Policy and Procedure for
Ear Irrigation Using the Propulse II and
Propulse III Universal Electronic
Irrigator
Author & Co-ordinator:
Paul E Murray
Reviewer:
Sheila Wheeler
Approver: Lead Nurse group
GP Sub-Committee
Signature
Signature
Signature
Identifier:
Review Date: May 2006
Date: May 2005
UNCONTROLLED WHEN PRINTED
Version 3
NHS Grampian Ear Irrigation Guidelines
Table of Contents
Guidance Document
………………………………………..…………..
3
Cerumen Management
………………………………………..…………..
4
Guidance for Ear Examination ………………………………………..…………..
4
…………………………………………………....
6
……………….……..
Guidance on the Use of Wax Softeners – Olive
Oil
…………………………………
Guidance on the Use of Syringes in the
Ear
…………..
Reasons for Carrying Out Ear Irrigation Using the
Propulse II
Reasons When Irrigation Should Not be Carried ……………………….
Out
………………………………………..…………..
Equipment Requirements
6
Guidance on Patient Ear Care
8
9
9
9
………………………………………..…………..
10
………………………………………..…………..
Guidance Notes for Aural
Toilet
Guidance Notes for Removal of Excessive Wax Using
Instrumentation ..
………………………………………..…………..
Decontamination
Guidelines(as approved by
………………………………………..…………..
FAQs
13
…………………………………………….
18
………………………………………..…………..
19
………………………..
20
Ear Irrigation Procedure
NHS Grampian Infection
Useful
Relating to Ear Care
ControlLinks
Teams)
Bibliography
Appendix 1: 3C Checklist for Ear Irrigation
14
15
17
Appendix 2: Suggested Ear irrigation Consent
………………..
24
Form
Appendix 3: Additional Information on the Propulse III
…… 25
Universal
……
……
An ear care website has been developed to support.. staff in
Grampian. As well as information and downloads, there is also a
discussion forum, an area for sharing good practice and an
opportunity to ask questions.
The website can be found via the NHS Grampian Intranet
NHS Grampian Ear Irrigation Guidelines - PEM
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homepage, click on microsites, then ear irrigation.
NHS Grampian Ear Irrigation Guidelines
Guidance Document

This guidance document has been produced to support all disciplines of staff
working within NHS Grampian who undertake otoscopy, ear irrigation, aural toilet and
manual wax removal. The experienced practitioner should always use their clinical
judgement to select the most appropriate procedure and method for ear examination and
wax removal.

These recommendations do not replace the need for education, training and
supervision in order to develop confidence and competence when performing these
procedures safely. If staff are undertaking ear irrigation as a new skill, then they are
encouraged to use the 3C Ear Irrigation Observation Checklist [see Appendix 1].

It is no longer acceptable practice to use a chrome, metal, plastic syringe or
the Propulse I for ear irrigation in Grampian. Please refer to ‘Guidance on the Use
of Syringes in the Ear’ (page 8) for further information.

These guidelines endorse the use of both the Propulse II and Propulse III
Universal for ear irrigation in Grampian. Where these guidelines refer to the Propulse II
only, it is assumed that the Propulse III Universal is also included.
Please refer to ‘Appendix 3’ for further information on the Propulse III Universal.

