditory meatus- (EAM) also known as the ear canal- a tunnel running from the outer
ear to the middle ear
3.11
Grommets - a tube surgically implanted in the eardrum to drain fluid from the middle ear.
3.12
Hygroscopic foreign bodies - (eg: peas and lentils) will absorb water and expand making
removal difficult.
3.13
Jobson Horne- a probe with a serrated end used in ear care
3.14
Mastoid process - a large, bony prominence on the base of the skull behind the ear, containing
air spaces that connect with the middle ear cavity
3.15
Microsuction - a wax-removal technique using a binocular operating microscope (which allows
depth-perception and magnification) to look straight into the ear canal and a very fine sterile
suction device at low pressure to remove the wax.
3.16
Noots tank- a receiver used to collect water during ear irrigation.
3.17
Otitis Externa - inflammation of the external auditory meatus
3.18
Otoscopy - an examination that involves looking into the ear with an instrument called an
otoscope (or auriscope). This is performed in order to examine the ear canal– the tunnel that
leads from the outer ear (pinna) to the eardrum.
3.19
Pinna - the projecting part of the external ear
3.20
Tinnitus - the word 'tinnitus' comes from the Latin word for 'ringing' and is the perception of
hearing sound in the absence of any corresponding external sound.
3.21
Tragus - a cartilaginous projection anterior to the external opening of the ear.
3.22
Tympanic membrane (TM) - also known as the eardrum - a thin membrane that serves as a
partition between the external ear and the middle ear, and transmits the motion of sound waves
to the small of bones in the middle ear.
3.23
Vertigo - a sensation of dizziness and loss of balance, associated with disease affecting the
inner ear or the vestibular nerve.
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4.
Duties and responsibilities
4.1
Key goals:
 To recognise when ear wax needs to be removed
 To remove earwax effectively and safely when indicated
 To refer appropriately for specialist assessment and management
4.2
All registered nurses are expected to develop and maintain their competence in accordance with
the NMC Code (2015) and follow Record Keeping (2009) guidelines.
4.3
All healthcare professionals must exercise their own professional judgement when using these
guidelines. However, any decision to vary from the guideline should be documented in the
patient’s records to include the reason for variance and the subsequent action taken.
5.
Main policy content
5.1
Cerumen Management
5.1.1
Cerumen, or wax as it is commonly known, is a normal secretion of the ceruminous glands the
external auditory meatus (EAM), which is generally thought to be protective to the ear. It is
slightly acidic, giving bactericidal qualities in both its wet, sticky form (as secreted by Caucasians
and African-Caribbeans) and dry, flaky form (as, for example, secreted by people from South
East Asia).
5.1.2
In addition to epithelial migration, jaw movement assists the movement of wax to the entrance of
the ear canal where it emerges onto the skin. A small amount of wax is normally found in the
EAM and its absence may be a sign that dry skin conditions, infection or excessive cleaning have
interfered with the normal production of wax.
5.1.3
It is only when there is an accumulation of excessive wax that removal may need to be
considered.
5.1.4
A build-up of wax is more likely to occur in older adults and patients with learning difficulties
(reason unknown), hearing aid users, people who insert implements into the ear or have a narrow
EAM. A build-up of wax may also occur as a result of anxiety, stress and dietary or hereditary
factors.
5.1.5
Excessive wax should be removed before it becomes impacted, or it can give rise to tinnitus,
hearing loss, vertigo, pain and discharge.
5.1.6
If wax is removed due to the presenting complaint of hearing loss, it is important to ascertain
whether good hearing is restored after treatment, or consider if the patient would benefit from a
formal assessment by the ENT surgeon or Audiologist.
5.1.7
Following assessment and examination the experienced practitioner can use his or her clinical
judgement on the best method for wax management and removal. Olive oil may be advised in
favour of other cerumenolytics as it is the softening agent with least likelihood of causing
irritation. The practitioner may decide that extended use of olive oil is preferable to wax removal
procedures.
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5.1.8
Options for removal of impacted wax include:




Use of softening agents
Aural Toilet/ removal of wax by instrumentation/ dry mopping
Ear irrigation with water using an electronic ear irrigation device
Referral to specialist; outcome may include removal of wax by micro suction
5.1.9
Patients should always receive education and advice, to help them to give informed consent for
any procedures, and written advice in the form of a patient leaflet may reduce contributory factors
and therefore the need for future ear irrigation or intervention (see Appendix 9).
5.2
History taking and Assessment
5.2.1
Prior to examination of the ear it is essential to talk to the patient and / or their carer to obtain a
detailed history and provide explanation of any examination or procedures. The service user
should be fully informed of possible complications of the procedure and effects of ear irrigation, to
ensure that the patient understands and gives consent.
5.2.2
Document the assessment and relevant history on the Ear Care Nursing Record- Initial
Assessment Form (See Appendix 2).
5.2.3
The form should include patient’s personal identification details, including name, date of birth,
address or NHS number.
5.2.4
Past medical history should be documented, including existing long term conditions, current
medication, allergy status and present or previous occupation.
Detailed ENT history should be taken to include the following:
 Grommets
 Cleft palate
 Recent ear infection
 Mastoid problem
 Any ear surgery
 Perforated ear drum
 Ear pain
 Ear discharge
 Tinnitus
 Vertigo
 Itchy ears
 Hearing aid
 Hearing loss
 Previous ear irrigation
 Previous microsuction
5.2.5
Details of the current presenting problem and any symptoms being experienced by the patient
should be documented.
5.3
Examination of both ears
5.3.1 The aim of the examination is to assess the amount and position of wax, and to support the
clinical decision making process regarding any procedures or interventions to be carried out.
5.3.2 Careful history taking will exclude any contra-indications to ear irrigation
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5.3.3 Physical assessment of the outer ear should describe findings relating to the pinna, the tragus
any swelling, skin lesions, mastoid tenderness
5.3.4 Otoscopic examination should be carried out by healthcare professionals who have been trained
and are competent in this procedure, following the SHFT Ear Examination procedure (see
Appendix 3)
5.3.5 Findings from both ears should be documented using the SHFT Nursing record and should
include the following: if tympanic membrane visible, light reflex, dry skin, scaling, erythema,
discharge, oedema, pain, wax amount & colour.
5.3.6 Any wax softening agents inserted already by patient or carer should be documented, to include
what agent has been used, how much has been inserted, how often and for how long?
