Proper Instillation of Ear Drops and Irrigation,

and Noise Pollution

Ear examination
1. Ensure that both you and the patient are seated comfortably at the same level if
possible and that you have privacy.
2. Examine the pinna, outer meatus and adjacent scalp. Check for previous surgery incision
scars, infection, discharge, swelling and signs of skin lesions or defects.
3. Decide on the most appropriate size of speculum that will fit comfortably in the ear and
place it on the auroscope.
4. Gently pull the pinna upwards and backwards to straighten the ear canal. (Localized
infection or inflammation will cause this procedure to be painful, if this
is present, do not continue.)
5. Hold the auroscope like a pen and rest the small digit on the patient’s head as a trigger
for any unexpected head movement. Use the light to observe the direction of the ear
canal and the tympanic membrane. There is improved visualisation of the eardrum 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.
6. Insert the speculum gently into the meatus to pass through the hairs at the entrance to
the canal, and using gentle movements of the auroscope and the patient’s head,
examine the walls of the canal, which are sensitive and fragile.
7. Identify any of the following: -
 Wax in the canal, this can range from black or dark brown and solid to yellow
and sticky to white and flaky (mainly seen in oriental people). However, white
and flaky debris may be due to an excess keratin signifying an external ear
infection.
 Foreign bodies.
 Inflammation in the canal – the canal could be red, swollen and tender, or pale
and moist.
 The nurse should also identify if an odour is present, or if there is a discharge
which may be creamy or have the apprearance of mucous.
 The normal eardrum – the colour is normally pearly light grey, shiny and
translucent.
 Other visible abnormalities.
8. Document what was seen in both ears

CONTRAINDICATIONS TO EAR IRRIGATION

 The patient has previously experienced complications following this procedure in
the past.
 There is a history of a middle ear infection in the last six weeks.
 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).
  The patient has a perforation or there is a history of a mucous discharge in the last year.
 The patient has a cleft palate (repaired or not).
 In the presence of acute otitis externa with pain and tenderness of the pinna.

Irrigation Procedure using an Electronic Irrigator

Equipment needed
 Auriscope
 Head light, spare batteries and spare bulb
 Propulse Electronic irrigator
 Jug containing tap water to 40°C approximately (warm to finger touch)
 Noots trough/receiver
 Jobson Horne probe and cotton wool
 Tissues and receivers for dirty swabs and instruments
 Disposable waterproof and absorbent covering Apron & gloves

1. Informed consent should be obtained prior to proceeding. The patient should be

informed of the risks of the procedure i.e. trauma, minor infection, chronic
infection, acute and chronic tinnitus, perforation of eardrum and deafness, to
enable them to give consent.

2. Examine both ears by following the ear examination procedure. Check to see if
the ears still require irrigation, the olive oil may have removed the wax.

3. Check whether the patient has had their ears irrigated previously, or if there are
any contra-indications why irrigation should not be performed. Wash hands prior
to procedure. Explain the procedure to the patient and ask the patient to sit in
chair with their head tilted towards the affected ear so that the nurse is still able
to see into the ear canal.

4. Place the protective cape and the absorbent covering on the patient’s shoulder
and under the ear to be irrigated. Ask the patient to hold the noots receiver on
the neck approximately two centimetres below the ear.

5. Check that the headlight is in place and the light is directed down the ear canal.
Fill the reservoir of the irrigator with water that is approximately 40C by finger
touch and testing it on the patient’s ear lobe. Set the pressure at minimum.

6. Connect a clean jet applicator or a disposable one to the tubing of the machine
until a firm ‘push/twist’ action. Push until a “click” is felt.

7. Warn the patient that you are about to start irrigating and ask them to alert you if they
become dizzy or experience any pain, so that the procedure can be discontinued
immediately. Direct the irrigator tip into the Noots receiver and switch on the machine for
 10-20 seconds in order to circulate the water through the system and eliminate any trapped
air or cold water. Discard some water onto the nurses own small finger to confirm that the
water is at the right temperature prior to commencing the procedure. This offers the
opportunity for the patient to become accustomed to the noise of the machine.
Demonstrate the gentleness of the water jet on their fingers before irrigating.

8. Twist the jet tip so that the water outlet is aimed at the posterior wall of the ear canal
(towards the back of the patient’s head) at the entrance of the meatus).

9. Gently pull the pinna upwards and backwards to straighten the ear canal.

10. Warn the patient that you are about to start irrigating. Place the tip of the nozzle
into the ear canal entrance and using foot control direct the stream of water
towards the posterior canal wall (directed towards the back of the patient’s head).
If you consider the entrance to the ear canal as a clock face, you would direct the water at
11 o’clock in the right ear and 1 o’clock in the left ear. Always start with two short
applications of water to determine if the patient is sensing water in the nose or throat,
which signifies a perforated tympanic membrane. The procedure can ten be terminated and
medical advice sought. However, if the patient does not experience such problems, the
procedure may be continued. Increase the pressure control gradually if there is difficulty-
removing wax. It is advisable that a maximum of two reservoirs of water is used in any one
irrigating procedure.

