1 2 3 practice guidance - british society of audiology · 89 ear wax removal is currently an...

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Practice Guidance 4

Aural Care (Ear Wax Removal) 5

Date: August 2019 6

Due for review: TBC 7

Practice Guidance Aural Care (Ear Wax Removal) BSA 2019

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General foreword 8

This document presents Practice Guidance by the British Society of Audiology (BSA). This 9 Practice Guidance represents, to the best knowledge of the BSA, the evidence-base and 10 consensus on good practice, given the stated methodology and scope of the document and at 11 the time of publication. 12 13 Although care has been taken in preparing the information supplied by the BSA, the BSA does 14 not and cannot guarantee the interpretation and application of it. The BSA cannot be held 15 responsible for any errors or omissions, and the BSA accepts no liability whatsoever for any loss 16 or damage howsoever arising. This document is the first published BSA Practice Guidance 17 document on this procedure and stands until superseded or withdrawn by the BSA. 18 19 Comments on this document are welcomed and should be sent to: 20 21 British Society of Audiology 22 Blackburn House, 23 Redhouse Road 24 Seafield, 25 Bathgate 26 EH47 7AQ 27 Tel: +44 (0)118 9660622 28

[email protected] 29 www.thebsa.org.uk 30 31 Published by the British Society of Audiology 32

© British Society of Audiology, 2019 33

All rights reserved. This document may be freely reproduced in its entirety for educational and not-for-34 profit purposes. No other reproduction is allowed without the written permission of the British Society of 35 Audiology. 36

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Authors & Acknowledgments 41

42 Produced by: The Professional Guidance Group 43 44 Key Authors: 45 Miss Sarah Riches, Senior Audiologist and Senior Teaching Fellow (SFHEA), Aston University, 46 Birmingham 47 Mr Martin Whitehouse, ENT Advanced Nurse Practitioner, Sandwell and West Birmingham 48 Hospitals NHS Trust 49 50 Declaration of interests: 51 Sarah: Course co-ordinator of the Basic Aural Care Course and Advanced Aural Care Course at 52 Aston University 53 Martin: Course Leader of the Basic Aural Care Course and Advanced Aural Care Course at Aston 54 University 55 56 Both authors have been involved in aural care training for ENT, other medical professionals, and 57 Audiology professionals since 2003, initially providing this training at Birmingham School of 58 Audiology before the courses were relocated to Aston University. 59 60 With thanks to: 61 Mr Arun Sinha, ENT Consultant Surgeon (Sandwell and West Birmingham Hospitals NHS Trust). 62 Colleagues in the Pharmacy, Optometry, and Engineering Department (Aston University, 63 Birmingham). 64 All Audiology, ENT and medical professionals who participated in the consultation process. 65 66

Citation 67

Please cite this document in the following format: 68

BRITISH SOCIETY OF AUDIOLOGY (2019), Aural Care (Ear Wax Removal). [Online]. Available at: 69 https://www.thebsa.org.uk/resources/ [Accessed date] 70

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https://www.thebsa.org.uk/resources/

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Contents 78

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1. Introduction…………………………………………………………………………………………………………. 6

1.1 Background and aims……………………………………………………………………………….. 6

1.2 Shared decision making……………………………………………………………………………. 6

2. Scope……………………………………………………………………………………………………………………. 7

2.1 Procedural Scope……………………………………………………………………………………… 7

2.2 Professional Scope……………………………………………………………………………………. 8

2.2.1 Registered professionals……………………………………………………………. 8

2.2.2 Other professionals…………………………………………………………………… 8

2.2.3 Supervision………………………………………………………………………………… 8

2.2.4 Training requirements ………………………………………………………………. 9

2.2.5 Fitness to practise considerations …………………………………………….. 9

3. Equipment and working environment.…………………………………………………………………. 9

3.1. Equipment………………………………………………………………………………………………… 9

3.1.1 Infection control related to equipment……………………………………… 9

3.1.2 Fitness for purpose……………………………………………………………………. 10

3.1.3 Safety and quality specifications and standards…………………………. 10

3.1.4 Conformity of equipment………………………………………………………….. 10

3.1.5 Equipment maintenance……………………………………………………………. 11

3.1.6 Risk assessments……………………………………………………………………….. 11

3.2 Environment…………………………………………………………………………………………….. 11

4. Preparation for the procedure ……….……………………………………………………………………. 11

4.1 Subject preparation………………………………………………………………………………… 11

4.1.1 Consent……………….……………………………………………………………………. 11

4.1.2 Softening of ear wax prior to the procedure…………………………….. 12

4.1.3 Position of the subject and professional…………………………………… 12

5. Procedure time …………………………….……………………………………………………………………… 13

5.1 Routine cases……………………………………………………………………………………………. 13

5.2 When a routine ear becomes non-routine……………………………………………….. 13

6. Contra-indications and special care considerations……………………………………………… 14

7. Risks associated with ear wax removal…………………………………………………………………. 14

7.1 Physical trauma………………………………………………………………………………………… 14

7.1.1 Direct trauma……………………………………………………………………………. 14

7.1.2 Pain and discomfort thresholds………………………………………………… 14

7.2 Pressure trauma……………………………………………………………………………………….. 15

7.3 Infection…………………………………………………………………………………………………… 15

7.3.1 Risk of infection from the procedure…………………………………………. 15

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7.3.2 Other infection risks………………………………………………………………….. 15