5.4
Softening agents
5.4.1 Following patient assessment and examination of both ears, if impacted wax is the problem
advice needs to be given to the patient/ and or carer regarding wax softening prior to any further
procedures being carried out. This is to promote patient safety by reducing risk of procedures,
and increasing likelihood of successful wax removal (See Appendix 4: Guidelines for wax
softening).
5.4.2 There is no evidence to confirm that any one wax softening agent is superior to another.
However, olive oil has been shown to be less irritant in some individuals, so is first line choice.
5.4.3 Olive oil should be at room temperature. Advise patient/ carer to insert olive oil into the affected
external auditory canal: Insert 2-3 drops, 2-3 x per day, for a minimum of 5-7 days.
5.4.4 Advise patient to lie on unaffected side, if possible, while olive oil is inserted using a dropper, and
to remain on side for 5 minutes afterwards.
5.4.5 Advise patient not to put cotton wool in to ear after olive oil has been inserted, as the cotton wool
absorbs the oil which could lead to ineffective wax softening.
5.4.6 The patient should be re-assessed, and ears re-examined after 5-7 days, and consider if any
further intervention is required, and document rationale for any procedures.
5.4.7 If further wax softening is required prior to further intervention the patient could be advised to
continue with olive oil or an alternative cerumenolytic could be tried eg: Earol spray ( if patient is
having problems instilling drops), sodium bicarbonate drops, Earex, or hydrogen peroxide based
solutions( eg: Otex).
5.4.8
Care must be taken not to advise any products that may contain nut oils, such as almond oil, if a
patient has a nut allergy, to avoid risk of anaphylactic reaction.
5.4.9
Aural Toilet (also known as dry mopping or removal of excessive wax by instrumentation)
5.4.10 This procedure should be carried out following patient assessment and examination, to support
patient safety, and determine if procedure is contra indicated (See Appendix 5).
5.4.11 Aural toilet should always be carried out to clear the external auditory meatus of excess fluid
following ear irrigation, to reduce risk of infection post irrigation procedure.
5.4.12 This procedure may also be considered as a treatment option to remove debris, discharge or soft
wax from the ear as an alternative treatment option, if irrigation is contra indicated, or as an
option which may be less traumatic and a more acceptable patient choice.
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5.4.13 The EAM is cleaned with a gentle rotary action, and the cotton wool should be replaced directly it
becomes soiled.
5.4.14 Care must be taken not to touch the tympanic membrane.
5.4.15 Intermittently re-examine the meatus, using the otoscope, during cleaning to check for any
debris/discharge/crusts which remain in the meatus at awkward angles.
5.4.16 Any wax, debris, dry skin or clearly visible foreign objects not removed by dry mopping could be
removed by instrumentation, for example using a wax hook, or crocodile forceps, but only if the
registered nurse has considerable experience and competence in ear care.
5.4.17 Document the procedure and what was observed in both ears, including the condition of the
tympanic membrane and external auditory meatus using SHFT Ear Care documentation record.
5.5
Ear Irrigation
5.5.1
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. (See Appendix 6).
This procedure should only be carried out by a registered nurse who has undergone training and
can demonstrate competency in accordance with NMC Code, to support safe clinical practice.
Nurses performing the procedure should understand the normal and abnormal anatomy and
physiology of the ear and be aware of the complications and contraindications of ear irrigation.
5.5.2
This procedure should only be carried out following patient assessment and examination of both
ears, to ensure patient safety, and determine if the procedure is contra indicated.
Consent needs to be obtained and the rationale for carrying out the procedure documented in
individual care plan.
5.5.3
This procedure should not be used for the removal of hygroscopic foreign bodies such as peas
and lentils, as these will absorb water and expand, making removal difficult.
5.5.4
Before commencing procedure ensure electronic irrigation machine has been maintained and
cleaned in accordance with manufacturer’s instructions. (See Appendix 7: Guidelines for cleaning
electronic irrigator). This is to promote patient safety and reduce risk of infection or trauma during
procedure.
5.5.5
This procedure should be carried out with both participants seated and under direct vision, using
a headlight or head mirror and light source, to aid visibility and support comfort and safety.
5.5.6
The tap water used for this procedure should be at body temperature to aid patient comfort and
reduce risk of problems, such as dizziness or trauma.
5.5.7
The pressure on the irrigation machine should be set at minimum and, using the foot control,
point the jet tip to direct a stream of water along the roof of the EAM and towards the posterior
wall (direct towards the back of the patient’s head), increasing the pressure control gradually if
there is difficulty removing the wax.
5.5.8
It is advisable that a maximum of one reservoir of water per ear is used in any one irrigation
procedure to prevent trauma or patient discomfort.
5.5.9
Periodically inspect the EAM with the otoscope and inspect the solution running into the receiver,
to monitor progress of the procedure, and minimise time and amount of water used for irrigation.
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5.5.10 After removal of wax or debris, dry mop and remove excess water from the meatus under direct
vision using the Jobson Horne probe and best quality cotton wool (See Appendix 5), as
stagnation of water in the ear canal and any abrasion of skin during the procedure predispose to
infection. Removing the water with the cotton wool tipped probe reduces the risk of post
procedure infection.
5.5.11 Irrigation may be uncomfortable but it should NEVER CAUSE PAIN.
STOP IMMEDIATELY if:
 Patient complains of pain
 Water comes down the nose
 Patient swallows excessively
 Bleeding occurs
5.5.12 Advise of possible complications following procedure, such as dizziness, infection, tinnitus, to
ensure an effective outcome for the patient and support continuity of care.
5.5.13 Refer patients if necessary following local referral guidelines (see Appendix 8)
5.6
On-going patient advice
5.7.1 Give advice to patient regarding on going ear care and provide SHFT written patient information
leaflet (see Appendix 9).
5.7.2
Patient should be advised that the only reason for carrying out ear irrigation is when hearing is
reduced due to wax impacted on the eardrum. Regular or routine irrigation is not recommended.
5.7.3
If wax has been removed due to the presenting complaint of hearing loss, they should check
whether good hearing is restored after treatment or would they benefit from a formal hearing
assessment by the audiologist.
5.7.4
Advise patients that wax protects the ear and that the ear is self-cleaning and does not need
poking with flannels and direct streams from the shower head or cotton buds or keys.
5.7.5
Ear candles are not a safe option of wax removal as they may result in serious injury.
