Pre‐procedure

ActionRationale

1. 1.Show
   Collect the equipment listed. Introduce yourself to the patient, explain and discuss the procedure with them, and explain all the potential risks, ensuring their comprehension and gaining their consent to proceed. Check whether irrigation has been previously performed and assess the patient to determine whether this procedure is appropriate and whether there are any contraindications to performing irrigation (see Box 9.6).
   To ensure efficient time use, reducing the need to leave the bedside. To ensure patient safety. E

   To ensure that the patient feels at ease, understands the procedure and gives their valid consent, and to ensure the appropriateness of the procedure (BSA [27], C; Millward [132], E; NMC [162], C).
2. 2.Show
   Prepare the irrigator as per the manufacturer's instructions, ensuring that it is in good working order and that a new irrigation tip is attached for the procedure.
   To ensure the equipment is used according to the manufacturer's guidance. E
3. 3.Show
   Carry out hand hygiene and apply personal protective equipment (apron and gloves).
   To prevent the spread of micro‐organisms and infection (Millward [132], E; NHS England and NHSI [148], C).
4. 4.Show
   Both the healthcare professional and the patient should be sitting in upright positions in chairs. Ensure that the patient is in a comfortable position that can be sustained throughout the procedure.
   To ensure patient stability, comfort and safety during the procedure (BSA [27], C; RPECCAS [202], C).
5. 5.Show
   Positioning the light source as necessary, examine both of the patient's ears. Commence with examining the pinna and adjacent scalp, then inside the auditory canal. Check for any evidence of skin defects or scarring that could indicate previous surgery.
   To ensure a thorough assessment of the ear prior to commencing irrigation (RPECCAS [202], C).
6. 6.Show
   Place the disposable waterproof cape around the shoulders of the patient, taking particular care to ensure it covers the area under the ear to be irrigated.
   To protect the patient's clothing from irrigation fluid and debris (BSA [27], C).
7. 7.Show
   If they are able, ask the patient to hold the receiver or Noots tank under the ear to be irrigated close to their head; if they are unable, a colleague or relative can assist.
   To collect the irrigation fluid and debris (BSA [27], C).
8. 8.Show
   Heat the irrigation fluid to 40°C and fill the irrigator reservoir to 500 mL. Check the temperature of the fluid: the temperature of the fluid irrigated into the ear should be approximately 37°C.
   Irrigation fluid should be at body temperature to avoid triggering the vestibular reflex – i.e. symptoms of nausea, vomiting and vertigo (BSA [27], C; NICE [153] C).
9. 9.Show
   Securely attach the new applicator irrigation tubing and probe, and set the irrigator machine pressure to minimum.
   To ensure that the probe will not dislodge from the irrigator under pressure from the water, potentially causing damage to the auditory canal. To ensure the pressure used is the minimum necessary, reducing the potential for damage (RPECCAS [202], C).
10. 10.Show
    Direct the irrigator into the receiver and switch on the machine. Let it run for 15–20 seconds. Discard any water in the receiver.
    To check the functioning of the machine and the water temperature. To eliminate any trapped air or cold water in the irrigator. To allow the patient to become accustomed to the noise of the irrigator (RPECCAS [202], C).

Procedure

1. 11.Show
   Inform the patient that you are about to start the procedure. Advise them to inform you of any pain or dizziness immediately. Gently pull the pinna upwards and outwards.
   To stretch and straighten the external auditory canal and hold the ear steady (BSA [27], C; NICE [153], C).
2. 12.Show
   Place the tip of the probe at the exterior auditory canal entrance at the posterior wall of the exterior auditory membrane. Direct the irrigator probe to the posterior wall.
   Aiming the stream of water incorrectly at the anterior wall risks stimulating the vagus nerve (Millward [132], E; RPECCAS [202], C).
3. 13.Show
   If the patient experiences any symptoms of nausea, dizziness or pain, stop the procedure immediately. It is recommended to seek immediate advice from ENT (ear, nose and throat) specialists if severe pain, deafness or vertigo occur during or after the irrigation procedure or if perforation is seen.
   To prevent further triggering of the vestibular reflex and prevent further damage to the tympanic membrane (NICE [153], C; RPECCAS [202], C).
4. 14.Show
   Direct a steady stream of water along the top of the external auditory canal, aiming towards to the posterior wall. The perimeter of the exterior auditory canal can be compared to a clock face:

   • For the left ear: aim the jet of fluid towards the 1 o'clock position.
   • For the right ear: aim the jet of fluid towards the 11 o'clock position.
   Fluid should not be directed at the tympanic membrane as this can cause perforation, nor should it be aimed directly at the wax plug as this can cause further impaction. It should flow behind the plug of wax and along the canal to wash out the wax plug (Millward [132], E).
5. 15.Show
   Inspect and monitor the ear canal (with the otoscope/auriscope) and the fluid draining into the receiver or Noots tank for traces of wax.
   To evaluate the effect of the irrigation and to determine whether the wax has been removed (RPECCAS [202], C).
6. 16.Show
   Further irrigation may be necessary. If the patient is comfortable, the pressure of the irrigator may, with caution, be gradually increased if there is difficulty in removing the wax plug. No more than 500 mL of water per ear should be used for irrigation (NICE [153]).
   To remove remaining ear wax while irrigating the ear on the lowest pressure setting to reduce the risk of complications (BSA [27], C; RPECCAS [202], C).
7. 17.Show
   Examine the ear with the otoscope/auriscope to check that all of the wax plug has been removed and that the tympanic membrane is intact.
   To monitor the condition of the ear and the success of the irrigation (NICE [153], C).
8. 18.Show
   If wax remains, seek further advice from ENT specialists.
   Medical advice should be sought if further treatment is required to remove impacted wax (NICE [153], C).
9. 19.Show
   Aural toilet: under direct vision using the otoscope/auriscope and the light source, dry the external auditory canal using the cotton wool carrier (Jobson Horne Probe or ProScoop tip wrapped in cotton wool) in a gentle rotation action. Change the cotton wool frequently and immediately if it is soiled. Avoid touching the tympanic membrane.
   Removal of stagnated water reduces the risk of maceration of the skin and infection. Abrasion increases the risk of perforation of the tympanic membrane (BSA [27], C; RPECCAS [202], C).

Post‐procedure

1. 20.Show
   Remove the waterproof (potentially contaminated) covering from the patient and dispose of it as per local policy. Dispose of single‐use used consumable equipment in the appropriate waste bag following local policy.
   To ensure correct disposal of contaminated material (Loveday et al. [114], R).
2. 21.Show
   Remove personal protective equipment and decontaminate hands.
   To reduce the risk of cross‐infection (NHS England and NHSI [148], C).
3. 22.Show
   Advise the patient to return promptly if they develop symptoms of earache, itching, ear discharge, odour, swelling or disruption of hearing. Provide verbal and written advice on complications and details of how to contact medical advice (if they occur).
   These symptoms may be signs of infection and further treatment may be required. So that inspection and appropriate referral and treatment can be instigated (BSA [27], C; NICE [153], C).
4. 23.Show
   Document the procedure and its outcome.
   To provide recorded documentation of care and aid communication to the multiprofessional team (NMC [162], C).
5. 24.Show
   Clean, disinfect and calibrate the irrigator according to the manufacturer's guidelines and local policy. Perform hand hygiene.
   To reduce the risk of cross‐infection (NHS England and NHSI [148], C; RPECCAS [202], C).