Thanks to everyone who have contributed and given feedback during the
development of these guidelines. Acknowledgement also to the Primary Ear Care
Centre (Rotherham Health Authority) for their guidance in preparing this document.
This document supercedes and replaces all previous Ear Irrigation
Guidelines in Grampian.
This document has been compiled by Paul E Murray, Clinical Training
Officer, NHS Grampian with input and approval from Clinical Staff, the
Lead Nurse Group, the GP Sub-Committee, Infection Control, Risk
Management and Mirage Health Group.
This document shall not be copied in part or whole without
the express permission of the author or the author’s
representative.
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NHS Grampian Ear Irrigation Guidelines
Guidelines
Cerumen Management
Wax or cerumen is a normal secretion of the ceruminous glands in the outer meatus and
is slightly acidic, providing bactericidal qualities.
A small amount of wax is normally found in the ear canal and its absence may be a sign
that dry skin conditions, infection or excessive cleaning has interfered with the normal
production of wax. It is only when there is an accumulation of wax that removal may be
necessary.
A build-up of wax is more likely to occur in people who insert implements into the ear
(frequent users of cotton buds, etc) have narrow ear canals, hearing aids, older adults
and patients with learning difficulties. A build-up of wax may also occur as a result of
anxiety, stress and dietary or hereditary factors.
Wax should only be removed if it is causing symptoms such as dulled hearing,
itch, or discomfort.
If wax is removed due to a complaint of hearing loss, ascertain whether good hearing is
restored after treatment or if the patient would benefit from a formal assessment by ENT
or Audiology.
Guidance for Ear Examination
1. Prior to the physical examination of the ear, listen to the patient, elicit symptoms and
take a careful history. Thorough hand hygiene (soap & water) should be undertaken
before the physical examination starts.
2. Consent
Explain each step of any procedure or examination and ensure that the patient
understands and gives consent.
Consent may be given verbally or written
depending on local preference [refer to appendix 2 for a suggested ear irrigation
consent form].
If verbal consent is given, then it is important for the Health Professional to record
that this has been asked and given in the patient’s notes.
3. Ensure that both you and the patient have privacy and are seated comfortably at the
same level. 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 on the most appropriate size of speculum that will fit
comfortably into the ear and place it on the auriscope.
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NHS Grampian Ear Irrigation Guidelines
Guidance for Ear Examination/ continued
4. Gently pull the pinna upwards and outwards to straighten the ear canal (directly
down and back in children). Localised infection or inflammation will cause this
procedure to be painful, so if this is present do not continue!
5. Hold the auriscope like a pen and rest your small finger on the patient's head as a
trigger against any unexpected head movement. Use the light to observe the
direction of the ear canal and the tympanic membrane.
6. There is improved visualisation of the ear drum 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.
7. Looking through the auriscope, check the ear canal and tympanic membrane. The
ear cannot be judged to be normal until all the areas of the membrane are viewed. 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.
8. If the patient has had canal wall mastoid surgery, methodically inspect all parts of the
cavity and tympanic membrane by adjusting your head and the auriscope. The
mastoid cavity cannot be judged to be completely free of ear disease until the entire
cavity and tympanic membrane has been seen.
9. The normal appearance of the membrane or mastoid cavity varies and can only be
learned by practice. Practice will lead to recognition of any abnormalities.
10. Carefully check the condition of the skin in the ear canal as you withdraw the
auriscope. If there is any doubt about the patient's hearing an audiological
assessment should be made. Thorough hand hygiene (soap & water) should again
be undertaken before going to complete any documentation.
11. Document what was seen in both ears, the procedure carried out, the condition of
the tympanic membrane and external auditory meatus and any treatment given.
12. Findings should be documented, following your Professional Body’s
recommendations on record keeping and accountability. If any abnormality is found,
a referral should be made to the ENT Outpatient Department following local
procedures.
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NHS Grampian Ear Irrigation Guidelines
Guidelines
Guidance on Patient Ear Care
Earwax forms a protective coating of the skin in the ear canal. Small amounts are made
all the time and the quantity of earwax produced varies greatly from person to person.
The ear canal is usually self-cleaning. Patients should be discouraged from putting any
implement into their ear as this can damage the delicate ear lining and increase the
likelihood of ear infection, itchiness and problems with the build-up of wax.
Remember wax is not formed in the deep part of the ear canal near the eardrum, but
only in the outer part of the canal. When a patient has wax blocked up against the
eardrum it is often because they have been probing their ears with cotton buds, pen
tops, match sticks, paper clips, Kirby grips or the end of their pencil!
Patients shouldn’t put anything into their ears!
Patients should also be encouraged to maintain the health and well-being of their ears
by keeping their ears dry during showering or bathing, as it may be their shampoo or
soap that is irritating the skin. Patients should also ensure that they dry their ears using
a towel or dry tissue afterwards.
Guidance on the Use of Wax Softeners – Olive Oil
Despite there being a vast array of wax softeners available, olive oil is the current oil of
choice. These NHS Grampian guidelines recommend the use of olive oil as it is
effective, cheap and readily available from Pharmacists in a glass dropper bottle that has
been specifically designed for applying into the ear.
Maintenance Use
Evidence and practical experience show that where patients suffer from excessive wax,
the insertion of 1 to 2 drops of olive oil on a regular basis (e.g. weekly, depending on
the Health Professional’s clinical judgement and the hardness of the wax) may help the
ear clean itself, thus reducing or eliminating the need for regular ear irrigation.
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NHS Grampian Ear Irrigation Guidelines
Guidance on the Use of Wax Softeners – Olive Oil/ continued
Other Oils In Use
It is impossible to give a complete and definitive guide to all the ear softening oils
available to patients, however some of the more commonly used oils include:

Almond Oil – should be avoided due to the risk of anaphylaxis caused by nut
allergy.
 Sodium Bicarbonate – can be effective, but tends to dry the ear, which is unhelpful
in older patients.
 ‘Over-the-counter’ products such as Cerumol or Otex are also not recommended
routinely as they are generally more expensive and have no clear clinical advantage
over olive oil. Their side-effects can also include local irritation to the ear lining which
can further compound the patient’s ear problems.
For further information on these drugs visit the BNF website at: http://www.bnf.org/bnf
Patient Advice Prior To Ear Irrigation
Insert 1 to 2 drops of olive oil into the ear(s) requiring
wax softening, every morning and evening commencing
at least 3-7 days prior to treatment. The olive oil should
be administered at 370. Patients can heat the oil to this
temperature by placing the closed glass dropper bottle
containing the oil into a cup of warm water for two
minutes or by allowing it to come up to room temperature.
The patient should always test a drop of the oil on their hand to ensure that it is not too
hot, before placing it in their ear and it may be easier for someone else to put the oil
drops in.
Patient Advice Following Ear Irrigation
The ear canal may be vulnerable to ear infection after irrigation. This is caused by
removal of all the wax, which has inherent protective properties for the ear canal.
Until the ear produces more wax to protect the canal, patients should be encouraged to
keep the ear(s) that have been irrigated dry from the entry of water for a minimum of four
or five days after the procedure. This would include activities such as showering,
bathing or swimming.
In the unlikely event that patients develop pain, dizziness, reduced hearing or discharge
from the ear after the procedure, then they should be encouraged to return and consult
with their nurse or doctor.
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NHS Grampian Ear Irrigation Guidelines
Guidance on the Use of Syringes in the Ear
Metal and plastic syringes are now obsolete for use in the ear canal.
Manual syringes are inherently dangerous due to a combination of the design, the
pressure of water it creates within the ear canal and the difficulty of disinfecting the
syringe after each use.
The Medicines and Healthcare Products Regulatory Agency (formerly the Medical
Devices Agency) also has reservations about the use of the metal syringe for wax
removal. They expressed concerns 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 the tympanic membrane.
More information can be found at their website: http://www.medical-devices.gov.uk
Electronic irrigators such as the "Propulse” allow irrigation of the ear canal rather then
wax removal under pressure. The Medicines and Healthcare Products Regulatory
Agency issued Safety Notice SN 9807 in February 1998, which advised 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 Propulse and from February 2005, the Propulse III Universal. This guidance
document recommends that practitioners use an electronic ear irrigator rather than the
manual syringe and refers to the procedure as ear irrigation. The Propulse II and III
irrigators have variable pressure control of minimum-maximum, allowing the flow of
water to be easily controlled by commencing irrigation on the minimum setting.
The use of the Propulse II or Propulse III Universal are the preferred
irrigation methods for all staff in NHS Grampian.
Mirage will offer a part exchange to staff when upgrading from a
Propulse I. For more information telephone: 0845 130 5440.
It is also recommended that only disposable ‘one use’ jet tips should be used. On no
account should ‘one use’ items be reused or reprocessed. These disposable one use jet
tips can be ordered directly from Central Stores.
Product Code:
Description:
Price:
FP00389
Tip Jet Disposal for Propulse II (Pack = 100)
£42.00
A complete range of accessories and replacement parts are also available from Mirage
by contacting 0845 130 5440 or go to www.miragehealthgroup.com and click on
‘Medical’.
Immediate queries can be sent to: uksales@miragehealthgroup.com
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NHS Grampian Ear Irrigation Guidelines
Reasons for Carrying Out Ear Irrigation Using the Propulse II
This procedure is only to be carried out by a competent doctor, registered nurse,
audiologist or by a learner who is being closely supervised by one of the above.
 Irrigating the ear is carried out to facilitate the removal of cerumen and foreign
bodies which are not hygroscopic*, from the external auditory meatus.
*Hygroscopic matter such as peas and lentils will absorb the water and expand, thus
making removal more difficult.
 Remove discharge, keratin or debris from the external auditory meatus.
 Correctly treat otitis externa where the meatus is obscured by debris.
An individual assessment should be made of every patient to ensure that it is
appropriate for ear irrigation to be carried out.
Reasons When Irrigation Should Not be Carried Out






