1. Ear care workshop

2. AIMS For the practitioner to be able to confidently carry out ear examinations, recognise abnormalities and to carry out appropriate ear care.

3. Objectives To enhance understanding of basic anatomy and physiology of the ear. Ear examination To recognise abnormalities and associated care Theory behind cerumen removal and associated guidelines To reflect on accountability, documentation Practical session

4. Basic anatomy and physiology of ear Outer (External) ear Pinna and external acoustic canal. Canal lined with small hairs next to which are small ceruminous glands The Tympanic Membrane

5. MIDDLE EAR Air filled chamber Contains 3 smallest bones in the body – malleus, incus and stapes = AUDITORY OSSICLES Eustachian tube Vibrations – Oval window - cochlear

6. Inner ear Inner ear Semi circular canals and vestibular apparatus The organ of corti is in the cochlea and is main organ for hearing

7. Nerves involved: Auditory nerve – inner ear ( CN VIII) Facial nerve – middle ear ( CN VII) Vagus Nerve - Outer ear (CN X)

8. Ear wax - Cerumen Not Like paraffin! Made of a lot of different chemical components Testerone control over production of sebum. What is its purpose?

9. People likely to produce excessive wax Learning disabilities Anxious people High lipid levels Genetic tendency Elderly

11. What issues can wax build up cause a patient?

12. Ear Examination History of presenting condition: What information would be required here?

13. History cont…… PMH - ? Relevant Meds Allergies

14. Assessment Examine Pina. Outer meatus and adjacent scalp / mastoid,checking for scars, signs of trauma/ infection Is ear inflammed -? Infection/ trauma Skin condition – ?seborrhoeic dermatitis/ Malignancy Ear canal discharge?

16. Identify wax…… In ear examination discern type of wax, position in canal and % of occlusion Is wax healthy, or bacterial debris, or dry and crumbly

17. Assessment cont.. Examine external auditory meatus. Should be pain free. What can cause pain? Furuncle Trauma Otitis externa Fungal infection

18. Assessment cont…. Check ear canal and tympanic membrane

19. Assessment cont… When withdrawing otoscope check external auditory meatus carefully. Document……! Document…..! Document….!

21. Ear cleaning / irrigation

22. Ear Preparation If wax hard will require softening for best irrigation results Choice of products – OTC drops – otex, cerumol – all contain hydrogen peroxide Bicarbonate soda 5% drops – possible irritant Olive oil Almond oil avoid if nut allergies! Totally contraindicated in any acute perforated Tympanic Membrane.

23. Application of drops No formal length of time and number of times a day Advise if using oil not to heat it up – room temp sufficient Not to over oil ears as becomes irritated

24. Manual removal If dry and crusty possibly can be gently manoeuvred out using Jobson Horne probe – head light and otoscope If too painful discontinue - skin becomes quickly traumatised

26. Ear Irrigation Equipment required: Auriscope Head light / ? Eye protectors/ apron/ gloves Electronic ear irrigator Warm water – approx room temp - NOT COLD!! Noots receiver ( disposable or lined) Jobson Horne probe/ cotton wool Tissues, receivers Waterproof cape / towel

27. Guidelines:…… ENSURE – device only used by trained clinician ENSURE that warnings and cautions are observed ENSURE patient exhibits NO contra indications ENSURE the unit been cleaned

28. Reasons for irrigation Remove and Improve!

29. Principles of ear irrigation Facilitate the removal of cerumen and foreign bodies Individual assessment of each patient by practitioner carrying out procedure.

30. Possible complications? Infection Perforation Tinnitus Vagal nerve stimulation Dizziness

31. Irrigation should not be carried out when: Informed consent not obtained and NSCP consent form signed for procedure Patient has had previous problems with procedure in past Hx of otitis media in past 6 weeks Any form of ear surgery in past 18 months and NOT been discharged from care of ENT Perforation or Hx of mucus discharge in past 12 months Cleft palate repaired or not Presence of acute otitis externa

32. Procedure to always be carried out with both practitioner and patient sitting, patient should be under direct vision using a headlight throughout.

33. DOCUMENTATION……. Record: What the patient says What you see in BOTH ears What you do – including advice given Why this treatment – rationale…. NMC record keeping guidelines 2010

34. Documentation tips… Always compare both ears - L=R Do not use word “Appears normal” - looks as though not aware of what you are doing be definite. – “ Tympanic membrane normal” or “Tympanic membrane normal features not visible” Word “impacted” – to be used if evidence wax has been pushed down canal with implement such as cotton bud ‘Occluded’ should be used is canal full of wax – say whether dark and hard, softy and light wax. Document advice given to patient written/ verbal post procedure.

35. DEAFNESS 3 types: 1. Conductive : Obstruction between external /middle ear 2. Sensori – neural: Obstruction between stapes footplate and the auditory centres of brain 3. Mixed Deafness: Combination of conductive and sensori – neural deafness Practical Time

37. Hearing Aid Care.. General Whistling Hearing aid controls Washing the ear mould Retubing ear mould

38. Tinnitus What is Tinnitis? How do you get it? Who is likely to get it? Hyperacusis

39. Patient Education E – Educate - Why problem there? A – Advise – How to prevent recurring Regular check ups R – Resolve – Treat the Problem, applying clinical judgement and ability

40. References and acknowledgements Rogers R, www.earcareservicesuk.com www.tinnutis.org.uk www.deafnessresearch.org.uk Action on ENT Steering Board (2007). Guidance Document in Ear Care. Primary Ear Care Centre. (http:// www.earcarecentre.com) Nursing and Midwifery Council (2006) Record Keeping Guidance for Nurses. NMC, London. Skills for Health :CHS20. Undertake examination of the external ear: -National Operation Standards: https://tools.skillsforhealth.org.uk/competence/show/ht ml/id/350/ (last accessed 11th April 2012)