5.7.6
To prevent build-up of excessive wax, if this is a recurrent problem, it may be helpful to instil olive
oil in to the ear canal once or twice a week and wear ear plugs when in water.
6.
Training requirements
All staff undertaking ear care should have attended SHFT Ear Care Training provided by the
LEaD Clinical Training Team, or an alternative recognised ear care training course, and be able
to demonstrate confidence and competence in carrying out safe and effective ear care using the
Southern Health Competency Framework Tool. It is advised that any health care professional
learning to carry out a new clinical skill, such as ear care, be supervised initially by a mentor in
practice who is already competent in ear care.
7.
Monitoring compliance
Element to be
monitored
Competency in Ear
Care
Lead
Tool
Frequency
Line
manager
Competency
Framework tool
Every two
years
Reporting
arrangements
Annual appraisal
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8.
Policy review
This policy will be reviewed every three years
9.
Associated trust documents
Infection prevention and control policy
Hand Hygiene and Aseptic and Clean Technique Procedures.
Management and Decontamination of Medical devices
10.
Supporting references
Ear Care Guidance Document (revised 2014) The Rotherham NHS Foundation Trust Primary Ear
Care Centre. http://earcarecentre.com.
National institute for health & excellence (NICE) Clinical knowledge summary (CKS): Earwax
(2012) http://cks.nice.org.uk/earwax
http://www.tinnitus.org.uk/what-is-tinnitus REFERENCES (EAR CARE GUIDELINES)
Ear care guidelines: Worcestershire Primary Care Trust (2006)
The Royal Marsden Manual of Clinical Nursing Procedures (9th Edition) 2015, Edited by
Dougherty, L & Lister, S. Wiley Blackwell, W Sussex.
Sharp JF, Wilson JA, Ross L, Barr-Hamilton RM (December 1990). "Ear wax removal: a survey of
current practice". BMJ 301 (6763): 1251–3
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Appendix 1: Training Needs Analysis
If there are any training implications in your policy, please complete the form below and make an appointment with the LEaD department (Louise Hartland, Quality,
Governance and Compliance Manager or Sharon Gomez, Essential Training Lead on 02380 874091) before the policy goes through the Trust policy approval process.
Training
Programme
Frequency
Course Length
Delivery Method
Facilitators
Recording Attendance
Ear care training
Once
1 day
Face to face
Clinical trainers
MLE
Directorate
Service
Adult Mental Health
Specialised Services
Strategic & Operational
Responsibility
Strategic – Director of Nursing
Operational – Head of Clinical
Development
Target Audience
All health care professionals including non-registered practitioners who are required to perform ear care
All health care professionals including non-registered practitioners who are required to perform ear care
MH/LD/TQ21
Learning Disabilities
TQtwentyone
ISD’s
Older Persons Mental Health
ISD’s
Adults
ISD’s
Childrens Services
Corporate
All
All health care professionals including non-registered practitioners who are required to perform ear care
All health care professionals including non-registered practitioners who are required to perform ear care
All health care professionals including non-registered practitioners who are required to perform ear care
All health care professionals including non-registered practitioners who are required to perform ear care
na
NA
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Appendix 2
EAR CARE NURSING RECORD
INITIAL ASSESSMENT
Patient Name
Date of Birth
Address
NHS NO:
Allergies:
Occupation:
Previous medical history/ existing
long term conditions
Current presenting problem
Symptoms
Current Medication:
Past ENT History:
 Grommets
 Cleft palate
 Recent ear infection
 Mastoid problem
 Any ear surgery
 Perforated ear drum
 Ear pain
 Ear discharge
 Tinnitus
 Vertigo
 Itchy ears
 Hearing aid
 Hearing loss
 Previous ear irrigation
 Previous microsuction
RIGHT EAR
LEFT EAR
Use of wax softening agents so far?
What agent has been used?
How much inserted?
How often?
For how long?
Date of initial assessment:
RIGHT EAR
LEFT EAR
Signature:
Position:
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Ear Examination Record
Patient Name
Date of Birth
Address
NHS No:
Consent: Yes / No
Physical assessment of
outer ear:















Pinna
Tragus
Swelling
Skin Lesions
Mastoid tenderness
Otoscopic Examination:
Tympanic membrane
visible
Light reflex
Dry skin
Scaling
Erythema
Discharge
Oedema
Pain
Wax
Amount
Colour
RIGHT EAR
LEFT EAR
RIGHT EAR
LEFT EAR
Picture representation of
examination of tympanic
membrane
Date of examination:
Signature:
Position:
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Ear Care Procedure Record
Patient Name
Date of Birth
Address
NHS No:
Procedure Carried out:
 Right ear:
Consent: Yes / No

Left ear:
Otoscopic Examination
following procedure:
 Dry mopping carried out
to clear any water post
procedure
 Tympanic membrane
visible
 Light reflex
 Trauma to canal
 Dry skin
 Scaling
 Erythema
 Discharge
 Oedema
 Pain
 Wax removed/
remaining
Amount
Colour
Picture representation of
examination of tympanic
membrane post procedure
Advice leaflet given to patient
following procedure:
Yes/ No
Date of examination:
RIGHT EAR
LEFT EAR
Verbal advice given:
Referral advised:
Signature:
Position:
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APPENIDX 3
Procedure for Ear Examination (Otoscopy)
Action
Obtain careful history from patient prior to
examination, including establishing whether patient
has any known allergies. Complete the SHFT Ear
Care Assessment Form
Explain each step of the procedure to the
patient, including potential risks and complications,
and ensure the patient understands and gives
consent.
If necessary refer to the Mental Capacity Act 2005,
and consider if the examination is in patient’s best
interest.
Identify patient by surname, first name and date of
birth using open questions checking against NHS
number.
Collect required equipment:
 Clean area
 Single use non sterile gloves
 Disposable apron
 Otoscope ( with spare batteries)
 Different sizes of disposable aural speculums
 Ear care assessment and examination record for
documentation
 Patient information leaflet
Decontaminate hands as per Southern Health Hand
Hygiene Procedure, and apply gloves and apron
Ensure that both you and the patient are seated
comfortably at the same level and that privacy is
maintained
Examine the pinna, outer meatus and adjacent
scalp
Identify the largest suitable speculum that will fit
into the ear and place it on the otoscope
Palpate the tragus
Gently pull the pinna upwards and backwards
If there is localised infection or inflammation this
may be painful and examination may be difficult.