The patient has previously experienced complications following this procedure.
Six-week history of middle ear infection.
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).
Twelve month history of perforation or mucous discharge.
The patient has a cleft palate (repaired or not).
In the presence of acute otitis externa with pain and tenderness of the pinna.
Equipment Requirements





Auriscope
 Jobson Horne probe
Disposable ‘one use’ jet tip
 Cotton wool
Noots trough
 Head mirror and light or head light
Non-sterile/ non-powdered gloves
 Disposable waterproof cape or towel
Propulse II or Propulse III Universal electronic irrigator with water heated to
40°C
 Staff may also wish to wear safety glasses during the procedure
This procedure should be carried out with both participants seated and under
direct vision, using a headlight or head mirror and light source throughout the
procedure.
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1 of 3
Ear Irrigation Procedure
Procedure
Rationale
1. Check reason and source for referral.
Ideally, medical staff or another suitably
qualified professional should make the initial
referral.
Although in reality, patients tend to self-refer!
2. Check whether the patient has had their ears A careful history and listening to the patient
irrigated previously, or if there are any will ensure no patient with contraindications
contraindications why irrigation should not be has their ears irrigated.
performed.
Explain the procedure to the patient and seek Consent and information are legal
verbal or written consent [refer to guidance requirements and ensures the practitioner
notes on consent, page 4].
and patient understands the procedure fully.
3. Thorough hand hygiene (soap & water) should be Refer to the ‘Guidelines for Hand Hygiene’
undertaken before the physical examination starts document issued by the Infection Control
then put on non-sterile/ non-powdered gloves.
Committee (2002) for further information.
Ask the patient to sit in an examination chair with The patients ear should be in the
the head tilted towards the affected ear.
practitioner’s direct line of vision with the
practitioner as close to the ear as possible.
A child could sit on an adult’s knee with the child’s A sudden movement by the patient
head held steady.
(particularly when it’s a child) could cause
injury to the ear.
4. Examine both ears with the auriscope and record
findings. These findings will determine whether
the patient does or does not require ear irrigation.
If the clinical decision is not to irrigate, then this
should be explained to the patient and
documented.
An examination of both ears offers an
opportunity for comparison. A written record
of findings should be made in accordance
with Professional for Record Keeping
Standards (e.g. NMC).
5. Place the protective cape and towel (to be The procedure should be as comfortable as
disposed of in orange bag later) on the patient's possible for the patient and the receiver
shoulder and under the ear to be irrigated. Ask the should catch the water from the ear.
patient to hold the receiver under the same ear.
6. Check that the headlight is in place and the light is The headlight ensures a well-lit area to work
directed down the ear canal.
safely. This is especially important when
irrigating in patient’s homes.
7. Check that the temperature of the water is Too cold water may cause the patient to
approximately 40°C and fill the reservoir of the jump increasing the risk of perforation and
irrigator.
too hot water may burn or damage the ear
canal.
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2 of 3
Ear Irrigation Procedure
Procedure
Rationale
8. Set the pressure to minimum.
Too strong a pressure, too early in the
procedure may cause the patient to feel
dizzy. If this does occur, stop irrigating and
ask the patient to fix their gaze on some
object for approximately 5 minutes until the
dizziness has passed.
9. Connect disposable ‘one use’ jet tip to tubing of This ensures that the applicator is
machine with a firm push/ twist action, pushing connected correctly.
until a ‘click’ is feIt.
It is recommended that the jet tips used are
disposable, one use only.
10. Always use a clean speculum and probe for each patient.
11. Direct the irrigator tip into the Noots receiver and
switch on the machine for 10-20 seconds,
circulating the water through the system,
discarding the initial flow of water.
This enables the noise of the machine to be
more easily accepted by the patient and to
remove any static water remaining in the
