Ear irrigation is an important tool for adult and pediatric patients in the Emergency Department (ED) with ENT complaints. Irrigation can be used to clear ear cerumen, visualize tough-to-see tympanic membranes, and remove foreign bodies. This may reduce the need for subspecialist care and improve the patient’s hearing and quality of life.1 Commercial electronic and mechanical devices are available for irrigation and have been studied. Moulton and Jones presented the improved efficacy of foreign body removal using an electric ear syringe in an (ED) population.2 In this trick of the trade, we present a low cost and effective way of “ear-rigation” taught to us by one of our veteran nurses using easily available tools in the ED.
Trick of the Trade:
Syringe and angiocatheter ear irrigation setup
- 14 or 16 gauge cannula (needle removed and tip trimmed)
- 20 mL syringe
- Body temperature saline
Steps: Remove the IV needle and cut the cannula tip to remove shorten angiocatheter length. Prepare a bottle or basin of saline at a physiological temperature. Connect the syringe to the cannula and irrigate as needed. Attempt to irrigate in all directions if trying to dislodge cerumen or foreign bodies.
- Consider using a kidney-shaped small emesis basin to catch the fluid as it drips out of the ear.
- It is important to have water slightly warm (at body temperature) as cool water causes vertigo/nystagmus, nausea, and possibly vomiting. This can be seen in this video as utilized in the caloric reflex test.3 (Remember COWS from med school? Cold/opposite, warm/same.)
- Pro tip: Also works well as a low cost water gun. Temperature of liquid in this scenario is provider-dependent.
This set up for irrigation has been evaluated in the literature. Kumar et al looked at the pressures generated using this technique in vitro and found it appropriate for use in patients without increased risk of tympanic membrane perforation.4 The pressures generated do not exceed the pressure needed to cause perforation.
Expert Peer Review
See the EPR below by Dr. Jonathan Bronner with his 3 additional clinical tips.
Copyediting by Dr. Michelle Lin
Great post and trick of the trade. Just some formatting issues that I made:
1. I changed the title from EAR-RIGATION because this makes your trick harder to search for since Google searches focus more on titles than the main text. So I changed to the less catchy EAR IRRIGATION term instead.
2. I moved your literature reference to the safety of this technique to its own section (Safety) and separate from the list of tips.
I personally have used this trick a lot for irrigation and would like to echo your recommendation to avoid cold saline. Makes people nauseous! Also I would recommend trying to angle the angiocatheter in all directions during a single bolus of saline to try to dislodge impacted cerumen/foreign bodies from the external canal edges.
Expert Peer Review by Dr. Jonathan Bronner
I 100% agree with Dr. Lin that this is an efficient and inexpensive procedural arrow to stash in your proverbial quiver of tools for the Emergency Department (ED). While the authors have covered the topic quite well with resources to get you started, this post prompts me to to think about 3 additional points:
1. The new academic year is now upon us and with that comes a fresh barrage of interns that are both eager and apprehensive to get to work. Perhaps this post should be posted in the #tipsfornewdocs feed on Twitter (https://twitter.com/search?q=%23tipsfornewdocs&src=tyah). As a junior learner in the ED a thorough physical exam is paramount for your patients, and squeamish children make for a challenging evaluation when you are sticking medical devices in their faces. The authors here present a great way to actually visualize the tympanic membrane (TM) and make a formal assessment for acute otitis media, foreign bodies, or other surprises.
2. As an addition to the thoughts above, I do think it is important to remember the safety factors at play--especially if you’ve got a 3 year old squirming around in the exam room. The references here report evidence that the pressure from your irrigation won’t perforate the TM, but I would caution the novice to have respect for the angiocatheter length and not to cause direct trauma with the tool you’ve designed. I’ve found that my pediatric nursing colleagues are real experts at this and usually happy to show you their own tricks...
3. In fact, the amazing nurses that helped to train me were very big on another adjunct to assist your Ear Irrigation adventures--liquid docusate sodium! Cerumenolytic agents have been well described and studied for this purpose and from my anecdotal experiences will make you job much easier. For an excellent review of Cerumen Impaction in kids, I refer you to my good friend and mentor Sean Fox’s post on Pediatric EM Morsels (http://pedemmorsels.com/cerumen-impaction/). Dr. Fox is a master educator and his weekly pearls will make you a better pediatric emergency physician.
Thanks again to Drs. Belcher and Avila for this great Trick of the Trade. I anticipate I’ll be washing out some wax on my next shift in the Peds ED!