7.4 Vertigo……………………………………………………………………………………………………… 16

7.5 Noise exposure…………………………………………………………………………………………. 16

7.6 Risks arising from over-cleaning the ear canal…………………………………………… 16

8. Methods of viewing the ear during wax removal………………………………………………….. 16

9. Manual removal using simple extraction instruments………………………………………….. 17

9.1 Subject instruction……………………………………………………………………………………. 17

9.2 Method……………………..……………………………………………………………………………… 17

9.3 Variations in method………………………………………………………………………………… 18

9.4 Limitations of the procedure…………………………………………………………………….. 18

9.5 Complications of the procedure……………………………………………………………….. 18

10. Irrigation using electronic irrigators …………………………………………………………………….. 19

10.1 Subject instruction……………….…………………………………………………………………… 19

10.2 Method…………………………………………………………………………………………………….. 19


10.4 Limitations of the procedure……………………………………………………………………. 20


11. Suction…………………………………………………………………………………………………………………. 21

11.1 Subject instruction……………….…………………………………………………………………… 21

11.2 Method…………………………………………………………………………………………………….. 21


11.4 Limitations of the procedure……………………………………………………………………. 21


12. Advice and after-care……………………………………………………………………………………………. 22

12.1 Immediate aftercare…………………………………………………………………………………. 22

12.2 Educating patients about ear wax management………………………………………. 23

13. References……………………………………………………………………………………………………………. 23

Appendices 25

A. Consent form for ear wax removal 25

B. Checklist to ensure ears are routine for wax removal by manual instruments, suction or water irrigation

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C. Cleaning guidelines for an electronic irrigator 29

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1. Introduction 81

This comprehensive BSA document provides best practise guidelines for safe removal of ear wax (aural 82 care) by professionals trained to complete this activity. 83

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1.1 Background and aims 85

The purpose of this document is to recommend safe aural care using manual instruments, water 86 irrigation and suction under magnification. 87 88 Ear wax removal is currently an extended scope of practice activity for Audiology professionals, with this 89 activity having previously been undertaken by the nursing or medical profession. As the National 90 Institute for Health and Care Excellence (NICE) has recently identified, wax removal using any method 91 currently has a limited evidence base. Therefore, the BSA would advise that audiology professionals 92 exercise due care and diligence in the adoption of this activity. The BSA advises that professionals must 93 therefore develop skills via training which meets the minimum training criteria described in BSA (2016) 94 Minimum Training Guidelines in Aural Care Delivered by Hearing Care Professionals. 95 96 The term ‘must’ is used in this document to refer to essential practise, and ‘should’ is used to refer to 97 desirable practise. 98 99 The document was developed in accordance with the current (2018) National Institute for Health and 100 Care Excellence (NICE) Hearing Loss in Adults; assessment and management guidelines. In addition, in 101 2017 a comprehensive Clinical Practice Guideline document was updated and published by The 102 American Academy of Otolaryngology (Head and Neck Surgery) which the authors recommend as 103 further useful reading on this subject. 104 105 Unless stated otherwise, this document represents the consensus of expert opinion and evidence as 106 interpreted by the Professional Guidance Group of the British Society of Audiology (BSA) in consultation 107 with its stakeholders. 108

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1.2 Shared Decision-making 110

111 It is implied throughout this document that the service user should be involved in shared decision-112 making when undertaking audiological intervention, receiving subsequent information and 113 understanding how it will impact on the personalisation of care. Individual preferences should be taken 114 into account and the role of the professional is to enable a person to make a meaningful and informed 115 choice. Audiological interventions bring a variety of information for both the clinician and the service-116 user which can be used for counselling and decision-making regarding technology and anticipated 117 outcomes. 118

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2. Scope 119

2.0 Scope of guidance 120

Children under the age of 16 years (children under the age of 18 outside a hospital environment) are 121

beyond the scope of this document and should only be treated by professionals who have undertaken 122

further training and have the facility to provide paediatric care within their clinical premises. 123

Please note that syringing and irrigation are not the same process. Irrigation of the ear with water 124 should be performed with an electronic irrigator. Manual syringing is a method of wax removal 125 prohibited by the current (2018) National Institute for Health and Care Excellence (NICE) Hearing Loss in 126 Adults; assessment and management guidelines and is therefore not covered in this document. 127 128 All professionals undertaking wax removal must hold professional indemnity and public liability 129

insurance specific to the procedure being undertaken and the context in which it is being performed. 130