tube.
12. Ensure the light from the headlight is shining To practice safely you must at all times be in
direct vision of the patients’ ear. If anything
over the ear throughout the entire procedure.
untoward does occur, you will be in a
position to act immediately.
13. Twist the disposable ‘one use’ jet tip so that the This ensures
water can be aimed along the posterior wall of the irrigating.
ear canal (towards the back of the patient's head).
the
safest
position
for
14. Advise patient you are about to commence, then To straighten the meatus.
gently pull the pinna upward and backward or
directly backward in children.
15. Warn the patient that you are about to start This will ensure that the patient is ready to
irrigating and that the procedure will be stopped if proceed and any problems can be identified.
they feel dizzy or experience any pain.
16. Place the tip of the nozzle into the ear canal
entrance and using the foot control*, direct the
stream of water along the roof of the ear canal,
towards the posterior canal wall.
The tip is the only part the manufactures
recommend to be placed at the opening of
the ear as damage may be caused by
inserting the tip into the ear.
If you consider the entrance to the ear canal as a *The manufacture recommends the use of
clock face, you would direct the water at 11 the foot pump. A direct water stream hitting
o'clock in the right ear and 1 o'clock in the left the tympanic membrane may cause a
ear.
perforation.
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3 of 3
Ear Irrigation Procedure
Procedure
Rationale
17. Increase the pressure control gradually, if there Gradual increase of pressure is usually
is difficulty removing the wax.
successful in moving earwax.
18. It is advisable that a maximum of two If wax does not move after the maximum
reservoirs of water are used in any one irrigating water is used the patient needs to instil olive
procedure.
oil for a further 3-7 days.
An increase in pressure would not be
recommended.
19. Irrigation should never cause pain. If the patient complains of pain - stop immediately!
20. If you have not managed to remove the wax The introduction of water via the irrigating
within five minutes of irrigating, it may be procedure will soften the wax and it may be
worthwhile moving on to the other ear.
worth retrying irrigation after about 15
minutes.
21. Periodically inspect the meatus with the If the meatus becomes red or inflamed or
auriscope and inspect the solution running into the show any signs of bleeding, the procedure
must stop!
receiver.
22. After removal of wax or debris, dry mop excess
water from the meatus under direct vision using
best quality cotton wool and the Jobson Home
probe (if available) [refer to guidance notes on
Aural Toilet].
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
infection.
23. Examine ear, both meatus and tympanic A careful examination establishes accurate
membrane and treat as required, following specific treatment. The whole ear starting on the
guidelines or refer to doctor if necessary.
outside working in, must be examined and
any treatment outwith the practitioners
If any abnormality is found a referral should be expertise should be referred to the doctor.
made back to the doctor or to the ENT Outpatient
department. Remove gloves and dispose in clinical
waste (orange bag).
24. Give advice regarding ear care and any relevant Patient education is essential to empower
information.
patients to take control of their own ear
Thorough hand hygiene (soap & water) should health and reduce ear problems.
again be undertaken before going to complete any
documentation.
25. Document what was seen in both ears including
the condition of the tympanic membrane and
external auditory meatus
- the procedure carried out and any treatment given
- the condition of both ears and any hearing
changes prior to leaving the patient.
This will ensure there is an accurate record
of what was seen prior to commencing, what
action was taken and the condition of the
ears prior to the patient leaving.
Records should be completed following
Professional Guidelines.
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NHS Grampian Ear Irrigation Guidelines
Guidelines
Guidance Notes for Aural Toilet
Aural toilet is used to clear the aural meatus of debris, discharge, soft wax or excess
fluid following irrigation. This procedure is only to be carried out by a competent
doctor, registered nurse, audiologist or by a learner who is being closely
supervised by one of the above.
