Possible side effects

Physical trauma -Direct trauma

• During any ear wax removal method there is the risk of physical trauma to the skin of the ear canal walls. Manual instruments such as loops, curettes, forceps and Cawthorne Hooks carry the greatest risk of abrasion to the skin, but suction tube appendages, Tumarkin and Rosen speculae, and endoscopes can also cause injury.
• Some subjects may be at higher risk of bruising, abrasions and bleeding, such as older adults with thinning skin and individuals with conditions such as diabetes or blood-clotting disorders, those with an immunocompromised state, and those who have had head or neck radiotherapy. Certain types of medication also increase the risk, such as blood anticoagulants and anti-platelets, non-steroidal anti inflammatory drugs (NSAID), steroids, medicines to treat cancer.
• To minimise this risk it is important that the subject position is as stable as possible, either lying on a raised couch or sat in an upright position in a chair.
• No instrument should be introduced into the ear beyond the line of sight of the professional performing the procedure. Furthermore it is not recommended that instruments are used near the ear drum due to the increased risk of damage due to proximity.

Pain and discomfort thresholds

• Although subjects should be encouraged to report any pain or discomfort during aural care, thresholds differ betIen individuals and this may affect how comfortable the aural care procedure is for a subject.
• For example, as an increased risk of bruising and bleeding subjects using blood anticoagulants can be more sensitive to pain as a side-effect (low pain threshold). In contrast, subjects with diabetes will sometimes have a higher pain threshold. Care must be taken to check that the subject remains comfortable throughout the procedure to minimise the risk of physical trauma or distress.

Pressure trauma

• Risk of damage to the tympanic membrane due to pressure from an irrigation or suction device is possible. These are minimised by restricting the depth of insertion of the suction tube and assistive Tumarkin or Rosen speculae. Risks from water pressure are minimised by ensuring that the irrigator pressure is kept regulated. High pressures from the irrigator are not necessary to remove ear wax from an ear which has been prepared Ill with softeners. In addition, the water jet from the irrigator should be directed superiorly at the ear canal wall or the wax itself and not at the tympanic membrane.

Infection - Risk of infection from the procedure

• For any ear wax removal method there is the risk of infection developing after the procedure. Risks can be minimised by ensuring adherence to infection control policies and manufacturer guidelines regarding equipment disinfection, and by ensuring that single use items are kept packaged until
• the point of use and not re-used. Effective audit should be used to ensure that consumable stock is rotated and items are not used if out of date. It is not necessary to use sterilised water for water irrigation.

Infection from Pseudomonas or other microbial agents may occur following these procedures. Following water irrigation the ear should be dried using a curette wrapped in cotton wool or can be dried using microsuction if appropriate, to minimise the risk of a Pseudomonas bacterial infection forming as a result of water remaining trapped in the ear. The development of necrotising otitis externa following wax removal, and following irrigation in particular, is possible. Evidence states that the risk is small but the possibility must be considered due to the severity of the impact of this condition. Risk of infection increases when the skin of the ear canal is already disrupted which is why wax removal on ears with current active skin conditions and abrasions is not recommended.

Vertigo

• Some subjects may experience dizziness as a result of wax removal. Dizziness due to caloric reactions can also arise in some subjects from temperature changes occurring in the ear canal and particularly at the tympanic membrane. Temperature variations can occur in the water used to irrigate the ear, or may arise from changes in temperature created by the suction device.
• During the pre-aural care checks all subjects must be asked if they have diabetes (high or low blood sugar), or high or low blood pressure as light-headedness or dizziness associated with these conditions may contribute to dizziness experienced during the aural care procedure.
• Although rare, in some subjects dizziness can be induced by the movement of the wax plug itself possibly due to resulting changes of air pressure. In very rare cases, fainting or vomiting may also occur. If the subject is lying down or
• in a stable seated position during the procedure this may make these occurrences of dizziness easier to manage.

Noise exposure

• Sound pressure levels created in the ear during irrigation but more particularly during suction have the potential to reach levels of greater than 85 dB A in some cases (Snelling et al. 2009).
• Noise levels from this procedure therefore have the potential to exacerbate or trigger existing tinnitus and in rare cases trigger newly presenting tinnitus. These levels also have the potential to cause a temporary hearing threshold shift, or a permanent hearing loss. Efforts should be made to minimise the time taken to complete the procedure so as to reduce the length of exposure to noise generated by the equipment and procedure, thereby reducing the risk of tinnitus and temporary threshold shift.

Risks arising from over-cleaning the ear canal

• Removal of essential moisture can encourage dryness and irritation of the ear canal skin. Skin layers may be physically disrupted resulting in the natural microbial flora of the skin surface entering the inner epidermal layers, and therefore possibly leading to the development of otitis externa. only necessary ear wax removal should be performed.