Some professionals may have appropriate experience such that their scope of practice may extend 131

beyond the scope covered in this guidance document, under which circumstances they must not rely on 132

this document alone as guidance in good practice. 133

2.1 Procedural scope 134

This document intends to describe aural care only in regards to necessary ear wax removal in routine 135

ears. 136

Necessary ear wax removal refers to the removal of ear wax which is: 137

occluding the view of the tympanic membrane and external auditory meatus thus preventing 138

their effective examination 139

causing the subject to report a blocked/occluded sensation 140

reducing the hearing beyond the usual baseline ability of the subject 141

causing symptoms considered to be related to the presence of (or occlusion by) wax in the 142

absence of detectable or discernible infection/abnormality 143

preventing a required procedure or activity from safely or effectively taking place which may 144

include a hearing test, tympanometry, impression-taking, or fitting of a hearing instrument 145

including probe microphone measurements 146

interfering with the performance of a hearing instrument when in situ 147

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Routine refers to ears which have none of the referable conditions described in the checklist in 149

Appendix B and which, to the best of the professional’s knowledge through otoscopy (or otherwise 150

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magnified view), history-taking and previous case notes (especially if unable to fully observe the 151

tympanic membrane), contain a tympanic membrane which is intact and healthy. 152

Therefore these practice guidelines do not extend to cover non-routine cases such as: 153

perforated ears 154

post-surgery ears including provision of post-surgery care/treatment 155

removal of foreign objects 156

treatment of medical conditions 157

removal of discharge or debris caused by acute or chronic ear infections, or which arise from 158

skin conditions such as eczema or psoriasis 159

160

See Appendix B for the complete checklist of contra-indications and special care conditions. 161

162

2.2 Professional scope 163

2.2.1 Registered professionals 164

The audiology, nursing or medical professional usually undertaking this procedure will be registered with 165

HCPC or RCCP, NMC or GMC. 166

2.2.2 Other professionals 167

If professionals of a non-statutory registerable status such as assistant audiologists, hearing care 168 assistants/healthcare assistants (HCA) are trained in the removal of ear wax they must complete the 169 same level of training in aural care as any other aural care professional – see Section 2.2.4. Their 170 organisation must ensure that the clinical governance regarding procedural and professional scope is 171 clear. 172 As for any other procedure the HCA must be adequately supervised by a registered professional. The 173

registered professional must ensure that the activity is regularly monitored and/or assessed to satisfy 174

themselves that the non-registered professional remains safe, capable and competent. 175

2.2.3 Supervision 176

Further to the points made in Section 2.2.2, registered professionals who are supervising staff 177

undergoing training in this activity must ensure that they are available for advice and supervision as 178

required. The supervisor must be trained in the delivery of the same wax removal method as the 179

method they are supervising, and must have been regularly practising this procedure for a minimum of 180

12 months. 181

Whilst undertaking training in aural care the supervisee must not attempt to undertake aural care 182

activities without the direct supervision of their supervisor until they have completed their training. 183

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2.2.4 Training requirements 184

The professional undertaking the procedure will have completed training in the removal of ear wax via a 185 course which meets the minimum training criteria described in BSA (2016) Minimum Training Guidelines 186 in Aural Care Delivered by Hearing Care Professionals. 187 188

2.2.5 Fitness to Practise considerations 189

As well as being appropriately trained, the professional undertaking the procedure must ensure that 190

they have sufficient visual ability and manual dexterity to undertake the procedure safely. 191

This extends to ensuring that the equipment they use (see Section 3.1) meets the correct quality and 192

safety specifications to allow them to examine the ear confidently, and that it is set up correctly for their 193

own vision. Magnification/viewing equipment should have clean lenses and a good light source and 194

should be set up prior to the appointment to meet the professional’s own visual requirements. This is 195

especially important for shared equipment. 196

Professionals must be aware that proceeding without being able to clearly see what they are doing, or 197

proceeding without the required manual strength or dexterity to manipulate the equipment is a Fitness 198

to Practise issue which could affect their registration. 199

Fitness to Practise for this procedure also includes: 200

A. adherence to infection prevention and control policies and procedures 201

B. adherence to referral guidelines reflecting recognition of scope of practice 202

203

3. Equipment and working environment 204

3.1 Equipment 205

3.1.1 Infection control related to equipment 206

Equipment must be kept clean in adherence to local infection control policies and according to the 207

manufacturers’ recommendations. 208

If equipment requires disinfection (such as the irrigation system) this must be carried out carefully 209

according to the manufacturer’s recommendations. Care should be taken when using chlorine cleaning 210

tablets for irrigation tanks that the hands are washed thoroughly afterwards, that fumes are not inhaled 211

and that contact with the eyes is avoided. During the soaking period, the irrigation system must be left 212

in a safe place to avoid spills. Following the recommended soak time, the system must be thoroughly 213

flushed with clean water and dried. See Appendix C – Cleaning Guidelines for an Electronic Irrigator. 214

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Single use consumables must not be disinfected or sterilised, and must be disposed of according to local 215

infection control and disposal policies. Single use items must stay in their protective packaging until the 216

point of use. 217

3.1.2 Fit for purpose 218

When purchasing equipment, procurers must be advised that equipment must be fit for purpose, and 219

recognised as appropriate for use for removal of bodily secretions and fluids in soft tissue orifices lined 220

with skin or mucous membrane as encountered in the ear, nose or throat. Ideally this equipment should 221

be an ENT grade medical product indicated for use in aural care if available. 222