1. An individual assessment should be made of every patient to ensure that it is
appropriate for aural toilet to be carried out.
2. Thorough hand hygiene (soap & water) should be undertaken before the Aural Toilet
starts and staff should put on non-sterile/ non-powdered gloves. Examine the ear
and dry mop using a 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), pull the pinna to straighten the canal and clean
the ear with a gentle rotary action of the probe.
Do not touch the tympanic membrane.
3. Replace the cotton wool as soon as it becomes soiled. Soiled cotton wool should be
disposed of in the clinical waste (orange bag). Pay particular attention to the
anterior-inferior recess, which can harbour debris.
4. Re-examine the meatus using the auriscope intermittently during cleaning to check
for any debris, discharge or crusts, which may remain in the meatus at awkward
angles.
5.
Patients who have mastoid cavities should be followed up in the ENT department
unless the nurse, doctor or audiologist has been specifically trained in this area. The
frequency of cleaning required by the cavity will depend on the individual patient. If
the cavity gets repeatedly infected the patient should be considered for revision
surgery.
6. If an infection is present treatment should follow patient group directives and referral
guidelines or as dictated by the result of a swab culture and sensitivities following the
failure of first line management. If the patient has repeated problems with the ear, an
ENT Surgeon should review the patient.
7. Give advice regarding ear care and any relevant information. Gloves should be
removed and hand hygiene (soap & water) should again be undertaken before going
to complete any documentation.
8. Document what was seen in both ears including the condition of the tympanic
membrane, the procedure carried out and any treatment given. Also record the
condition of both ears and any hearing changes prior to leaving the patient. If any
abnormality is found a referral should be made to the ENT Outpatient Department
following local policy.
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NHS Grampian Ear Irrigation Guidelines
Guidance Notes for Removal of Excessive Wax Using
Instrumentation
This procedure is only to be carried out by a competent doctor, registered nurse,
audiologist or by a learner who is being closely supervised by one of the above.
These notes are for guidance only and the practitioner should use their clinical
judgement on the most appropriate method to remove wax.
1. Thorough hand hygiene (soap & water) should be undertaken before the
examination takes place and staff should put on non-sterile/ non-powdered
gloves. Examine the ear to discern the type of wax to be removed. Ask yourself
if it is healthy wax or may it be bacterial debris of wax-like appearance? Is it dry
crumbly wax related to Dermatitis or soft and beige wax in both ears which can
be associated with high cholesterol?
2. Hard, crusty wax can often be gently manoeuvred out of the meatus with a ring
probe, using a head mirror or light for illumination. If this treatment becomes
painful, do not continue as the meatal lining quickly becomes traumatised,
risking infection.
3. Instruct the patient according to your clinical judgement – they may be required to
go and use olive oil for a further week. The patient can then return for irrigation or
further instrumentation. Excessive soft wax or crumbly wax and debris can be
wiped out with cotton wool wound onto a Jobson Horne probe (see Aural Toilet
guidance on previous page) or irrigation. Gloves are removed and hand hygiene
(soap & water) should again be undertaken before going to complete any
documentation.
4. If a perforation is suspected behind the wax, advise the patient to use olive oil in
very small amounts, but to stop using it if they experience any pain.
5. Give advice regarding ear care and any relevant information.
6. Document what was seen in both ears including the condition of the tympanic
membrane and external auditory meatus, the procedure carried out and any
treatment given. Also record the condition of both ears and any hearing changes
prior to leaving the patient. If any abnormality is found a referral should be made
to the ENT Outpatient Department following local policy.
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NHS Grampian Ear Irrigation Guidelines
Decontamination Guidelines
Aural care and ear irrigation are clean not sterile procedures and staff have two
options when decontaminating their non ‘single use’ equipment.