Hold the otoscope like a pen and rest the little
finger on the patient’s head.
Use the left hand for the left ear and the right hand
for the right ear
Insert the speculum gently into the meatus, using
the light to observe the direction of the External
Auditory Meatus and the TM to pass through any
hairs at the entrance to the canal.
Rationale
To assess symptoms, and identify any possible
contra indications for treatment if required, and
reduce the risk of allergic reaction.
To ensure patient is informed of procedure and
happy to proceed.
To ensure correct identification of the patient.
To ensure procedure is performed
without disruption to maintain patient
safety.
To reduce the risk of infection.
To ensure patient comfort and safety and ease of
access to the ear
To check for previous surgery, incision scars,
infection, discharge, signs of skin lesions or defects
To ensure patient comfort and safety, while
allowing clear examination of the ear
To identify if the patient has any pain
To straighten the ear canal.
If this is painful, proceed with caution, and consider
referral to GP.
To stabilise and anchor the otoscope and act as a
trigger for any unexpected head movement
To improve visualisation of the tympanic
membrane
To aid visualisation of the tympanic membrane
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Looking through the otoscope check the EAM and
TM, adjusting your head and the otoscope to view
all of the eardrum as the ear cannot be judged to
be normal until all the areas of the membrane are
viewed: the light reflex, handle of malleus, pars
flacida, pars tensa and anterior recess.
If the presence of wax inhibits examination of the
tympanic membrane the wax removal may be
necessary
As the otoscope is withdrawn carefully check the
condition of the skin in the EAM.
Always examine both ears.
Dispose of all equipment as per Handling and
Disposal of waste policy, remove gloves and apron
and decontaminate hands as per the Hand Hygiene
Procedure.
Document what was seen in both ears, the
procedure carried out, the condition of the tympanic
membrane and any treatment advised or given,
using the SHFT Ear care assessment and
examination form.
If any abnormality is found ensure an appropriate
referral is made in line with local policy
To ensure full examination of the ear
To ensure full examination of the ear
To ensure thorough patient assessment and
examination has been completed.
To ensure staff and patient safety and to prevent
infection.
To comply with NMC Code and SHFT guidelines
on documentation
To promote continuity of care and patient safety.
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Appendix 4
Guidance for wax softening
Action
Rationale
Following patient assessment and examination
of both ears, if impacted wax is the problem
advice needs to be given to the patient/ and or
carer regarding wax softening prior to any further
procedures being carried out.
Advise patient/ carer to insert olive oil into the
affected external auditory canal:
Insert 2-3 drops, 2-3 x per day, for a minimum of
5-7 days.
Olive oil should be at room temperature.
Advise patient to lie on unaffected side, if
possible, while olive oil is inserted using a
dropper, and to remain on side for 5 minutes
afterwards.
Advise patient not to put cotton wool in to ear
after olive oil has been inserted.
To ensure patient safety and reduce risk of
procedures.
Re-assess patient and re-examine ears after 5-7
days, and consider if any further intervention is
required, and document rationale.
If further wax softening is required prior to further
intervention the patient could be advised to
continue with olive oil or an alternative
cerumenolytic could be tried eg: Earol spray ( if
patient is having problems instilling drops),
sodium bicarbonate drops, Earex, or hydrogen
peroxide based solutions( eg: Otex).
Care needs to be taken not to advise any
products that may contain nut oils, such as
almond oil, if a patient has a nut allergy.
Re-assess patient and re-examine ears again
after a further 5-7 days, and consider if any
further intervention is required, and document
rationale using SHFT Ear care documentation.
To ensure patient safety and reduce risk of
procedures, and ensure effective removal of wax.
To soften wax to make removal easier.
There is no evidence to confirm that any one
wax softening agent is superior to another.
However, olive oil has been shown to be less
irritant in some individuals, so is first line choice.
The cotton wool absorbs the oil which leads to
ineffective wax softening.
To aid wax softening and reduce risk of
procedure
To avoid risk of anaphylactic reaction
To ensure patient safety and reduce risk of
procedures, and ensure effective removal of wax.
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Appendix 5
Procedure for Aural Toilet
Dry mopping/ Removal of wax by instrumentation
Action
This procedure is only to be carried out by a nurse
with recognised ear care training, who can
demonstrate competency. These notes are to be
used as a guide: when the practitioner has
developed their skills they can use their own
clinical judgement on the most appropriate method
and instrumentation to remove wax.
Identify patient by surname, first name and
date of birth using open questions, and the
procedure, including potential risks and
complications should be explained to the patient
and informed consent gained.
Refer to the Mental Capacity Act 2005 if
It is considered that the procedure is in the
patient’s best interests.
This procedure should only be carried out following
patient assessment and examination (see
procedure Appendix 2: Ear examination) of both
ears, and rationale for carrying out procedure
should be documented in individual care plan.
Aural toilet should always be carried out to clear
the external auditory meatus of excess fluid
following irrigation, and may also be considered as
a treatment option to remove debris, discharge,
soft wax from the ear.
Decontaminate hands as per Southern
Health Hand Hygiene Procedure and apply gloves
and apron.
Clean the EAM with a gentle rotary action.
Replace the cotton wool directly it becomes soiled.
Do not touch the tympanic membrane.
Intermittently re-examine the meatus, using the
otoscope, during cleaning to check for any
debris/discharge/crusts which remain in the
meatus at awkward angles.
Any wax, debris, dry skin or clearly visible foreign
objects not removed by dry mopping could be
removed by instrumentation, for example using a
wax hook, or crocodile forceps, but only if the
registered nurse has considerable experience and
competence in ear care
If this treatment becomes painful, do not continue.
Ensure patient is comfortable following procedure.
Rationale
In accordance with NMC Code and to support
safe clinical practice
To ensure patient understands and is happy to
proceed
To support patient centred care
To ensure patient safety, and determine if
procedure contra indicated.
To reduce risk of infection post irrigation
procedure.
As an alternative treatment option if irrigation
contra indicated, or an option which may be less
traumatic and a more acceptable patient choice.
To reduce the risk of infection.
To reduce risk of infection and trauma and to
promote patient comfort.
To increase effectiveness of procedure
To increase effectiveness of procedure and
reduce risk of trauma or infection.