3.1.3 Safety and quality specifications and standards 223

For otorhinolaryngology and endoscopic medical products such as suction units, warm water rinsing 224

devices and nasopharyngoscopes the equipment must meet the following necessary minimum safety 225

and quality standard specifications according to the International Organisation for Standardisation (ISO) 226

and the Conformité Européene CE (translation = European Conformity): 227

1. The class II medical equipment must possess a CE certificate from an official certification body 228

which confirms that it “meets the requirements of Annex IX, excluding section 4 of the directive 229

93/42/EEC. The manufacturer of the equipment must be able to prove that they have a quality 230

assurance system which is subject to periodic surveillance, defined by Annex IX, section 5 of the 231

aforementioned directive. For placing on the market of class III devices covered by the 232

certificate a CE design-examination certificate according to Annex IX, section 4 is required.” 233

(Standard CE Certificate wording). 234

2. The equipment must also possess a certificate from an official certification body that it meets 235 the requirements specified in EN ISO 9001:2008, and also EN ISO 13485:2012 and EN ISO 236 13485:2012/AC:2012 237 238

3.1.4 Conformity of equipment 239

Professionals must seek to ensure the equipment they intend to use for aural care is appropriately 240

designed and CE-marked as required, and meets the “Fit for purpose” requirements described in Section 241

3.1.2. The UK Government Medicines and Healthcare products Regulatory Agency (MHRA) guidelines 242

provide comprehensive information about conformity of equipment. Practitioners and service-providing 243

organisations are advised to keep up to date with changes in equipment requirements for aural care. 244

Should they become aware of changes in equipment safety or quality legislation which could affect their 245

practise, they should respond with a plan to phase out equipment and introduce replacement products 246

which conform to the legislation within a reasonable timescale. 247

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3.1.5 Equipment maintenance 250

A planned preventative maintenance (PPM) schedule must be in place to ensure that equipment is in 251

good working order and checked and replaced regularly. 252

The aural care procedure must be abandoned immediately if it is suspected or identified that a machine 253

has developed a fault whilst in the process of undertaking the procedure. 254

3.1.6 Risk assessments 255

Procedural risk assessments for wax removal must include appropriate use of equipment and should 256

therefore also acknowledge as a potential risk the possibility of inappropriate use of the equipment. 257

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3.2 Environment 259

Aural care must only be performed where room lighting levels allow safe illumination of the equipment 260

and the ears being treated. This must be further supported by additional light sources e.g. head loupes, 261

otoscopes etc. 262

For all wax removal methods the environment must be conducive to effective infection control. 263

There must be appropriate waste and sharps disposal facilities. 264

For irrigation, there should be easy access to a sink with hot and cold water. 265

Infection control and waste management may be more difficult to manage in domiciliary and other 266

settings so adequate appropriate risk assessments must be completed. 267

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4. Preparation for the procedure 269

4.1 Subject preparation 270

4.1.1 Consent 271

Subjects must give informed consent for this procedure. Wherever possible this should be written 272

consent, and if oral consent has been given, this fact should be recorded in the clinical notes. 273

The risks of the procedure must be clearly explained to the subject. See Section 7 for details of risks. 274

Subjects must be advised to report to the GP immediately if discomfort, pain, swelling, discharge or 275

odour, or disruption to the hearing is experienced following any procedure. If the subject reports back to 276

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the practitioner they must advise and inspect as appropriate and provide a referral as soon as possible. 277

See Section 13 regarding advice and aftercare. 278

See Appendix A for an example of a consent sign-off form. 279

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4.1.2 Softening of ear wax prior to the procedure 281

Prior to ear wax removal, subjects may be advised to use an ear wax softener where appropriate. This is 282

usually in the form of pharmaceutical olive oil spray or drops but may also be water if safe to introduce 283

this into the ear. This applies unless the subject or professional is aware of any known previous reactions 284

to the proposed preparation, in which case additional caution shall be taken by the practitioner when 285

assessing the condition of the wax prior to the procedure. This must be used for up to 5 days prior to the 286

procedure following the manufacturer’s guidelines on use which usually involves application between 2 287

to 4 times daily. If the ear wax remains very firm, water or olive oil can be applied 15 minutes prior to 288

the irrigation procedure to assist the softening process. If wax removal is unsuccessful on the first visit, 289

the olive oil may be applied for up to a further 5 days. Expert opinion varies regarding the use of olive oil 290

prior to the microsuction procedure. 291

The subject must be advised that their ear may feel more occluded following application of an ear wax 292

softener due to the expansion of the ear wax. For some it may also induce fluctuations in their hearing 293

and mild discomfort or irritation. In addition, for subjects who wear hearing instruments, particularly 294

those with receiver in the ear/canal (RITE/RIC) and in the ear/canal (ITE/ITC/CIC) models, olive oil may 295

adversely affect the function of the hearing instrument if it enters the hearing aid, therefore it may be 296

