 |
Guidance for Ear Examination
|
Before careful physical examination of the ear, listen to the
patient, elicit symptoms and take a careful history. Explain each
step of any procedure or examination and make sure that the patient
understands and gives consent. Be sure that both you and the patient
are seated comfortably, at the same level, and that you have privacy.
Examine the pinna, outer meatus and adjacent scalp. Check for
previous surgery incision scars, infection, discharge, swelling
and signs of skin lesions or defects. Decide in the most appropriate
sized speculum that will fit comfortably into the ear and place
it on the auriscope.
Gently pull the pinna upwards and outwards to straighten the ear
canal (This will be directly down and back in children). Localised
infection or inflammation will cause this procedure to be painful
so do not continue.
Hold the auriscope, like a pen and rest the small digit on the
patients head as a trigger for any unexpected head movement. Use
the light to observe the direction of the ear canal and the tympanic
membrane. There is improved visualisation of the eardrum by using
the left hand for the left ear and the right hand for the right
ear, but clinical judgement must be used to assess your own ability.
Insert the speculum gently into the meatus to pass through the
hairs at the entrance to the canal.
|
|
Looking through the auriscope, check the ear canal and tympanic
membrane. Adjust your head and the auriscope to view all of the
tympanic membrane. The ear cannot be judged to be normal until
all the areas of the membrane are viewed, including the light
reflex, handle of malleus, pars flaccida, pars tensa and anterior
recess. If the ability to view all of the tympanic membrane is
hampered by the presence of wax, then wax removal will have to
be carried out.
If the patient has had canal wall down mastoid surgery, methodically
inspect all parts of the cavity, tympanic membrane or drum remnant
by adjusting your head and the auriscope. The mastoid cavity cannot
be judged to be completely free of disease until the entire cavity
and tympanic membrane or drum remnant has been seen.
The normal appearance of the membrane or mastoid cavity caries
and can only be learned by practice. Practice will lead to recognition
of abnormalities.
Carefully check the condition of the skin in the ear canal as
you withdraw the auriscope. If there is any doubt about the patients
hearing, an audiological assessment should be made. Providing
they meet certain criteria stated in local referral guidelines,
older adults with bilateral hearing loss can be referred directly
to the audiology department.
Document what you have seen in both ears, the procedure carried
out, the condition of the tympanic membrane and external auditory
meatus, and treatment given. Findings should be documented, with
nurses following NMC guidelines on record keeping and accountability.
If any abnormality is found, a referral should be made to the
ENT outpatient department following local policy.
Ref: Hilary Harkin, The Auricle, Winter 2002/03, Royal College
of Nursing, Maxilo-facial Nursing Forum.
Guidance for Ear Examination
The metal syringe is obsolescent for use in the ear canal. The
syringe design is inherently dangerous. Combined with the danger
of the syringe itself and the pressure of water it creates within
the ear canal, there is the difficultly of disinfecting the syringe
after each use. The Medical Devise Agency (MDA) also has reservations
about the use of the metal syringe for wax removal. There are
issues around the poor manufacture of some syringes, allowing
them to break and cause injury during use, and the pressure of
water that can be exerted manually on they tympanic membrane.
Electronic irrigators such as the Propulse and the Otoscilo allow irrigation of the ear canal, rather than wax removal under
pressure. The MDA issued Safety Notice SN9807 in February 1998
to advise users that the original Propulse electronic irrigator
required an isolation transformer for electrical safety. Subsequently,
the manufacturer designed and marketed the Propulse II to replace the original model. The guidance document recommends
that practitioners use an electronic ear irrigator rather than
the manual syringe and refer to the procedure as ear irrigation.
The Propulse II irrigator has a pressure variable control of minimum-maximum,
allowing the flow of water to be easily controlled by commencing
irrigation on the minimum setting. For patient safety, Propulse has limited the maximum pressure available. This limit is stated
in the user instructions. The Propulse II irrigator has specific disinfecting guidelines issued with approval
from infection control committees.
The only other equivalent device available on the British market
is the German ear irrigator called Mulimed-Otoscillo irrigating jet machine. In this device, the numbers one to six
denotes the pressure control but, as the manufacturer does not
state a maximum limit, it is difficult to assess the maximum pressure
developed by the irrigator. There is no evidence promoting this
machine as an ear irrigator and there is no documentation about
safe pressure exerted by it. A further failing is that the design
of the irrigator tip does not offer the preferred direction against
the posterior ear canal wall. The manufacturers do not recommend
a specific solution to disinfect the irrigating machine and this
presents the danger if users choosing inappropriate solutions
and the machine harbouring infection.
The Welch Allyn Ear Wash System is an American irrigator that attaches to a combined hot and
cold water tap. There are problems in the United Kingdom with
attachment to a number of taps found within the community and
hospital setting. It is of comparable price to both the electronic
irrigators, but there may be the added cost of having the tap
changed to a suitable model. The system cannot be used in rooms
where there is no access to water – for example, for patients
confined to a sitting room in a nursing home or community setting.
It does limit the maximum amount of
water pressure exerted in the ear and controls variation in the
flow of water. If there is an increase/decrease in the temperature
of water, the machine will stop the flow until it is altered.
This machine has a suction system which returns the discharge
and debris away from the ear and can be used without the flow
of water to remove the remaining moisture from the ear canal.