Mirage only recommend the use of their own Propulse Cleaning Tablets. They are
provided in an easy-to-use formula, removing the need for clinicians to mix batches
of cleaning solution. This also eliminates unnecessary wastage.

The second option is to use NaDCC (Sodium Dichloroisocyanurate
0.1%) available in Grampian as HAZ tablets. These tablets should be
stored in a cool, dry place away from sunlight.
COSHH regulations must be observed when using NaDCC.
Non-sterile gloves and a disposable apron should be worn when carrying out any
decontamination procedure. This procedure should be undertaken in a designated deep
sink and not in a 'hand wash’ sink, as these basins should be used for hand hygiene
only.

Propulse Electronic Ear Irrigator
Stage 1: Each day before use, the electronic ear irrigator must be disinfected.

Using the Propulse Cleaning Tablets :
1. Place one Propulse cleaning tablet into the reservoir, fill with warm water to the
500ml mark on the reservoir and wait for the tablet to completely dissolve.
2. Run the Propulse Electronic Ear Irrigator for a few seconds to fill the pump and hose.
3. Leave to stand for 10 minutes. DO NOT leave the solution in the unit for longer.
4. Empty the reservoir of the solution, then fill the reservoir with cool boiled water and
flush through the whole system to ensure no cleaning solution is left.

Using NaDCC Tablets :
1. Follow the manufacturer's instructions to get a solution which provides 1000 parts
(NaDCC) per million (0.1%).
2. Fill the water tank with the NaDCC solution.
3. Run the irrigator for a few seconds to allow the solution to fill the pump and flexible
tubing.
4. Leave to stand for 10 minutes.
5. Empty the water tank then rinse the system through with tap water before use.
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NHS Grampian Ear Irrigation Guidelines
Decontamination Guidelines/ continued
Stage 2: At the end of the day (or at the end of the ear irrigation session), the
irrigator should again be decontaminated.

Using the Propulse Cleaning Tablets :
1. Place one Propulse cleaning tablet into the reservoir, fill with warm water to the
500ml mark on the reservoir and wait for the tablet to completely dissolve.
2. Run the Propulse Electronic Ear Irrigator for a few, then leave to stand for 10
minutes. DO NOT leave the solution in the unit for longer.
3. Empty the reservoir of the solution, then fill with cool boiled water and flush the whole
system to ensure no cleaning solution is left.

Using NaDCC Tablets :
1. Follow the manufacturer's instructions to get a solution which provides 1000 parts
(NaDCC) per million (0.1%).
2. Fill the water tank with the NaDCC solution.
3. Run the irrigator for a few seconds to allow the solution to fill the pump and flexible
tubing, then leave to stand for 10 minutes.
4. Empty the water tank then rinse the system through with cool boiled water.
5. Any NaDCC solution must be discarded at the end of each session/ day.
Following decontamination, all equipment must be stored dry, preferably in a container
that will ensure safe storage and prevent the accumulation of dust or debris on the
equipment.
Note: The water does not have to be of 'injection quality' as this would be too expensive
and impractical for irrigation or rinsing purposes. Similarly tap water is not acceptable
and must not be used for the final rinse.

Only disposable ‘one use’ jet tips should be used. On no account should ‘one
use’ items be reused or reprocessed.
After each individual patient treatment, items of equipment should also be
disinfected:


Jobson Horne Probe - send to Central Sterilising Services or use an instrument
washer/ disinfector followed by an autoclave. Instruments must be allowed to cool
completely before further use.
Speculum for Otoscope – as above, although some practitioners may find it more
appropriate to use disposable speculae.
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NHS Grampian Ear Irrigation Guidelines