advisable to avoid wearing the hearing instrument when olive oil has recently been administered, and 297

therefore overnight use may be advisable. 298

If the ear wax is very hard and has been present for a long time, sodium bicarbonate drops may be of 299

benefit. This preparation should be obtained following consultation with a pharmacist and should 300

generally only be applied to ears which are considered to be routine. Sodium bicarbonate may cause 301

irritation in some routine ears. The subject should also be advised that this can fizz up in the ear as it 302

comes in to contact with the wax, and may create a chalky deposit. Sodium bicarbonate can be applied 303

for up to 5 days following manufacturer’s application guidelines and can also be applied 15 minutes 304

prior to the procedure if so required. 305

4.1.3 Position of the subject and professional 306

The professional must be seated in a stable position for wax removal, no matter which method of wax 307

removal is being employed. BSA Recommended Procedure for Ear Examination states "The examiner 308

shall adopt a stable position and, unless unavoidable or inappropriate, should be seated when 309

examining the ear using an otoscope". This is also applicable for any method of viewing the ear during 310

aural care. If there are specific ergonomic reasons why this is not possible for an individual or for a 311

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particular room this should be investigated and if it cannot be resolved by modifications to the 312

environment it may be more appropriate for the subject to be referred to an alternative provider. 313

The subject may be lying down on a raised couch, or may be sat upright on a stable chair. The use of a 314

head support on the chair may be useful in some cases but is not essential. For some subjects the use of 315

a head support may decrease rather than increase comfort, unless the chair can be reclined. 316

If a subject is unable to support their own head steadily in a stable upright position e.g. in the case of 317

someone with Parkinson’s disease, the practitioner needs to assess if the head can be supported in any 318

other way to minimise movement of the head and allow safe completion of the procedure. The 319

professional will need to assess the subject’s neck control, and check for any neck pain before deciding 320

the best course of action. 321

322

5. Procedure time 323

5.1 Routine cases 324

Adequate time should be allocated to allow the safe removal of the ear wax using whichever method is 325

deemed most suitable by the professional. Sometimes a combination of removal methods may be 326

required in order to remove the ear wax and time should be sufficient to allow for a switch in method if 327

required. Providing that the ear wax has been softened sufficiently it should not take longer than half an 328

hour on average to clear both ears. If a noisy procedure such as irrigation or microsuction is chosen, the 329

risk of the potential adverse impact of the noise exposure on the individual should be assessed. Care 330

should be taken to keep the duration of noise exposure to a minimum for all subjects. 331

It can sometimes be the case that the softener has not completely penetrated a long or very hard plug 332

of ear wax and it may have only softened the outer layers. This means that it is not always possible to 333

remove all of it. In this case it is important to be able to recognise when to cease the procedure and 334

advise further application of the softener so that the remaining ear wax can be removed on a future 335

appointment. 336

5.2 When a routine ear becomes non-routine 337

During ear wax removal it can sometimes be the case that an ear considered to be routine is revealed as 338

non-routine as the ear wax comes away. For example a foreign object may be uncovered, or an infection 339

or trauma or other referable abnormality may become visible. If this occurs the procedure should be 340

stopped and the subject must be informed. They should be referred for a medical opinion and for 341

continued treatment according to the condition revealed and the professional referral guidelines, unless 342

the individual has declined onward referral after being advised of the risk, under which circumstances, 343

the advice given and such refusal must be noted in the record. See Appendix A for details. 344

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6. Contra-indications and special care considerations 345

See Appendix B for a checklist to help identify if an ear is to be considered as routine. Ear wax removal 346

should not be attempted if the ear is identified prior to the procedure as non-routine. See Section 2 for 347

more details on Scope. 348

349

7. Risks and complications associated with ear wax removal 350

The following risks and complications are identified and discussed in the 2018 NICE Hearing loss in 351 adults; assessment and management guidelines, the 2016 NICE Clinical Knowledge Summaries, and 352 other practice guidance reviewed during the development of this document. 353

7.1 Physical trauma 354

7.1.1 Direct trauma 355

During any ear wax removal method there is the risk of physical trauma to the skin of the ear canal 356

walls. Manual instruments such as loops, curettes, forceps and Cawthorne Hooks carry the greatest risk 357

of abrasion to the skin, but suction tube appendages, Tumarkin and Rosen speculae, and endoscopes 358

can also cause injury. 359

To minimise this risk it is important that the subject position is as stable as possible, either lying on a 360

raised couch or sat in an upright position in a chair. No instrument should be introduced into the ear 361

beyond the line of sight of the professional performing the procedure. Furthermore it is not 362

recommended that instruments are used near the ear drum due to the increased risk of damage due to 363

proximity. See Section 2.0 Scope of guidance, paragraph 4 for further information. 364

7.1.2 Pain and discomfort thresholds 365

Although subjects should be encouraged to report any pain or discomfort during aural care, thresholds 366

differ between individuals and this may affect how comfortable the aural care procedure is for a subject. 367