To prevent trauma to the meatal lining and
reduce risk of infection
To ensure patient comfort and a positive patient
experience
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Dispose of equipment as per the disposal and
handling of waste policy. Remove apron and
gloves. Decontaminate hands as per Hand
Hygiene procedure.
Document procedure and what was observed in
both ears, including the condition of the tympanic
membrane and external auditory meatus using
SHFT Ear Care documentation record.
To ensure patient and staff safety.
Findings should be documented following the
NMC guidelines on record keeping and
accountability to support effective patient centred
care
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Appendix 6
Procedure for Ear Irrigation
Action
This procedure should only be carried out by a
registered nurse who has undergone training and
can demonstrate competency.
Identify patient by surname, first name and
date of birth using open questions, and the
procedure, including potential risks and
complications should be explained to the patient
and informed consent gained.
Refer to the Mental Capacity Act 2005 if
It is considered that the procedure is in the
patient’s best interests.
This procedure should only be carried out
following patient assessment and examination of
both ears (see Appendix 2: Ear examination
procedure), and rationale for carrying out
procedure should be documented in individual
care plan.
This procedure should not be used for the removal
of hygroscopic foreign bodies such as peas and
lentils.
Ensure electronic irrigation machine has been
maintained and cleaned in accordance with
manufacturer’s instructions prior to use
( See Appendix: Guidelines for cleaning electronic
irrigator)
Gather together all equipment necessary to carry
out procedure.
Equipment required:
 Hand washing facilities/ tap water
 Otoscope and a variety of sizes of single
use speculae
 Electronic irrigator eg: Propulse III or NG.
 Disposable jet tips
 Head torch
 Noots trough/ receiver
 Jobson Horne Probe and cotton wool
 Disposable waterproof cape and paper
towels/ tissues
 Disposable apron and non sterile gloves
 Rubbish bag
Decontaminate hands as per Southern
Health Hand Hygiene Procedure and apply gloves
and apron.
This procedure should be carried out with both
participants seated and under direct vision, using
a headlight or head mirror and light source.
Place the protective cape and paper towel on the
Rationale
In accordance with NMC Code and to support safe
clinical practice
To ensure patient understands and is happy to
proceed
To support patient centred care
To ensure patient safety, and determine if
procedure contra indicated.
These will absorb water and expand making
removal difficult.
To ensure patient safety and reduce risk of
infection or trauma during procedure.
To provide continuity of care and reduce
interruption, and improve patient experience.
To reduce the risk of infection.
To aid visibility and support comfort and safety.
To protect patient’s clothing
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patient’s shoulder and under the ear to be
irrigated. Ask the patient to hold the receiver under
the same ear.
Check the temperature of the water with the
patient to ensure it is warm enough, and fill the
reservoir of the irrigator.
Set the pressure at minimum on the irrigation
machine.
Connect a new disposable jet tip applicator to the
tubing of the machine with a firm ‘push/twist’
action. Push until a "click" is felt.
Direct the irrigator tip into the Noots receiver and
switch on the machine for 10-20 seconds to
discard the initial flow of water. Check the
temperature of the water again.
Twist the jet tip so that the water can be aimed
along the posterior wall of the External Auditory
Meatus- EAM (towards the back of the patient’s
head)
Gently pull the pinna upwards and outwards.
Warn the patient that you are about to start
irrigating and that the procedure will be stopped if
he/she feels dizzy and/or experiences any pain.
Ensure that the light is directed down the EAM.
Place the tip of the nozzle into the EAM entrance
and, using the foot control, direct a stream of
water along the roof of the EAM and towards the
posterior wall (direct towards the back of the
patient’s head).
Increase the pressure control gradually if there is
difficulty removing the wax, and use the foot
control to manage the stream of water.
It is advisable that a maximum of one reservoir
of water per ear is used in any one irrigation
procedure.
You may find it beneficial to instil water into both
ears (if both require irrigation with water) and
return to the procedure after a rest of 15 minutes.
Periodically inspect the EAM with the otoscope
and inspect the solution running into the receiver.
After removal of wax or debris, dry mop and
remove excess water from the meatus under
direct vision using the Jobson Horne probe and
best quality cotton wool.
(see Apendix: Procedure for aural toilet/ dry
mopping)
Examine the ear, both meatus and tympanic
membrane, and document what was observed in
both ears, the procedure carried out, the condition
of the tympanic membrane and external auditory
meatus and treatment given. Use the SHFT Ear
care nursing record.
Ensure patient is comfortable following procedure.
The water should be at body temperature to aid
patient comfort and reduce risk of problems, such
as dizziness or trauma, during procedure.
To avoid cross infection, and to ensure the jet tip
does not fall off causing potential injury to canal
during procedure.
To remove any static water remaining in the tube,
circulate the water through the system and
eliminate any trapped air or cold water. This also
offers the opportunity for the patient to become
accustomed to the noise of the machine.
To minimise risk of trauma during the procedure
To straighten the EAM, and to hold the ear steady
to prevent injury
To prevent trauma or patient discomfort
To prevent trauma or patient discomfort
To prevent trauma or patient discomfort, and
increase likelihood of an effective outcome.
To prevent trauma or patient discomfort
There is evidence to suggest that leaving water in
the canal for 15 minutes will increase the chance
of success.
To monitor progress of procedure, and minimise
time and amount of water used for irrigation
Stagnation of water and any abrasion of skin
during the procedure predispose to infection.
Removing the water with the cotton wool tipped
probe reduces the risk of post procedure infection.
Findings should be documented following the
NMC guidelines on record keeping and
accountability to support effective patient centred
care
To ensure patient comfort and a positive patient
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Dispose of equipment as per the disposal and
handling of waste policy. Remove apron and
gloves. Decontaminate hands as per Hand
Hygiene procedure.
If any abnormality is found a referral should be
made following local referral pathway.
Irrigation may be uncomfortable but it should
NEVER CAUSE PAIN.
STOP IMMEDIATELY if:
 Patient complains of pain
 Water comes down the nose
 Patient swallows excessively
 Bleeding occurs
Give advice to patient regarding on going ear care
and provide SHFT written patient information
leaflet, and advise of possible complications
following procedure, such as dizziness, infection,
tinnitus.
Document procedure and what was observed in
both ears, including the condition of the tympanic
membrane and external auditory meatus using
SHFT Ear Care documentation record.
experience
To ensure patient and staff safety.
