Download Ear Wax Management pathway

Title
Ear Wax Management
Classification
Clinical Pathway
Areas For Use
Primary Care
Objective
To reduce inappropriate referrals to secondary care and ensure that
first-line treatment is offered in primary care by clarifying the role of the
GP practice and district nursing service.
Acknowledgements
Rotherham Ear Care Centre
Evidence base
Earwax, Clinical Knowledge Summaries (2007):
http://www.cks.nhs.uk/earwax
Best practice statement: ear care, NHS Quality Improvement Scotland
(2006):
http://www.nhshealthquality.org/nhsqis/files/Best%20Practice%20State
ment%20-%20Ear%20Care.pdf
Guidance document in ear care, Primary Care Ear Centre (2007):
http://www.earcarecentre.com/protocols.htm
Consultation
PEC, PBC Leads, Confederation.
Date of first round:
June 2010
Date of second round: (if
substantial changes
required as result of 1st
set of responses)
Not required
Approved by PBC
Confederation
June 2010
Date noted by PEC:
June 2010
Date Of Next Review
March 2016
Authors
Andy Hilton GP, Michael Boyle GP
Map of Medicine
No pathway on Map of Medicine
Further reviews of the document
Version number
Date
Author
1
20 October 2010
As above
2
08 December
2014
As above/ Document
amended by S.
Ashmore,
Commissioning
Manager, SCCG
Comments
Ear Wax Pathway
- Previous complications with irrigation
- Ear pain or infection in last 6 weeks
- Ear surgery (excl. grommets removed
over 18 months ago)
- Perforated ear drum
- Cleft palate
- Recent head injury
- Deaf in one ear
See Box 2 below
Perform aural assessment
Take relevant history
Contraindications on
assessment?
Yes
No
Examine outer ear, pinna,
ear canal, tympanic
membrane
- Evidence of surgery
- Infection, discharge, swelling,
lesion, swelling
- Foreign body, perforation
- No wax
See Box 2 below
Contraindications on
examination?
Yes
No
Wax present?
Oil/drops 7 days
Repeat if necessary
See Box 3 below
Self care leaflet
See Box 3 below
Yes
Ear clear of wax?
No
Irrigation
contraindicated?
See Box 2 below
Yes
No
Irrigate.
Repeat if necessary
See Box 3 below
No
Yes
Ear clear of wax?
No
Note: Ear wax management will be provided by all GP practices for
ambulant patients. Patients who are housebound should be referred
to the district nurse for ear wax management. The patient should be
added to the district nurse caseload for the required period.
Refer to GP
Earwax Management
1
2
Refer to ENT1

Suspected perforated ear drum

History of ear surgery (including cleft palate)

Foreign body in ear (including vegetable matter)

Repeated drops (suggest 3-5 day course, twice) and repeated irrigation (twice) unsuccessful
Contra-indications for irrigation
 Previous ear surgery, (apart from grommets that have come out at least 18 months before and patient
discharged from ENT) or cleft palate (including when repaired)

Recent head injury
 Problems with previous ear irrigations
 Recent (last 6 weeks) middle ear pain or ear infection
 Have or had a perforated ear drum
 Where there is hearing in one ear only do not irrigate that ear
The
3
Treatment
Remove wax when:

It is totally blocking the ear canal and any of the following are present:
- Hearing loss
- Earache
- Tinnitus
- Vertigo
- Cough suspected due to earwax

Tympanic membrane obscured but must be viewed to establish diagnosis

Before referral for hearing (re)assessment or if wax causing hearing aid to whistle
How should earwax be removed?

Prescribe oil or drops for 7 days initially to soften wax and repeat for further 7 days if necessary.
- Sodium bicarbonate 5%, sodium chloride 0.9%, olive oil, almond oil
- Sodium chloride 0.9% is not available as a proprietary product. However sodium chloride 0.9% nasal
drops can be prescribed for use in the ear (off label use)

If symptoms persist, repeat oil or drops for second week = 7-10 days all told. If any of eardrum visible
irrigation should not be necessary

Where recurrent build up, consider oil or drops on a regular basis to see if this prevents problem

Advise anyone who has earwax removed to return if they develop ear ache, significant itching, discharge
from the ear or swelling of the ear canal as these may indicate infection.
Earwax removal using electronic irrigator

The metal syringe is obsolescent for use in the ear canal

Take history to check there are no contraindications (Box 2)

Warn of possible dizziness and explain procedure will be stopped if patient feels dizziness or nausea.
Irrigation may cause slight discomfort. If patient complains of pain STOP immediately and refer to GP.

Obtain written consent by completing ‘Ear Irrigation Checklist and Consent’ form below.

Follow manufacturer’s instructions for use of equipment.
Self care
Patient UK has a leaflet covering ear drops, irrigation and prevention which may be useful:
http://www.patient.co.uk/health/Ear-Wax.htm
1
References
Earwax, Clinical Knowledge Summaries (2007): http://www.cks.nhs.uk/earwax
Best practice statement: earcare, NHS Quality Improvement Scotland (2006):
http://www.nhshealthquality.org/nhsqis/files/Best%20Practice%20Statement%20-%20Ear%20Care.pdf
Guidancedocument in eare care, Primary Care Ear Centre (2007): http://www.earcarecentre.com/protocols.htm
Ear irrigation checklist and consent
Name:
Date of birth:
Allergies:
Occupation or previous occupation, related to dust/noise?
Yes/No
The patient complains of:
Findings following examination before treatment:
History:
Left
Right
Current cold/catarrh?
Pain in ears?
Yes/No
Yes/No
Yes/No
Yes/No
Current or recent treatment?
Yes/No
Yes/No
Discharge from ears?
Yes/No
Yes/No
Mastoid or other ear surgery?
Yes/No
Yes/No
Recent myringoplasty?
Yes/No
Yes/No
Tympanic membrane perforation?
Yes/No
Yes/No
Grommets in situ?
Cleft palate repaired or not?
Yes/No
Yes/No
Yes/No
Yes/No
Vertigo?
Yes/No
Yes/No
Cochlear implant?
Yes/No
Yes/No
Healed perforations?
Has patient been applying oil for minimum of 7-10 days as recommended?
Yes/No
Yes/No
Yes/No
Yes/No
Previously had ears syringed?
Yes/No
Yes/No
Experienced problems previously with irrigation?
If yes, what were the problems?
Yes/No
Yes/No
Is referral to GP required?
Yes/No
Patient consent:
The nurse has:
- Asked me the above questions related to the ear irrigation procedure
- Explained the proposed treatment
- Given me written information about ear care, including drops and irrigation.
I understand and consent to the proposed irrigation treatment.
Patient’s signature
Date
Parent/carer signature
Date
If consenting for child or someone you help look after
Any follow-up treatment required: