Ear hygiene should be carried out carefully to avoid causing damage to the ear. Public awareness of this is low and leads to attempts to remove wax with instruments such as cotton swabs and hairpins (NICE [153]). As well as traumatizing the skin, these actions often contribute to increased wax production and impaction (see Box 9.4) and can also impair the self‐cleansing mechanism of the organ. Fundamentals of ear hygiene include the following:

If there are any signs of inflammation or the patient is complaining of any discomfort:

A good light source and an operating lamp positioned above and behind the nurse are necessary prior to commencing ear care procedures to enable careful assessment of the ears (RPECCAS [202]). The patient and nurse should be sitting at the same height to examine the outer ear and pinna (NICE [153]). Any alteration to the appearance of the ear must be reported to the doctor.

Before proceeding with any form of invasive ear care, it is important to undertake careful examination of the ear, taking note of any discharge, redness or swelling, and the amount and texture of any ear wax present, as this will give an indication of the general health of the ear. A small amount of wax should be expected in the ear canal. Its absence may be a sign of a dry skin condition, infection or excessive cleaning that has interfered with the normal wax production (Millward [133]).

The nurse should discuss with the patient their current level of hearing and after the procedure they should ask the patient whether there are any changes, so as to monitor the effectiveness of the intervention. Consideration should always be given to a patient's hearing aids and assistance should be given, as required, to clean these. Advice regarding the most appropriate method should be sought, preferably from the patient. Irrigation of the inner ear is sometimes necessary to remove foreign bodies or to clear excessive build‐up of ear wax (cerumen) (Millward [132]).

Poor ear care can cause:

Special care should be taken to avoid damage to the aural cavity and eardrum.

Due to the invasive nature of ear irrigation, it is advised that the patient first tries using wax softeners such as olive oil, which may avoid the need for irrigation (BSA [27], Millward [132]). It is advised that this should be administered two to four times daily for a minimum of three to five days, following the manufacturer's guidance. The British Society of Audiology advocates that if the ear wax remains very firm, the softening oil or spray can continue to be applied for up to a maximum of 10 days (BSA [27]).

Ear irrigation should only be carried out by healthcare professionals who have had specialist training and have demonstrated theoretical and practical competence to carry out the procedure. Physical fitness to practise should also be considered, as this procedure requires manual dexterity and good vision (BSA [27]). The BSA ([27]) recommends that the audiology, nursing or medical professional usually undertaking this procedure should be registered with the Health and Care Professions Council (HCPC) or the Registration Council for Clinical Physiologists (RCCP). It goes on to recommend that non‐registered professionals, such as assistant audiologists, hearing care assistants and healthcare assistants who are trained in the removal of ear wax, should ensure that their employers make their procedural and professional scope clear, and they must demonstrate theoretical and practical competence (BSA [27]).

Ear irrigation should not be carried out using a syringe. The traditional method of irrigation using a metal water‐filled, hand‐held syringe is no longer recommended practice due to the high risk of infection and the potential to cause trauma to the ear and the delicate structures within the ear; these syringes are also difficult to decontaminate after use (Millward [133], NICE [153], NICE [157]). There are a number of electronic ear irrigators available. NICE ([153]) recommends that an approved electronic irrigator fitted with an ear probe is used for ear irrigation. It should have a variable pressure control to enable the water pressure to be controlled more precisely so that the ear irrigation can commence at the minimum pressure and so that the direction of the water can be better controlled (Millward [132]). The water temperature should be 37°; if too hot or cold, it can cause dizziness or vertigo (RPECCAS [202]).

Following irrigation, the patient's symptoms should resolve. If the symptoms continue, further treatment may be required and in some cases referral to ENT (ear, nose and throat) specialists may be appropriate. Irrigation is not the only method of removing excess earwax. Those patients who have contraindications to ear irrigation (Box 9.6) still require wax removal, and this can be done via instrumentation or microsuction. This must only be carried out by a nurse trained in the procedure. This procedure is not readily accessible in primary care so patients are usually referred to local ENT clinics.