Nootes Ear Tank – as above.
FAQs
CAN I STILL USE THE OLD CHROME OR PLASTIC SYRINGES?
No. The NHS Grampian Ear Irrigation Guidelines are based on the National Ear Care
Guidance Document (endorsed by the Royal College of Practitioners, the Royal
College of Nursing, the Primary Ear Care Centre and the Medicines and
Healthcare Products Regulatory Agency). These guidelines state that the
chrome/ plastic syringe is now obsolete. Continued use of these manual syringes
endangers patient safety and undermines the integrity of the Health Professional.
Remember 90% of litigation concerning ear irrigation involves the chrome syringe!
MY WORKPLACE STILL USES THE PROPULSE I, IS THIS ACCEPTABLE?
No.
The Medicines and Healthcare Products Regulatory Agency issued Safety
Notice SN 9807 in February 1998, which advised users that the original Propulse
electronic irrigator required an isolation transformer for electrical safety.
(More information can be found at: http://www.medical-devices.gov.uk)
In the majority of areas a ‘circuit-breaker’ was not being used and the Propulse was
withdrawn. The Propulse II and Propulse III Universal now have in-built isolation
transformers, making ear irrigation much safer. There is a general consensus in
Grampian that the Propulse I is now antiquated and staff are advised to only use the
Propulse II or Propulse II Universal.
Mirage will offer a part exchange to staff when upgrading from a Propulse I and for more
information telephone: 0845 130 5440.
HOW LONG SHOULD THE PATIENT USE OLIVE OIL DROPS BEFORE HAVING EAR
IRRIGATION?
It is dependent on the Health Professional's clinical judgement, however practitioners in
Grampian generally agree that 3 – 7 days work best. [See page 6 of these guidelines
for more details]
CAN I IRRIGATE A CHILD'S EARS?
This again depends on the Health Professional's clinical judgement and skill.
If
irrigation is indicated, then most clinical areas in Grampian will refer the child to Sick
NHS Grampian Ear Irrigation Guidelines - PEM
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Children’s A&E or ENT. However, if you do proceed then ask yourself, is the irrigation
really necessary, will the child co-operate, does the parent consent and is the person
carrying out the irrigation fully trained and competent to do so?
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NHS Grampian Ear Irrigation Guidelines
Useful Links Relating to Ear Care
NHS Grampian Ear Care Website
NHS Grampian Intranet homepage 
microsites  ear irrigation
This website has been developed to support all staff in Grampian. As well as
information and downloads, there is also a discussion forum, an area for sharing
good practice and an opportunity to ask questions.
Primary Ear Care Centre
www.earcarecentre.com
The Primary Ear Care Centre is a unique pioneering organisation providing
and promoting effective ear care for people with ear and hearing problems
in the primary care setting.
Mirage Health Group
http://miragehealthgroup.com
Manufacturers of ear irrigation products including the Propulse II and
Propulse III Universal Electric Ear Irrigator.
Royal College of Nursing
www.rcn.org.uk
Website representing nurses and nursing, promoting excellence in practice
and shaping health policy.
Nursing Midwifery Council
www.nmcuk.org
The Nursing and Midwifery Council website providing guidelines for
standards of care to patients and clients.
Royal College of General
Practitioners
www.rcgp.org.uk
Website run by the Royal College of General Practitioners for GPs.
Department of Health
www.doh.gov.uk
Department of Health website highlighting current issues in the NHS
ENT Nursing
www.entnursing.com
A website providing a national approach to ENT Nursing development, sharing good
practice, and enhancing professional and personal development.
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NHS Grampian Ear Irrigation Guidelines
Bibliography

Aung,T. ; Mulley.G.P. (2002) Removal of ear wax. British Medical Journal. 325:27

Eckhof J A H, de Beck G h. Le Cessie S. Springer M P. (2001) A quasi-randomised
controlled trial of water as a quick softening agent of persistent earwax in general
practice. British Journal of General Practice August: 635-637

Fisher,E.W.;Pfleiderer,A.G. (1992) Assessment of the otoscopic skills of general
practitioners and medical students: is there room for improvement?. British Journal
of General Practice. Vol. 42:65-67.

Price, J. (1997) Problems of ear syringing. Practice Nurse. 14:126-8

Ney, D.F. (1993) Cerumen impaction, ear hygiene practices and hearing acuity.
Geriatric Nursing. Mar/ Apr.:70-73.

Nursing Midwifery Council (2002) Code of Professional Conduct: Standards for
Conduct, Performance and Ethics.
.

.

Nursing Midwifery Council (2004) Guidelines for Records and Record Keeping.
Rodgers, R. (2001) The National Diploma of the Primary Ear Care Centre
booklet

Rodgers R.W. (2002) Continued education: preventive ear care. Nursing in
Practice. March: 71-73

Rodgers R. (2000) Understanding the legalities of ear syringing. Practice Nurse
19(4)166-169

Roesser, R.J.; Ballanchanda, B.B. (1997) Physiology, pathophysiology, and
anthropology/ epidemiology of human ear canal secretions. Journal of American
Academy of Audiology. Vol. 8:391-400.

Rotherham Primary Ear Care Centre.

Sharp, J.F.; Wilson, J.A.; Ross, L.; Barr-Hamilton, R.M. (1990) Ear wax removal: a
survey of current practice. British Medical Journal. Vol. 301:1251:1252.

Spiro, S. (1997) A cost-effective analysis of ear wax softeners. Nurse Practitioner.
Vol. 22(8): 28,30-31.
+ Appendix 1 (3C Checklist), Appendix 2 (Consent Form)
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and Appendix 3 (Propulse III Universal Information)
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