To ensure effective outcome for patient and
support continuity of care.
To prevent damage to ear and trauma to patient.
To ensure effective outcome for patient and
support continuity of care.
Findings should be documented following the
NMC guidelines on record keeping and
accountability to support effective patient centred
care
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Appendix 7
Cleaning guidelines for an Electronic Irrigator
Ear irrigation is a clean procedure.
Disposable jet tips must be used with the electronic irrigator.
The frequency for decontamination of Propulse Electronic Ear Irrigator pumps and waterways
should be once a day only and take place prior to the first use.
Stage 1: BEFORE USE
•
•
•
•
•
•
•
Before use, the electronic irrigator must be disinfected using a solution of Sodium
Dichloroisocyanurate 0.1% (NaDCC). This is available in the form of Chlor-Clean tablets, or
Presept. These or similar products should be used according to manufacturer’s instructions, to
make a solution which provides 1000 parts (NaDCC) per million (0.1%). Chlor-Clean is
mentioned particularly because it contains a surfactant (i.e. detergent) in addition to a
disinfectant. Any damage caused to the propulse electronic irrigator by not using the
recommended cleaning agent will invalidate the manufacturer’s warranty.
Place 1 propulse cleaning tablet into the reservoir, fill with warm water to the 500ml mark and
wait for the tablet to completely dissolve.
Run the irrigation system for a few seconds to allow the solution to fill the pump and flexible
tubing.
Leave to stand for 10 minutes.
DO NOT leave the solution in the unit for longer than stated.
Empty the reservoir of the solution, and then fill the reservoir with either cool boiled water or wellrun cold tap water and flush through the whole system to ensure no cleaning solution remains.
This procedure should be carried out prior to each day’s usage of the ear irrigator.
Stage 2: AFTER USE
•
•
After use empty the reservoir and operate the device to purge any residual water.
The manufacturer’s guidelines do not ask that it is disinfected again at the end of the day, but to
ensure that is thoroughly dry before putting away for storage.
(Adapted from The Rotherham Primary Ear Care Centre guidelines: 2014 and the Propulse NG user
manual: 2012)
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DATA SHEET: Sodium Dichloroisocyanurate (NaDCC)
1. Hazards identification
HARMFUL if swallowed. Irritating to eyes and respiratory system. Contact with acid liberates toxic gas.
On contact with moisture, NaDCC readily decomposes to Chlorine, Hypochlorous Acid & Cyanuric Acid.
2. First aid measures
Eye Contact: Immediately flush with plenty of clean water for at least 15 minutes. If irritation persists,
seek medical attention.
Skin Contact: Promptly wash thoroughly with water for at least 15 minutes whilst removing
contaminated clothing. Wash any contaminated clothing well, before re-use.
Ingestion: Immediately rinse mouth, then drink plenty of water or milk. Do not induce vomiting. Seek
medical attention.
Inhalation: Move to fresh air. If irritation persists, seek medical attention.
3. Fire-fighting measures
Special Fire or Explosion Hazards: Product is not flammable itself, but contact with combustible material
may cause fire. Product combustible if dehydrated by drying. Decomposes above 250OC with release of
chlorine & other toxic fumes.
A thermal decomposition can be extinguished by flooding with copious amounts of water or by isolating
the decomposing material in open air and allowing it to be consumed. Use self-contained breathing
apparatus and goggles. Do not approach from leeward.
Suitable Extinguishing Media: Pressurised water or dry powder. Do not use dry fire extinguishers
containing ammonium compounds.
Other Recommendations: Remove the product if it is safe to do so, before using water for fire fighting, in
order to minimise hazards from release of toxic fumes. It will often be safer to let the fire burn itself out.
Where it is decided to fight the fire with water, large quantities must be used. If insufficient water is used
there may be an explosion hazard associated with hot damp material. NaDCC may generate nitrogen
trichloride when it is left under damp conditions.
4. Accidental release measures
Any spillage should be cleaned up as soon as possible to prevent contamination with foreign materials
with which it may react - see section 8 (Stability and Reactivity) below. Handle spillage carefully, do not
return spilled material to original container.
If tablets are dry and uncontaminated, collect into heavy-duty plastic bag; where possible and suitable,
use material as originally intended. Wash away any residue with copious amounts of water.
If tablets are contaminated they should be transferred to waste ground, spread thinly and covered with a
thin layer of earth; a smell of chlorine will be noted until the material has degraded. Keep people,
vehicles and animals away from the disposal area.
If tablets become damp they will effervesce, evolving carbon dioxide and may decompose to give off
chlorine fumes; transfer spillage to unsealed plastic bags, avoiding any large masses of material within
the bags, and remove to waste ground for immediate treatment/disposal as above; avoid breathing
fumes. Wash away residue with copious amounts of water.
If spillage of tablets is large (more than 100Kg), place into bins lined with polythene bags and eliminate
in accordance with locally valid disposal regulations.
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5. Handling and storage
Recommended Storage Conditions:
Store away from all incompatibles and combustibles - see section 8 (Stability and Reactivity) below.
Store in a cool, dry, well-ventilated place. Moisture sensitive. Avoid high humidity levels. Do not allow
water to get into container. Keep away from fire, heat, flame & direct sunlight. Keep container tightly
closed. Keep out of reach of children. Never store damp or contaminated material.
Recommended Handling Precautions:
Avoid contact with eyes, skin & clothing.
When handling large quantities of tablets, wear chemical resistant gloves and safety goggles.
Avoid breathing any dust.
Wash thoroughly after handling.
Use protective equipment recommended in section 6 (Exposure controls/personal protection).
Do not eat, drink or smoke when handling this material.
6. Exposure controls/personal protection
Occupational Exposure Limits (EH40/2002):
Long Term Exposure Limit to Chlorine – (8 hours TWA) 0.5ppm 1.5mgm-3.
Short Term Exposure Limit to Chlorine – (10 minutes) 1ppm 2.9mgm-3
Long term exposure Limit to amorphous silica – (8 hours TWA) - 6mgm-3
Respiratory Protection: Where any dust in the breathing zone cannot be controlled with ventilation, wear
an officially approved respirator (NIOSH/MSHA or equivalent agency) for protection against airborne
dust.
Ventilation: Use local exhaust ventilation where appropriate.
Eye Protection: If airborne dust concentrations are high, wear appropriate protective goggles.
