Trick of the Trade: Ear Irrigation in the Emergency Department

2016-11-11T19:47:00+00:00

Ear pediatricEar 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

Equipment needed:

  1. 14 or 16 gauge cannula (needle removed and tip trimmed)
  2. 20 mL syringe
  3. Body temperature saline

 

ear irrigation 3

 

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. 

 

IMG_0553

 

Tips

  1. Consider using a kidney-shaped small emesis basin to catch the fluid as it drips out of the ear.
  2. 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.)
  3. Pro tip: Also works well as a low cost water gun. Temperature of liquid in this scenario is provider-dependent.

Safety

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.

1.
Memel D, Langley C, Watkins C, Laue B, Birchall M, Bachmann M. Effectiveness of ear syringing in general practice: a randomised controlled trial and patients’ experiences. Br J Gen Pract. 2002;52(484):906-911. [PubMed]
2.
Jones I, Moulton C. Use of an electric ear syringe in the emergency department. J Accid Emerg Med. 1998;15(5):327-328. [PubMed]
3.
Chris N. Oculocephalic and oculovestibular reflexes. Life in the Fast Lane. http://lifeinthefastlane.com/ccc/oculocephalic-and-oculovestibular-reflexes/. Published 2008. Accessed August 10, 2016.
4.
Kumar S, Kumar M, Lesser T, Banhegyi G. Foreign bodies in the ear: a simple technique for removal analysed in vitro. Emerg Med J. 2005;22(4):266-268. [PubMed]

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.

Michelle Lin, MD
ALiEM Editor in Chief; UCSF Professor of Emergency Medicine

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!

Jonathan Bronner, MD
Assistant Professor and Assistant Program Director, University of Kentucky Department of EM; ALiEMU Education Design Officer

Chris Belcher

Chris Belcher

EM Resident
Department of Emergency Medicine
Captain, United States Air Force Reserve
Chris Belcher

Latest posts by Chris Belcher (see all)

Jacob Avila, MD RDMS

Jacob Avila, MD RDMS

Clinical instructor and Ultrasound fellow
Department of Emergency Medicine
University of Kentucky
  • 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.

  • 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!

  • Ron Berant

    Very useful. Use it all the time to remove foreign bodies in kids, when community ENT fail… One comment – lukewarm tap water just as good as saline.

  • Maneesha Agarwal

    Definitely agree that these are useful tricks. HOWEVER, liquid docusate has been recalled due to concerns of contamination with B cepacia. We’ve been using debrox in the interim, although I haven’t been as happy with the results.

    https://www.cdc.gov/hai/outbreaks/b-cepacia/index.html

    Maneesha Agarwal MD
    Assistant Professor of Pediatric Emergency Medicine
    Emory University/Children’s Healthcare of Atlanta

    • Chris Belcher

      Thanks Dr. Agarwal. This is a great salient point. As Dr. Fox points out in his review of cerumenolytics, there are multiple over the counter remedies. Although I’m not sure as effective also. Ive found debrox takes more than one distillation to be effective. I’d be willing to bet there are solutions similar to docusate that are equal in polarity, solubility and efficacy. But I’ll have to do more hunting or consult a friendly pharmacist for help.

    • Jonathan Bronner

      Thanks Maneesha! This is yet another reason I love working with my PEM friends… still lamenting the loss of Auralgan for our patients: (http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm453430.htm).

      Tips for any meds we can still safely drop into the ears of our pediatric patients?

  • Nick Sawyer

    I can say with total confidence that I DID NOT puke after that awake cold water calorics test. I wanted too, but I didn’t.