Preventative care

Many OH nurses have had little or no training in ear care.
However, with a greater understanding of the anatomy and physiology of ears,
nurses can improve their clinical judgement of ear problems, by Rosemary
Rodgers

We are all ‘earmarked’, no two ears are alike, so a good understanding of
their care is vital. OH practitioners are commonly concerned with hearing
problems and preventing them within the workplace, yet during a recent OHNs
conference, when delegates were asked how many people present had participated
in previous primary ear care training, only one nurse had.

This is not surprising when it is realised that 47 per cent of litigation
costs related to ear syringing were the result of poor technique1. There is
further evidence of the lack of nurse training in this field. In one study, 60
per cent of the nurses questioned had never received ear care training and 100
per cent of NVQs do not include ear care2. The author is able to confirm this
lack of ear care knowledge nationally by quoting from course evaluation
figures. Of the 366 nurses taught by her in the past six months, 91 per cent of
them have never received prior ear care training or have learnt on a "see
one, do one" basis. One nurse has been syringing ears for the past 33
years on this basis.

Yet there are many benefits to be gained through using knowledgeable
clinical judgement to prevent, recognise and treat presenting ear problems.
These are:

– Prevention of recurrences

– Patient satisfaction

– Reduction in physical distress and discomfort

– Improved quality of life of client through better communication.

– Improved understanding of solutions for ear problems

– Minor problems treated sooner, enabling major problems to be frequently
eliminated

– Consultant, doctor, nurse and patient time saved

– Reduction in work absentees

It is essential for OH to relate the knowledge of anatomy and physiology of
the ear to each individual patient and their lifestyle, to gain a holistic
understanding for the future prevention of the problem. It is also important to
understand the normal ear in order that any abnormal pathology can be
recognised more easily.

Skin, bone, blood, nerves and glands all combine to enable the ear to
function efficiently. By understanding this, the nurse is able to provide an
improved clinical judgement for the resolution of the presenting problem. This
paper aims to help identify ear problems and give a greater understanding of
future prevention.

Background anatomy basics

The external ear comprises the pinna, tragus, ear meatus and tympanic
membrane. The skin covering this area is squamous epithelium (skin) and for
this reason it is important to remember that any skin pathology elsewhere in
the body can also be presented in the ear meatus.

The pinna comprises yellow elastic cartilage and is supported by the
auricular cartilage in the first third of the meatus, an area covered by thick
non-tender epithelium, containing hairs, sebaceous and ceruminous glands. The
inner two thirds of the external ear meatus is bony and covered by thin
sensitive skin. There is a narrowing in the meatus where the cartilage and bone
meet. The meatus is curved, therefore it is necessary to gently pull the pinna
postero-superiorly to bring the cartilage in line with the bony curve and
obtain the optimum view of the tympanic membrane.

Cerumen (ear wax) is only produced at the entrance to the meatus. The skin
of the meatus migrates outwards in a spiral movement from the centre of the
tympanic membrane and together with the jaw movements encourages the movement
outwards of the accumulated cerumen. Knowledge of the unique nature of the
meatal skin enables improved detection of personal ear care and enables the
nurse to give advice for future care of the ear. Providing access to an ear
diagram will also enable improved patient understanding.

Cerumen is a normal secretion of the ceruminous glands. A small amount is
normally found at the entrance to the meatus and its absence may be a sign that
an infection, or dry skin condition exists or that the person has been
meticulous in ear cleaning. A build-up of wax in the meatus can be caused by
many factors and is more common in people with learning-difficulties and
elderly people who produce less sebum and therefore a harder dryer wax3.

Anxiety and stress cause a greater production of sweat from the apocrine
sweat glands and can lead to the production of wetter wax. The lipid content of
sebum, which provides the oily properties to lubricate the epithelium, may be
increased by changes in diet.3 (For further information see removal of
excessive wax, below.)

The normal features of the tympanic membrane are easily recognised when it
is understood that it is formed in three layers and the malleus bone in the
middle ear space is attached to the fibrous layer of the tympanic membrane. As
the middle ear space is so small, it is also frequently possible to view the
long process of the incus posterior to the handle of malleus when examining the
ear. The handle of malleus will appear more horizontal and the tympanic
membrane indrawn if the patient has eustachian tube dysfunction. Recognition of
a normal pars flaccida and anterior recess (see figure 2) will also help the
nurse to identify any abnormal pathology.