Wash eyes with clean water where there is potential eye contact.
Skin Protection: When handling large bulk quantities wear protective gloves.
Wash immediately if skin is contaminated. Remove and wash contaminated clothing and clean up
equipment before re-use.
Wash thoroughly with soap and water after handling.
7. Physical and chemical properties
Appearance: White flat bevelled tablet Oxidising Properties: Non-Oxidising
Odour: Characteristic Chlorine Odour Flash point: Not flashing
pH: As is - not applicable Flammability: Not flammable
pH: In solution - 5.0 - 6.0 approx. Autoflammability: Not autoflammable
Solubility: Freely soluble Explosion Properties: Not explosive
8. Stability and reactivity
Conditions to Avoid:
Do not store on or near heat sources or naked flame. Avoid moisture.
NaDCC decomposes at temperatures above 240OC liberating toxic gases.
Materials to Avoid:
Contact with water liberates chlorine, and with nitrogen compounds may cause explosion. Avoid organic
materials, oils, grease, sawdust, reducing agents, nitrogen-containing compounds, calcium hypochlorite,
other oxidizers, acids, alkalis, cationic and certain non-ionic surfactants.
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9. Toxicological information
Route of entry: inhalation, skin contact & ingestion.
Inhalation of NaDCC is irritating to the nose, mouth, throat and lungs.
Ingestion of NaDCC can cause irritation and or/burns to the gastrointestinal tract.
Skin & Eye Contact with NaDCC can cause severe irritation and/or burns, characterized by redness,
swelling and scab formation. May cause impairment of vision and corneal damage.
Toxicological Data: NaDCC
Acute toxicity
Oral LD50 (rat) ca. 1825mg/kg
Eye Irritation (rabbit) Severe irritant
Rabbit dermal LD50 >20,000mg/kg
Carcinogenicity: This chemical is not considered to be carcinogenic by any reference source.
10. Ecological information
NaDCC is highly toxic to fish. Do not discharge into lakes, ponds, streams or public water unless in
accordance with the permit of official regulations.
11. Disposal considerations
Disposal should be carried out in accordance with all official regulations. If material is dry, incineration is
recommended.
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Appendix 8
REFERRAL GUIDELINES
This guideline will provide information on the management of the following common conditions which can
affect the ear, and when to refer to the GP for referral on to the local ENT department:
 Wax Impaction
 Otitis Externa
 Recurrent Acute Otitis Media
 Otitis Media with Effusion (Glue Ear)
 Dizziness
 Tinnitus
 Deafness
Wax Impaction
Treatment: Wax can be removed by ear irrigation, aural toilet or microsuction. Olive oil or other
cerumenolytics can reduce build up and soften wax, although water and saline drops have been shown
to be as good as more costly products.
A Guide to the Management and Referral of
When to refer: Refer to the routine ENT clinic if there is difficulty removing the wax despite olive oil.
Refer if a patient is uncooperative or there is uncertainty about the condition of the tympanic membrane.
The local ENT department may have a direct referral ear care clinic.
Patients will require microsuction if contraindications to irrigation exist such as: indications to
irrigation:
• The patient has a tympanic membrane perforation or a mucoid discharge which may suggest a
perforation.
• The patient has had otitis media or acute otitis externa in the last six weeks.
• The patient has had previous ear surgery, seek advice.
• The patient has suffered complications with previous ear irrigation.
• The patient has a profound hearing loss in the other ear as it would be inadvisable to risk complications
in the only hearing ear.
• The patient has had a cleft palate as he is more prone to middle ear disease.
Contra
Otitis Externa
Otitis externa is extremely common. Predisposing factors are scratching of the external canal with cotton
buds or other implements and narrow external auditory canals. A particularly important factor is wet ears
(humid climates, swimming, syringing without drying the canal, frequent hair washing or lying in the bath
to wash the hair).
Symptoms and signs: Whatever the predisposing factor, the skin of the external auditory canal
becomes oedematous. Otalgia, otorrhoea and a blocked sensation in the ears with a mild hearing loss
are common in the acute stage. In the chronic form itching is a frequent complaint.
Treatment: It is essential that debris in the ear canal is removed so that the ear drops can penetrate
effectively. If the practice nurse is not trained in aural toilet, the patient may need to be referred for
suction clearance. Systemic antibiotics are not usually required unless there are signs of associated
lymphadenitis, perichondritis or cellulitis. Advise the patient to keep the ears dry and not to insert
implements.
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The first line of treatment is a combination steroid and antibiotic (eg. neomycin) drop or spray. If the
patient does not respond to this within a few days, take a swab, change to an alternative antibiotic /
steroid combination and repeat the aural toilet. Consider fungal infection. For recurrent mild conditions,
proprietary diluted acetic acid can be used in primary care to prevent the condition progressing.
When to refer: If the patient does not respond to the second line treatment, refer to the emergency ENT
clinic. Refer if there is persistent discharge or pain, diagnostic doubt about the condition of the tympanic
membrane or if the patient is immuno-compromised or a poorly controlled diabetic as there is a risk of
“malignant “ otitis externa (temporal bone osteomyelitis). If the skin of the external canal is so swollen
that drops will patently not enter the canal, then a dressing or wick may need to be inserted.
Dizziness
The majority of dizziness in the elderly is of vascular or degenerative origin. Unsteadiness and
lightheadedness are usually non-otological.
Medical: Cardiovascular, metabolic and neurological conditions, anaemia, ocular disease, medications
and cervical spine problems.
Psychological: Anxiety and hyperventilation.
Otological: Benign paroxysmal positional vertigo, acute vestibular failure (labyrinthitis), Mèniére’s
disease, some middle ear disease and very rarely acoustic neuroma.
Symptoms: If the symptoms are from the inner ear then the patient will describe a hallucination of
movement, usually rotational in nature and frequently accompanied by nausea, vomiting and nystagmus.
Mèniére’s syndrome consists of a triad of episodic vertigo, associated tinnitus and a fluctuating hearing
loss. In benign paroxysmal positional vertigo (BPPV), short-lived episodes of rotational vertigo usually
occur when turning over in bed. Loss of consciousness is unlikely to be caused by inner ear problems.