Ref: Hilary Harkin, The Auricle, Winter 2002/03, Royal College
of Nursing, Maxilo-facial Nursing Forum.
Guidance for Ear Irrigation Using The Electronic Irrigator
Principles
Irrigating the ear is carried out to:
• Facilitate the removal of cerumen and foreign bodies which are
not hygroscopic matter (such as peas and lentils) will absorb
the water and expand making removal more difficult.
• Remove discharge, keratin or debris from the external auditory
meatus.
Reasons for using this procedure
Use this procedure to:
• Correctly treat otitis externa where the meatus is obscured
by debris,
• Improve conduction of sound to the tympanic membrane when blocked
by wax,
• Remove debris to allow examination of the external auditory
meatus and the tympanic membrane.
Irrigation Should not be carried out when:
• The patient has previously experienced complications following
this procedure in the past.
• There is a history of a middle ear infection in the last six
weeks
• The patient has undergone any form of ear surgery (apart from
grommets that have extruded at least 18 months previously and
the patient has been discharged from the ENT department)
• The patient has a perforation or there is a history of mucous
discharge in the last year.
• The patient has a cleft palate (repaired or not)
• The patient presents with acute otitis externa with pain and
tenderness of the pinna.
Requirements
• Auriscope
• Head Light and spare batteries or head mirror and light.
• Electronic Irrigator
• Jug containing tap water to 40o
• Noots trough/receiver
• Jobson Horne Probe and cotton wool
• Tissues and receivers for dirty swabs and instruments
• Waterproof cape and towel
Procedure
1. Informed consent should be obtained prior to proceeding.
2. Examine both ears by first inspecting the pinna, outer meatus
(ear canal) and adjacent scalp by direct light. Check for previous
surgery incision scars or skin defects, then inspect the external
ear with the auriscope.
3. Check whether the patient’s ears have been irrigated previously
or if there are any contraindications why irrigation should not
be performed.
Explain the procedure and ask the patient to sit in an examination
chair with the head tilted towards the affected ear. (A child
could sit on an adult’s knee with the child’s head held steady).
4. Place the protective cape and towel on the patients shoulder
and under the ear to be irrigated. Ask the patient to hold the
receiver under the same ear.
5. Check your headlight is in place and the light is directed
down the ear canal. Check that the temperature of the water is
approximately 40°C and fill the reservoir of the irrigator. Set
the pressure at minimum.
6. Connect clean jet tip applicator to tubing of the machine with
a firm push/twist action. Push until “click” is felt.
7. Direct the irrigator tip into the noots receiver and switch
on the machine for 10-20 seconds to circulate the water through
the system and eliminate any trapped air or cold water. This offers
the opportunity for the patient to become accustomed to the noise
of the machine. The initial flow of water is discarded, thus removing
any static water remaining in the tube.
8. Twist the jet tip so that the water can be aimed along the
posterior wall of the ear canal (towards the back of the patients
head).
9. Gently pull the pinna upwards and outwards to straighten the
ear canal (directly backwards in children).
10. Warn the patient that you are about to start irrigating and
that the procedure will be stopped if they feel dizzy or have
any pain. Place the tip if the nozzle into the ear canal entrance
and using foot control, direct the stream of water along the roof
of the ear canal and towards the posterior canal wall (directed
towards the back of the patient’s head). If you consider the entrance
to the ear canal as a clock face, you would direct the water at
11 o’clock on the right ear and 1 o’clock on the left ear. Increase
the pressure control gradually if there is difficulty removing
the wax. It is advisable that a maximum of two reservoirs of water
be used in any one irrigating procedure.
11. If you have not managed to remove the wax within five minutes
if irrigating, it may be worthwhile moving onto the other ear
as the introduction of water via the irrigating procedure will
soften the wax and you can retry irrigation after about 15 minutes.
12. Periodically inspect the ear canal with the auriscope and
inspect the solution running into the receiver.
13. After removal of wax or debris, dry mop excess water from
meatus under direct vision, using the Jobson Horne probe and best
quality cotton wool. Stagnation of water and any abrasion of skin
during the procedure predispose to infection. Removing the water
with the cotton will tipped probe reduces the risk of infection.
14. Examine ear, both meatus and tympanic membrane, and treat
as required following specific guidelines or refer to doctor if
necessary.
15. Give advice regarding ear care and any other relevant information.
Ref: Hilary Harkin, The Auricle, Winter 2002/03, Royal College
of Nursing, Maxilo-facial Nursing Forum
Guidance for Ear Irrigation Using The Electronic Irrigator
Principles
Aural toilet is used to clear the aural meatus of debris, discharge,
soft wax or excess fluid following irrigation.
Procedure
1. Examine the ear.
2. Dry mop, using Jobson Horne probe and a small piece of fluffed
up cotton wool (the size of a postage stamp) applied to the probe.
Under direct vision (with headlight or head mirror and light)
and pulling pinna to straighten the canal, clean the ear with
a gentle rotary action of the probe. Do not touch the tympanic
membrane.
3. Replace the cotton wool directly it becomes soiled. Pay particular
attention to the anterior-inferior recess, which can harbour debris.
4. Re-examine the meatus intermittently, using the auriscope,
during cleaning to check for any debris/discharge/crusts which
remain in the meatus at awkward angles.
Ref: Hilary Harkin, The Auricle, Winter 2002/03, Royal College
of Nursing, Maxilo-facial Nursing Forum
|
|
|