11. If you have not managed to remove the ear wax within five minutes of irrigating, it
may be worthwhile moving onto the other ear (if both ears are required to be
irrigated) as the introduction of water via the irrigating procedure will soften the
wax and you can retry ear irrigation after about 15 minutes.

12. Periodically inspect the ear canal with the auroscope and inspect the solution
running into the receiver.

13. After removal of earwax or debris, dry mop excess water from the meatus under
direct vision using the Jobson Horne probe and best quality cotton wool.
Stagnation of water and any abrasion of skin during the procedure or by previous
attemps at self clearing the ears can predispose to infection. Removing the water
with the cotton wool and tipped probe reduces the risk of infection.

14. Give advice regarding ear care and any relevant information and provide leaflet.

15. Document what was seen in both ears, the procedure carried out, the condition
of the tympanic membrane and external auditory meatus and treatment given.
Findings should be documented, following the NMC guidelines on record
keeping. If any abnormality is found a referral should be made to the GP.
 IRRIGATION SHOULD NEVER CAUSE PAIN. IF THE PATIENT COMPLAINS OF
PAIN – STOP IMMEDIATLEY.

ALWAYS USE A CLEAN SPECULUM, JET TIP APPLICATOR AND PROBE FOR
EACH PATIENT.

Ear Drops Instillation

1. In preparation for ear irrigation and to encourage normal wax expulsion from the outer
ear.
2. Lie down on your side with the affected ear uppermost
3. Drop 2 or 3 drops of oil (at room temperature) into the ear canal
4. Massage the tragus, just in front of the ear
5. Pull the pinna backwards and upwards. This enables the oil to run down the ear canal.
6. Stay lying down for 5 minutes and then wipe away any excess oil.
7. Do not leave cotton wool at the entrance to the ear
8. Repeat the procedure with the opposite ear if necessary.
9. Prior to irrigation, insert the drops twice a day for at least 7 days

NOISE POLLUTION

Noise pollution (or environmental noise) is displeasing human, animal or machine-

created sound that disrupts the activity or balance of human or animal life. The word noise
comes from the Latin word nauseas meaning seasickness.

The source of most outdoor noise worldwide is mainly construction and transportation
systems, including motor vehicle noise, aircraft noise and rail noise. Poor urban planning may
give rise to noise pollution, since side-by-side industrial and residential buildings can result in
noise pollution in the residential area.

Indoor and outdoor noise pollution sources include car alarms, emergency service
sirens, mechanical equipment, fireworks, compressed air horns, groundskeeping equipment,
barking dogs, appliances, lighting hum, audio entertainment systems, electric megaphones, and
loud people.

Human Sensory Effects

 Hearing loss
The mechanism of hearing loss arises from trauma to stereocilia of the cochlea, the
principal fluid filled structure of the inner ear. The pinna combined with the middle ear
amplifies sound pressure levels by a factor of twenty, so that extremely high sound pressure
levels arrive in the cochlea, even from moderate atmospheric sound stimuli. Underlying
pathology to the cochlea are reactive oxygen species, which play a significant role in noise-
induced necrosis and apoptosis of the stereocilia. Exposure to high levels of noise have differing
effects within a given population, and the involvement of reactive oxygen species suggests
possible avenues to treat or prevent damage to hearing and related cellular structures.
The elevated sound levels cause trauma to the cochlear structure in the inner ear, which gives
rise to irreversible hearing loss. A very loud sound in a particular frequency range can damage
the cochlea's hair cells that respond to that range thereby reducing the ear's ability to hear
those frequencies in the future. However, loud noise in any frequency range has deleterious
effects across the entire range of human hearing.[10] The outer ear (visible portion of the human
ear) combined with the middle ear amplifies sound levels by a factor of 20 when sound reaches
the inner ear.

 Age Related (Presbycusis)

Hearing loss is somewhat inevitable with age. Though older males exposed to significant
occupational noise demonstrate significantly reduced hearing sensitivity than their non-
exposed peers, differences in hearing sensitivity decrease with time and the two groups are
indistinguishable by age 79. Women exposed to occupational noise do not differ from their
peers in hearing sensitivity, though they do hear better than their non-exposed male
counterparts. Due to loud music and a generally noisy environment, young people in the United
States have a rate of impaired hearing 2.5 times greater than their parents and grandparents,
with an estimated 50 million individuals with impaired hearing estimated in 2050.
In Rosen's work on health effects and hearing loss, one of his findings derived from tracking
Maaban tribesmen, who were insignificantly exposed to transportation or industrial noise. This
population was systematically compared by cohort group to a typical U.S. population. The
findings proved that aging is an almost insignificant cause of hearing loss, which instead is
associated with chronic exposure to moderately high levels of environmental noise.