Treatment: A general medical examination, a careful history and blood pressure measurement may
point to the cause of the dizziness. If “the room is spinning” the patient may find it helpful to focus on a
fixed object. Maintain hydration if nausea and vomiting are a feature. Vestibular sedatives such as
Prochlorperazine or Cinnarizine are usually helpful in acute vertigo (eg. acute labyrinthitis, acute episode
of Mèniére’s), but long term use does not help with vestibular rehabilitation. Longer term treatment with
Betahistine may be helpful in Mèniére’s disease.
A Guide to the Management and Referral of
When to refer: Some ENT departments run special neurotology clinics. Refer to ENT if there are ear
symptoms or signs such as a discharging ear as some chronic ear disease can cause vertigo. For
patients with BPPV,most can be helped by “repositioning” manoeuvres, performed in the ENT/audiology
department. In the absence of otological signs or symptoms accompanying the dizziness the patient may
benefit from a neurological opinion.
Tinnitus
Tinnitus is the sensation of sound which does not come from an external source. Tinnitus is a
troublesome and common condition which is not always curable. It can occur in any age group but is
more common with increasing age. Persistent tinnitus occurs in about 10% of the population. It is
essential to exclude serious pathology (such as an acoustic neuroma if the tinnitus is unilateral) and then
to treat and to support the sufferer as best one can.
Aetiology
Local: Any hearing loss.
General: Hyperdynamic circulations (as in hypertension or anaemia), carotid bruits (associated with a
carotid artery stenosis).
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Drugs : eg. NSAIDs, caffeine, alcohol.
Symptoms: Tinnitus affects people in different ways. On the one hand it may be non intrusive, or on the
other hand it can contribute to suicide. Most patients recognise the link between their level of emotional
and physical stress and the perceived “loudness” of the tinnitus.
Treatment: A full otological and general history must be taken to exclude other pathologies. Exclude
obvious local causes such as wax impaction. A pure tone audiogram is of use in establishing the degree
of hearing loss that may be associated with the tinnitus. The importance of unilateral tinnitus (versus
bilateral symmetrical tinnitus) is that it is sometimes a symptom of an acoustic neuroma. Direct the
patient towards specialised help such as a hearing therapist, self help groups and the British Tinnitus
Association. Relaxation techniques help some patients.
When to refer: Refer to the routine ENT clinic if the tinnitus becomes intrusive (sleep disturbance), if it is
unilateral, or if the tympanic membranes are abnormal.
Common Ear Conditions
Adult Deafness
Sudden-onset conductive hearing loss (usually unilateral)
After URTI / air flights / diving. The patient is unable to ‘pop’ the ear (no movement of the drum on
performing the Valsalva manoeuvre). There may be the appearance of fluid behind the drum. The bone
conduction is better than air conduction in that ear.
Treatment: Decongest the nose and encourage auto-inflation of the ears.
When to refer: If there are continued problems despite nasal treatment then refer to a routine ENT
clinic.
Sudden–onset unilateral sensori-neural hearing loss
The patient will usually report suddenly going deaf in one ear. There is a normal looking tympanic
membrane.
Treatment: Treatment remains controversial because of the lack of high quality evidence. Many doctors
in the UK use a short course of prednisolone, possibly combined with antivirals. Spontaneous recovery is
seen in 50% of patients.
When to refer: Refer to the ENT emergency clinic within a week of onset.
Presbyacussis : A symetrical, gradual, high frequency hearing loss in old age.
When to refer: Direct referral to the audiology department should be used if this facility exists. If the
hearing loss is asymetrical then refer routinely to ENT as further investigations may be required to
exclude an acoustic neuroma.
Recurrent Acute Otitis Media (RAOM)
Approximately 40% of children will suffer one or more episodes before the age of 7 years. At least 85%
will resolve within 72 hours without treatment and it is uncommon in adults. A significant proportion of
children with RAOM failing medical management appear to have a partial maturational IgA deficiency.
Children with RAOM may require long-term low-dose antibiotic treatment or grommet insertion until they
grow out of the condition. Grommet surgery in children with RAOM can prevent infection, pain and the
need for antibiotics.
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Symptoms and signs: Earache, hearing loss and a red bulging drum prior to tympanic membrane
rupture. The child may be irritable with a fever and sickness. After rupture there will be relief of pain and
a purulent discharge.
Treatment: Analgesia such as a combination of ibuprofen and Paracetamol. If unresolved after three
days prescribe amoxicillin or erythromycin. If antibiotics are prescribed the length of the course should
be reviewed after three days. Encourage nose blowing.
If treatment fails with the first line antibiotics, prescribe co-Amoxiclav or Clarithromycin.
When to refer: Refer to a routine ENT clinic if:
a) there is a failure of the infection to resolve despite the above treatment.
b) there is a persistent perforation.
c) there are more than 6 attacks in one year for a period of more than one year.
Otitis Media with Effusion (OME) ‘Glue Ear’
85% of children experience glue ear at some stage. 50% will resolve spontaneously within three months.
Peak ages are two and five years and a hearing assessment quantifies severity. Winter, URTIs, child
care settings and passive smoking are accepted environmental risk factors.
Symptoms and signs: There will be a noticeable hearing impairment and/or speech and language
difficulties and behavioral problems. There may be an association with recurrent acute otitis media. The
key features on examination are a drum that appears dull, retracted or poorly mobile. There may be an
air-fluid level or bubbles visible behind the tympanic membrane.
Treatment: Reduce exposure to cigarette smoke. Persistent effusions do not respond to oral
decongestants or mucolytics. Treatment of rhinitis may be appropriate and helpful. Auto-inflation of the
eustachian tube has been shown to produce short term improvement in older children. Generally, a three
month period of watchful waiting is recommended prior to referral. If the condition persists and there is a
clinically obvious effect on speech, language, learning or behaviour, then children over 3 1/2 years may
benefit from adenoidectomy and/or ventilation tube (grommet) insertion.
When to refer: Refer children to the routine ENT clinic if there have been 8-12 weeks of hearing
problems, associated speech delay or behavioural problems (4 weeks if the child has other disabilities
making correction of the hearing loss more urgent). Referral should take into account parental concerns
or those raised by the school or health visitor.
Refer adults urgently if there is no history of URTI or barotrauma and especially if oriental (higher risk of
nasopharyngeal carcinoma).
Adapted from: A Guide to the Referral of Common ENT Conditions Paul Harkness Consultant ENT
Surgeon Rotherham General Hospital Revised 2011
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Appendix 9
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Ear Care Guidelines
Version 1
June 2016