For example, subjects taking medication such as Warfarin can be more sensitive to pain as a side-effect 368

and, in contrast, subjects with diabetes will sometimes have a higher pain threshold. Care must be taken 369

to check that the subject remains comfortable throughout the procedure to minimise the risk of physical 370

trauma or distress. 371

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7.2 Pressure trauma 374

Risk of damage to the tympanic membrane due to pressure from an irrigation or suction device is 375

possible. These are minimised by restricting the depth of insertion of the suction tube and assistive 376

Tumarkin or Rosen speculae. 377

Risks from water pressure are minimised by ensuring that the irrigator pressure is kept regulated. High 378

pressures from the irrigator are not necessary to remove ear wax from an ear which has been prepared 379

well with softeners. In addition, the water jet from the irrigator should be directed superiorly at the ear 380

canal wall or the wax itself and not at the tympanic membrane. 381

7.3 Infection 382

7.3.1 Risk of infection from the procedure 383

For any ear wax removal method there is the risk of infection developing after the procedure. 384

Risks can be minimised by ensuring adherence to infection control policies and manufacturer guidelines 385

regarding equipment disinfection, and by ensuring that single use items are kept packaged until the 386

point of use and not re-used. (See Section 3.1.1). Effective audit should be used to ensure that 387

consumable stock is rotated and items are not used if out of date. It is not necessary to use sterilised 388

water for water irrigation. 389

Infection from Pseudomonas or other microbial agents may occur following these procedures. Following 390

water irrigation the ear should be dried using a curette wrapped in cotton wool or can be dried using 391

microsuction if appropriate, to minimise the risk of a Pseudomonas bacterial infection forming as a 392

result of water remaining trapped in the ear. 393

7.3.2 Other infection risks 394

Awareness must be maintained regarding the risk of transmission of communicable skin and blood 395

conditions/infections through skin to skin contact and via contact with the wax itself. Although only a 396

small amount of studies have been conducted there has been some evidence to suggest the possibility 397

of transmission of the Hepatitis B virus in ear wax, therefore in the interests of safety these findings 398

should be considered. During the pre-aural care checks, all subjects must be asked if they have Hepatitis 399

B or MRSA. It is not advisable to proceed if these are reported. Due to the risk of non-disclosure of such 400

conditions all professionals must take steps to protect themselves and future service users from the risk 401

of transmission. Infection control and clinical waste disposal policies must be adhered to, and the 402

professional should consider the use of latex or plastic gloves. It is also recommended that the 403

professional ensures that their Hepatitis B vaccinations are up to date. 404

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7.4 Vertigo 406

Some subjects may experience dizziness as a result of wax removal. Dizziness due to caloric reactions 407

can also arise in some subjects from temperature changes occurring in the ear canal and particularly at 408

the tympanic membrane. Temperature variations can occur in the water used to irrigate the ear, or may 409

arise from changes in temperature created by the suction device. 410

During the pre-aural care checks all subjects must be asked if they have diabetes (high or low blood 411

sugar), or high or low blood pressure as light-headedness or dizziness associated with these conditions 412

may contribute to dizziness experienced during the aural care procedure. 413

Although rare, in some subjects dizziness can be induced by the movement of the wax plug itself 414

possibly due to resulting changes of air pressure. In very rare cases, fainting or vomiting may also occur. 415

If the subject is lying down or in a stable seated position during the procedure this may make these 416

occurrences of dizziness easier to manage. 417

7.5 Noise exposure 418

Sound pressure levels created in the ear during irrigation but more particularly during suction have the 419 potential to reach levels of greater than 85 dB A in some cases (Snelling et al. 2009). 420 Noise levels from this procedure therefore have the potential to exacerbate or trigger existing tinnitus 421

and in rare cases trigger newly presenting tinnitus. These levels also have the potential to cause a 422

temporary hearing threshold shift. 423

Efforts should be made to minimise the time taken to complete the procedure so as to reduce the 424

length of exposure to noise generated by the equipment and procedure, thereby reducing the risk of 425

tinnitus and temporary threshold shift. 426

7.6 Risks arising from over-cleaning the ear canal 427

Removal of essential moisture can encourage dryness and irritation of the ear canal skin. 428

Skin layers may be physically disrupted resulting in the natural microbial flora of the skin surface 429

entering the inner epidermal layers, and therefore possibly leading to the development of otitis externa. 430

As detailed in Section 2.1, only necessary ear wax removal should be performed. 431

432

8. Methods of viewing the ear during wax removal 433

Ideally the ear canal should be viewed under magnification through a binocular microscope or 434

endoscope, either with its own light source or with an additional directional external light source. A 435

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more portable option is a head-worn binocular microscope or head loupe, with its own light source, or a 436

portable endoscopic system. 437

Otoscopy can be used regularly throughout the procedure with vision further supported by an additional 438

light source to illuminate the ear canal. Less commonly now, the equipment may include a simple head 439

torch or head mirror and lamp. This option offers a more limited view during the procedure and may 440

therefore be more appropriate for irrigation and simple wax extraction near to the entrance of the 441

canal. 442

All of these viewing methods require appropriate training to obtain competency in their use. See Section 443