Examination of the ear is improved by having an otoscope (auriscope) with a
fibreoptic, white halogen light and holding this instrument correctly as demonstrated
in figure 3. Sit at the same level as the patient and use a clean speculum on
the otoscope for every patient.

Understanding the inner ear

Because hearing loss is just as likely to be caused by factors other than
noise at work, it is important to understand the function and working of the
inner ear. Blood content and circulation, drugs or renal problems are other
contributing factors. Likewise, Agromegaly (excess bone growth due to a gland
misfunction) or Padgets Disease may be the cause of a conductive hearing loss,
which illustrates the importance of recording a thorough clinical history.

It is also of benefit to both nurse and patient for the nurse to be able to
translate, in simple terms, the results of an audiogram. This enables the
patient to understand and be aware of the reasons for mishearing conversation.

It also helps them understand why a hearing aid is not the answer every
time. A tuning fork test to accompany each audiogram identifies the type of
deafness and also helps identify a dangerous ear problem.

Guide to examining the ear

– Listen to the patient. Elicit symptoms

– Take a careful history. Include any previous ear problems, but also
consider other general health problems that may be related to the presenting
problem. Allergies, hayfever, nasal problems and personal lifestyle are all
important

– Be certain the patient understands each step of the examination procedure
and consent is given

– Ensure the patient is comfortable and privacy is maintained

– Examine the pinna and adjacent scalp. Check for skin disorders,
pre-malignancies and surgery incision scars. Note if the ear is inflamed or any
discharge present

– Examine the external auditory meatus, keeping in mind that the skin lining
the meatus is very delicate and sensitive

– Hold the otoscope (auriscope) as you would hold your pen. Rest your little
finger against the patient’s head. Insert the specula gently into the eatus –
use the largest specula that will fit comfortably in the entrance of the ear

– Check the ear canal and ear drum. Methodically inspect all parts of the
meatus and tympanic membrane by varying the angle of the speculum. The
appearance of the tympanic membrane is pearly grey and the handle of malleus
can be seen centrally. Above the handle can be seen the short (lateral) process
of the malleus.

On many normal ear-drums there is a reflection of light – cone of light –
extending from the umbo (at the base of the handle of malleus) to the lower perimeter
of the pars tensa. The anterior recess should be free of debris. It is often
possible to see the long process of the incus through the pars tensa posterior
to the handle of malleus. By asking the patient to lean their head towards the
other shoulder, the pars flaccida area is more clearly visualised

– The normal appearance of the membrane varies, and can only be learned by
practice. This and the keeping of an ear care diary will enable improved
recognition of the normal and thereby lead to recognition of abnormalities

The complete version of this checklist can be accessed on www.earcareservices.co.uk

Guidance for the removal of excessive ear wax

It has been demonstrated that people who produce excessive wax benefit from
an ear examination every six months, when any excess wax can be lifted clear.
This reduces the incidence of wax occlusion or even impaction (where the
patient is in the habit of using cotton buds to clean ears).

One of the causes of tinnitus, hearing loss, vertigo, pain, discharge,
otitis externa and stimulation of the vagus nerve (cough reflex) is wax
occlusion/ impaction and this can be prevented.

Wearers of hearing aids frequently produce excess wax4 that can cause the
aid to produce an acoustic feedback whistle. Other causes of ear wax problems
are those with a narrow ear meatus and men with excess hairs growing on the
tragus. General ENT advice is that if the wax is normal leave it in situ, but
by lifting excess wax out regularly a normal amount of wax remains to protect
the skin of the meatus. This is preferable to the person having deafness and
requiring irrigation, which removes all the wax and takes a longer time.

Cerumen removal must only be carried out by an ear trained nurse, doctor or
audiologist. The method used for removal is dependent upon the condition of the
presenting patient, their skin and the cerumen. Clinical judgement must be used
to determine the most appropriate method to meet the individual’s needs.

A person with an ear canal occluded with keratin debris can benefit from a
gentle irrigation, prior to other treatment5. A wet meatus predisposes to
otitis externa6 so it is advisable to dry the meatus following irrigation. It
is then beneficial to recognise any inflammation of the meatal skin and treat
it with anti-inflammatory/antiseptic ointment, according to Patient Group
Directions, so preventing further infection. Guidance for these and ear
irrigation is available on www.earcareservices.co.uk.

