# Ear Irrigation

## Overview

This module describes how to irrigate the ear to remove cerumen or foreign bodies.

## Indications

1. Cerumen impaction obstructing otoscopy

2. Symptomatic cerumen impaction

3. Cerumen impaction in patients with dementia or intellectual disability

4. Removal of foreign bodies from the ear

## Contraindications

1. Perforated tympanic membrane or history of ear surgery

2. Weigh up the risks and benefits in patients with coagulopathy (higher risk of bleeding from the ear canal), immunocompromise (higher risk of otitis externa), or a history of

   head and neck radiation
   head and neck radiation

   These patients have drier cerumen that should be removed carefully, because injury to the ear canal can lead to osteoradionecrosis (exposure and necrosis of nearby bony structures).

## Patient information & consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“When I examined your ear, I saw a buildup of earwax or an object that needs removal.”

### What can my patient expect?

“I will first put some drops in your ear and ask you to lie down. After a while, I’ll wash out your ear with a syringe and some water. This only takes 15 minutes.”

### What is my patient’s role?

“Tell me if you have any allergies or medical conditions. Let me know if you have pain or dizziness while I wash out your ear.”

## Preparation

Prepare a trolley with equipment. Have a good light source.

### Documentation

1. Patient notes

### Equipment

1. Alcohol-based hand rub

2. Cerumenolytic drops
   Cerumenolytic drops

   Water-based and oil-based cerumenolytics are available. Peroxide is a commonly used agent. If unavailable, the drops can be omitted.

3. 20 ml syringe

4. 14-16 G IV cannula or a suction catheter cut short

5. A jug or bowl for the syringing water

6. Kidney dish to catch the water as it pours out of the ear

7. Linen saver

8. Sterile water at body temperature

9. Otoscope

## Site & Positioning

Position the patient sitting upright, sideways in front of you with the ear to be syringed pointing towards the source of light. Syringing should be done in good light so that you can see where you are placing the tip of the syringe. A child should be seated on an adult’s lap with both the head and the body firmly held.

## Procedure

Follow medical asepsis without gloves.

1. Perform hand hygiene.

2. Apply cerumenolytic drops to the patient’s ear and ask them to lie on their side with the ear facing up for 5 minutes.

3. Ask the patient to sit up. Place the linen saver on their shoulder and ask them to hold the kidney dish under their ear.

4. Use the syringe and cannula with the needle removed to draw up water.

5. Fill and squirt out the syringe a few times to ensure that the cannula does not come off when you squirt a jet of water through it as hard as you can.

6. Pull the ear slightly up and back in adults, or down and back in children.

7. Insert the cannula tip only 1 cm into the ear canal and irrigate gently with continuous pressure.

8. Continue drawing up more water and irrigating until cerumen is visualised leaving the ear.

9. Examine the ear with an otoscope to confirm cerumen removal.

10. Repeat the whole process a few times until the ear is clean.

11. Dispose of medical waste safely.

12. Record completion of the procedure in patient notes.

## Troubleshooting

My patient is unable to follow instructions.

These patients may need procedural sedation. Discuss this with a senior colleague before attempting.

I’ve tried everything, but I can’t get the cerumen out. It is hard and impacted.

Remember that wax dissolves in water, so if cerumenolytic drops are unavailable, lie the patient down with the wax filled ear uppermost and fill the ear canal with water. Ask the patient to pump the tragus—refilling the canal a few times—and then try syringing again. Repeat this again if necessary. If still unsuccessful, ask the patient to fill their ear with water and pump the tragus a few times during the rest of the day, returning the next day for another attempt. If unsuccessful, instrumental cerumen removal may be indicated. Ask a senior colleague for assistance, or refer to otolaryngology.

The syringe plunger does not move smoothly up and down.

Try a different syringe or a larger 50 ml syringe. If unsuccessful, use a metal syringe if one is available.

I have scratched my patient’s ear canal with the tip of the cannula.

Explain to the patient what has happened and put some ear drops in it. Explain that they should return if the ear becomes sore or begins to discharge.

My patient has a living bug in their ear.

First, drown it using a few drops of oil. Then remove it using the method above.

## Risks

1. Otitis externa

2. Local irritation or rash

3. Ear trauma including tympanic membrane perforation

## References

1. Meyer F, Preuß R, Angelow A, Chenot JF, Meyer E, Kiel S. Cerumen Impaction Removal in General Practices: A Comparison of Approved Standard Products. J Prim Care Community Health. 2020;11:2150132720973829. doi:10.1177/2150132720973829

2. Sevy JO, Singh A. Cerumen Impaction Removal. [Updated 2021 Jul 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448155/

3. Michaudet C, Malaty J. Cerumen Impaction: Diagnosis and Management. Am Fam Physician. 2018;98(8):525-529..