Ear Irrigation – Indications, Contraindications

Ear irrigation is an important tool for adult and pediatric patients in the Emergency Department (ED) with ENT complaints. Irrigation can be used to clear ear cerumen, visualize tough-to-see tympanic membranes, and remove foreign bodies. This may reduce the need for subspecialist care and improve the patient’s hearing and quality of life.¹ Commercial electronic and mechanical devices are available for irrigation and have been studied. Moulton and Jones presented the improved efficacy of foreign body removal using an electric ear syringe in an (ED) population. In this trick of the trade, we present a low cost and effective way of  “ear-rigation” taught to us by one of our veteran nurses using easily available tools in the ED.

Anatomy and Physiology

Following treatment of cerumen impaction, one should be able to evaluate the tympanic membrane anatomy. The normal coloring of a tympanic membrane is pearly gray and translucent. There is a cone of light in the anterior, inferior quadrant of the tympanic membrane, and it points towards the nose. One should also be able to observe the umbo and the handle of the malleus. The tympanic membrane is somewhat conical in shape, with a concavity noted at the umbo. A normal tympanic membrane has no perforation.

If you observe a bulging tympanic membrane, there is usually a distortion of the cone of light, and there is little to no visibility of the umbo and the handle of the malleus. This can indicate an infection or fluid in the middle ear space, a serious or purulent otitis media.

A Eustachian tube dysfunction usually causes a retracted tympanic membrane.

Coldwater should not be used for ear irrigation; the water temperature should be warm and close to the patient’s natural body temperature. Coldwater on the tympanic membrane can cause a sensation of dizziness due to cranial nerve VIII, the vestibulocochlear nerve. The vestibulocochlear nerve has two parts: the vestibular nerve and the cochlear nerve. The semicircular canals of the inner ear are innervated by the vestibular nerve, which is responsible for orientation in space, balance, and coordination. The cochlear nerve is responsible for promoting hearing. [rx]

Indications of Ear Irrigation

• Cerumen impaction irritates the ear canal with itching, pain, chronic cough, or decreased hearing. Another indication of impactions is an inability to visualize the tympanic membrane due to cerumen when inspection of the tympanic membrane is needed.[rx]
• Ear irrigation can also be used for caloric stimulation. This method is discussed in a different topic. [rx]

Contraindications of Ear Irrigation

There are a few contraindications to performing irrigation of the ear including lack of patient consent.

• These contraindications are a patient’s inability to sit upright, a patent tympanostomy tube, a patient who is unwilling or unable to sit still, foreign body present in the ear canal, perforated tympanic membrane, an opening into the mastoid, and severe swimmer’s ear (otitis externa).
• Also, a history of middle ear disease, ear surgery, inner ear problems (especially vertigo), or radiation in the area is an additional reason to choose another method for cerumen dis-impaction.

Equipment of Ear Irrigation

Face Shield (universal precautions)

• To safely perform ear irrigation, one should use an otoscope. You will need your cerumenolytic of choice. The water you will use for irrigation must be warmed before use. You can either use a thirty milliliter to a 60-mm syringe with a 16 or 18 gauge intravenous (IV) catheter attached (with the needle removed) or a pulsating water device (such as a WaterPik) to irrigate the impacted cerumen out of the ear. You will also need an ear irrigation basin or emesis basin to catch the water and pieces of cerumen as it leaves the ear.
• Due to the availability of syringes and IV catheters when compared to pulsating water devices, the syringe and IV catheter method is more common.
• A cerumen spoon or alligator forceps can be used to remove loose cerumen pieces following the ear irrigation procedure.

Personnel

• An assistant can help by holding traction on the pinna. This straightens the ear canal, allowing for more efficient and effective cerumen removal.

Preparation

Some providers may choose to soften the wax before irrigation. Multiple agents may be used including mineral oil, 1% sodium docusate solutions, and carbamyl peroxide solutions.

• Warm the solutions and the water that will be used during the irrigation to near body temperature to prevent dizziness. Cold solutions put in the ear are likely to have an uncomfortable effect on the patient, and it may make them dizzy or nauseous.
• If using an IV catheter and syringe, ensure the needle is removed from the IV catheter.

Technique

• Ask the patient to sit upright. Place your cerumenolytic of choice in the external auditory canal and leave it in the ear for fifteen to thirty minutes before initiating irrigation.
• Draw up the warm water into the syringe and attach the IV catheter to the end of the syringe. Place the IV catheter into the external ear canal, no further than the cartilage/bone junction. The cartilaginous portion usually makes up the outer two-thirds of the external auditory canal.
• Hold the emesis or ear irrigation basin tightly to the skin below the ear, in an attempt to catch the water during irrigation. This will help keep the patient from getting wet.
• Direct the IV catheter superiorly and posteriorly in the ear canal so that the water will separate the cerumen from the tympanic membrane. Do not direct the water stream directly at the tympanic membrane, because this can cause perforation of the tympanic membrane.
• Following irrigation, you can remove any loose pieces of wax with a cerumen scoop or alligator forceps, being careful not to damage the external auditory canal and the tympanic membrane.
• To dry the remaining moisture in the external auditory canal, apply several drops of isopropanol. This step is especially contraindicated if the tympanic membrane is ruptured.

Following prolonged irrigation

• Topical steroid containing suspension drops, such as ciprofloxacin/hydrocortisone drops, may be soothing to the external auditory canal. Some providers will prescribe these for a few days following the ear irrigation procedure.
• Many providers prescribe antibiotic drops (example: fluoroquinolones) to patients at high risk for severe infections, such as diabetic patients. These drops are usually prescribed for several days following the ear irrigation procedure to prevent the complication of otitis externa.[rx][rx]

Complications

Irrigation of the ear can lead to otitis externa, vertigo, perforation of the tympanic membrane, and middle ear damage if the tympanic membrane is perforated. These complications are less common with the syringe and IV catheter technique than when compared to the pulsating water device technique.

Using a cerumen spoon to remove remaining wax can cause damage to the skin covering the external auditory canal.

Symptoms of complications include sudden pain, ringing in the ears, loss of the ability to hear, nausea, and dizziness. If a patient experiences any of these symptoms, the provider should immediately stop and examine the ear canal and tympanic membrane with an otoscope.

If the tympanic membrane is ruptured, prescribe the patient oral antibiotics to treat otitis media prophylactically. Refer the patient to an otolaryngologist for specialty consult.

References