2.2.4 regarding training requirements. 444

445

9. Manual removal using simple extraction instruments 446

Please note these are practice guidelines, not step-by-step recommended 447

procedures. 448

9.1 Subject instruction 449

The subject must be instructed to remain as still as possible and to keep the professional informed of 450

changes in comfort. The professional must also regularly visually and verbally monitor the comfort of 451

the subject. 452

The subject may be lying down on a raised couch, or may be sat upright on a stable chair. The 453

professional must also be seated during the procedure. The subject should be able to keep their head 454

still for this procedure to be undertaken safely. The use of a head-rest or pillow may on some occasions 455

be helpful but not essential. See Section 4.1.3 for more detail. 456

9.2 Method 457

Safe use of instruments such as loops, curettes and forceps must be demonstrated. When holding the 458

instrument, bracing a finger on the subject’s cheek is recommended to steady the hand where it is 459

physically possible to do so, according to the professionals’ hand and finger span and where safety will 460

be improved by doing so. 461

The pinna should be pulled backwards and upwards to open and straighten the ear canal and improve 462

the line of sight. 463

The working end of the instrument must be directly applied to the wax itself. Contact of the working end 464

of the instrument with the skin, and proximity and contact with the eardrum must be avoided. 465

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The ear canal should be viewed at all times during this procedure. See Section 8 for methods of viewing 466

the ear during wax removal. 467

9.3 Variations in method 468

Use of ear speculae, such as Tumarkin or Rosen speculae, may assist the process by keeping the ear-469

canal open and the skin protected. 470

9.4 Limitations of the procedure 471

This method must only be used to remove ear wax which is within easy reach in the outer regions of the 472

ear canal, within a clear line of sight and of a consistency which is soft enough to extract without causing 473

disruption to the ear structures or discomfort to the patient. 474

Ear wax may remain adhered to the ear canal walls if the softening preparation has only penetrated the 475

outermost layers of the ear wax obstruction. 476

The procedure must be abandoned if the subject reports the procedure to be painful, if the ear wax 477 remains too solid to move, is positioned too deeply in the ear canal to avoid close proximity of 478 instruments with the ear drum, or if the usual procedure time has been significantly prolonged. 479 480

9.5 Complications of the procedure 481

Professionals must not perform this procedure on ears which are not routine unless it is within their 482

current scope of practice. See Section 2.1 and 2.2 for details. 483

Infection is possible even when ears are routine due to the risk from abrasion by the wax removal 484

instruments. Where the skin of the ear is already traumatised due to existing abrasions, cuts, bruising, 485

inflammation, infection, or where skin conditions such as otitis externa, eczema and psoriasis are 486

currently in their active state (e.g. causing pain, swelling, irritation or discharge), the risk may be 487

increased, therefore these are contra-indications to the procedure. See Section 8.3 regarding risks. 488

Subjects who take anticoagulant medicines may be at more risk of abrasion, bruising and bleeding with 489

this method if the wax removal instruments come into contact with the skin. Proceed with caution. 490

If a subject has a dry, irritable or tickly cough, this method may trigger or exacerbate it due to 491

stimulation of the cough reflex. Proceed with caution. 492

Subjects must be advised to report back to the professional as soon as possible if discomfort, pain, 493

swelling, discharge or odours occur, or if any disruption to hearing is experienced in the hours or days 494

following this procedure. This will ensure that ear examination and referral can take place. See Section 495

12 for more details on advice and aftercare. 496

497

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10. Irrigation using irrigation machines 498


procedures. 500




the subject. 504

The subject must be sat upright on a stable chair as this procedure may be difficult to perform without 505

getting the subject wet if they are lying down. The subject should be able to keep their head still for this 506

procedure to be undertaken safely. The use of a head-rest may on some occasions be helpful but not 507

essential. The professional must also be seated during the procedure. See Section 4.1.3 for more detail. 508

The subject’s shoulder and clothes should be protected from water spillage using absorbent paper on 509

the neck and shoulder, or a cape. They may be asked to hold the water-collecting receptacle securely 510

under their ear during the procedure. A colleague or relative may need to hold this if the subject lacks 511

the dexterity or strength to do this. 512

10.2 Method 513

An electronic water irrigator is used to gently circulate water in the ear canal. 514


the line of sight 516

The jet tip must rest gently in the inter-tragal notch while the water jet is directed superiorly at the ear 517

canal walls or at the wax itself, and not at the tympanic membrane. 518

The water jet must enter the ear under regulated pressure according to the pressure gauge on the 519

equipment. 520

Following water irrigation, the ear should be dry-mopped using a curette wrapped in cotton wool to 521

minimise the risk of a Pseudomonas bacterial infection forming as a result of water remaining trapped in 522

the ear. See Section 7.3.1. 523


For ear wax which proves difficult to remove, sodium bicarbonate powder may be added to the 525

irrigation water to assist in the reduction of ear wax adherence to the ear canal walls. 526

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The procedure must be abandoned if the subject reports the procedure to be painful, if the ear wax 530

remains too solid to move, or if the usual procedure time has been significantly prolonged. 531


Within the scope of this document, irrigation is not suitable for ears which are not routine. 533