Irrigation may be your choice of method for removal when the wax is
occlusive and of a soft or sticky appearance. If you have tried to irrigate one
ear and been unsuccessful, repeat the irrigation after about 10 minutes as the
water introduced rehydrates the keratin and begins to loosen the wax7. This is
most useful when the outer soft wax has been removed, and behind this there is
darker harder wax.

Awareness of abnormalities

– Excess production of cerumen

– Foreign bodies

– Itchiness, pain and discharge can signify infections or disease. The
meatus may be inflamed and oedematous (swollen tissue). Middle ear disease may
also present, with an intermittent scanty offensive discharge and hearing loss.
The anterior recess may be filled with keratin debris and discharge. There may
be a golden crust in the pars flaccida area or on the posterior pars tensa and
behind this may be keratin debris, signifying the possible formation of a
cholesteatoma (a collection of dead skin cells in a space that has become
infected).

Because this disease can lead to damage of surrounding nerves and tissues,
the patient will need urgent referral for possible surgery.

Other causes of itchiness can be irritation of the skin by ear plugs, excess
perspiration when wearing ear defenders, dermatitis caused by touching the ear
with unclean hands, and exposure to chemicals. It is ineffective to treat the
pinna skin without identifying the source of the infection. It is helpful to
offer a regular check and relieve the condition by painting the ear with
ointment

– Narrowed ear canal, either anatomical or caused by exostosis – caused by
the reaction of cold water over a long term (if the person is a regular diver
as in oil rigs or sailboarder and so on) within the bony area of the ear canal.
Swellings occur which can grow enough to block the ear canal

– Anything, which is not in your knowledge of the normal, must be considered
as abnormal. Compare both ears, because what initially appears to be abnormal
may be normal anatomy for this person and will be seen similarly in both ears

– Perforated tympanic membrane – may be caused by trauma, barotrauma (caused
by ear pressure during flying when suffering from a heavy cold or any other
tube dysfunction which prevents air entering the middle ear) or chronic/ acute
infection. Document the size and position of the perforation, preferably in a
diagram

– Tympanosclerosis can follow repeated infections or trauma

– Middle ear problems occur through chronic obstruction of the eustachian
tube

– Eustachian tube dysfunction can be recognised by asking the patient to
hold their nose and swallow while the tympanic membrane is viewed (Tonybee
manouvre). In adults there should be slight movement of the drum due to air
pressure changes

– A viral infection can cause unusual abnormalities

– Barotrauma can be recognised by a history of air travel or diving causing
pain on descent

– An ear examination should include a simple assessment of hearing.
Unilateral conductive hearing loss for no obvious reason should be referred, as
should a sudden total hearing loss in one ear

– Keep accurate records of each consultation:

– Patient’s presenting complaint

– What you see in both ears (examine best ear first)

– What you do (including advice given and relevant leaflets)

– Why this treatment was chosen

The complete version of this can be found on www.earcareservices.co.uk

Conclusion

Within the confines of this article it has been possible to supply minimal
information to enable a clearer understanding of preventive ear care. By
sharing good clinical practice, some of the strongly-held ideas that can cause
confusion in the primary care treatment of people with ear problems may have
been reviewed.

Key points

– There are many benefits to be gained through practicing preventive ear
care

– Holistic appraisal of the presenting problem enables individual effective
ear care

– Relate knowledge of anatomy and physiology to each patient and their
lifestyle

– Hearing loss is just as likely to be caused by other factors than noise

– If irrigation is unsuccessful, leave for 10 minutes and try again

– Be aware of minor abnormalities and prevent them from becoming major incidents

Resources

Contact Rosemary W Rodgers for advice and information on training sessions
or lectures.

Further information, complete guidelines, patient group directives and
enhanced reference list are available at www.earcareservices.co.uk E-mail rorodg1stearcare@aol.com

Rosemary W Rodgers MA(Ed) PGDip.Ed. MCGI RGN RSCN
Consultant specialist nurse (ear care)
Rosemary Rodgers Ear Care Services, Stag Medical Centre, South Yorkshire S60
4JW, Tel: 01709 830065

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