In particular, harm could occur if water is introduced into an ear where the ear drum is known (or is 534

suspected) not to be intact, e.g. where the ear currently has (or has had) perforations, surgery, where 535

grommets remain in situ, or where cleft palates are present (even if repaired) as water may enter areas 536

of the cranium which would not normally admit water and may create a risk of infection. 537

Infection from Pseudomonas or other microbial agents is possible even when ears are routine and the 538

skin presents originally as intact. Where the skin of the ear is already traumatised due to existing 539

abrasions, cuts, bruising, inflammation, infection, or where skin conditions such as otitis externa, 540

eczema and psoriasis are currently in their active state (e.g. causing pain, swelling, irritation or 541

discharge), the risk may be increased, therefore these are contra-indications to the procedure. See 542

Section 8.3 regarding risks, and Appendix B. 543

Careful monitoring of the water temperature should be maintained to reduce the risk of dizziness, even 544

in patients who do not have existing or known vertigo. The water temperature should be at body 545

temperature 37° C or within a variation tolerance of ideally less than 1 degree Celsius above or below 546

body temperature. 547

If a subject has a dry, irritable or tickly cough, care must be taken as this method may trigger or 548

exacerbate it due to stimulation of the cough reflex. 549

Efforts must be made to minimise the time taken to complete the procedure so as to reduce the length 550

of exposure to noise generated by the equipment, and to reduce the risk of triggering new tinnitus or 551

affecting existing tinnitus, or creating a temporary hearing threshold shift. 552

Care must be taken to keep the water pressure regulated to prevent discomfort or pressure trauma. 553

Subjects must be advised to report back to the professional as soon as possible if discomfort, pain, 554


following this procedure. This will ensure that ear examination and referral can take place. See Section 556

12 for more details on advice and aftercare. 557

558

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11. Suction 559


procedures. 561




the subject. 565

The subject may be lying down on a raised couch, or may be sat upright on a stable chair. The 566 professional must also be seated during the procedure. The subject should be able to keep their head 567 still for this procedure to be undertaken safely. The use of a head-rest or pillow may on some occasions 568 be helpful but not essential. See Section 4.1.3 for more detail. 569

570

11.2 Method 571

A suction device should be used to extract the ear wax from the ear canal. 572


the line of sight. The ear canal may also be held open by the insertion of a Tumarkin or Rosen speculum 574

which will also serve to protect the skin of the ear canal. 575

The working end of the suction instrument must be directly applied to the ear wax itself. Contact with 576

the skin and proximity and contact with the eardrum must be avoided. 577

The ear canal should be viewed at all times during this procedure. See Section 8 for methods of viewing 578

the ear during wax removal. 579


The subject must be able to keep the head still, or be assisted to do so, for the procedure to be 581

undertaken safely. A chair head rest or pillow behind the head can therefore be of help. 582


This method should only be used to remove ear wax which is within a clear line of sight and of a 584

consistency which is soft enough to extract without causing disruption to the ear structures or 585

discomfort to the subject. 586



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The procedure must be abandoned if the subject reports the procedure to be painful, if the ear wax 589

remains too solid to move, is positioned too deeply in the ear canal to avoid close proximity of 590

equipment with the ear drum, or if the usual procedure time has been significantly prolonged. 591


An aural care professional must not perform this procedure on ears which are not routine unless it is 593

within their current scope of practice. See Sections 2.1 and 2.2 for details. 594

Infection is possible even when ears are routine due to the risk from abrasion by the wax removal 595

instruments. Where the skin of the ear is already traumatised due to existing abrasions, cuts, bruising, 596

inflammation, infection, or where skin conditions such as otitis externa, eczema and psoriasis are 597

currently in their active state (e.g. causing pain, swelling, irritation or discharge), the risk may be 598

increased, therefore these are contra-indications to the procedure. See Section 7.3 regarding risks, and 599

Appendix B. 600

If the patient has troublesome vertigo, this may be triggered or exacerbated by this procedure due to 601

possible caloric effects caused by changing temperatures in the ear canal by the suction device, or by 602

stimulation of local nerves. 603

Subjects who take anticoagulant medicines may be at more risk of abrasion, bruising and bleeding with 604

this method if the wax removal instruments come into contact with the skin. Proceed with caution. 605

If a subject has a dry, irritable or tickly cough this method may trigger or exacerbate it due to stimulation 606

of the cough reflex. Proceed with caution. 607

Efforts must be made to minimise the time taken to complete the procedure so as to reduce the length 608

of exposure to noise generated by the equipment, and to reduce the risk of triggering new tinnitus, 609

affecting existing tinnitus, or creating a temporary hearing threshold shift. 610

See Section 12 for more details on advice and aftercare. 611

612

12. Advice and aftercare 613

12.1. Immediate aftercare 614

Patients must be advised to report back to the professional as soon as possible if discomfort, pain, 615


following any ear wax removal procedure. This will ensure that inspection and referral can take place. 617

Patients should be given written details of possible complications to take away and given clear advice 618

about how to contact the professional or seek medical advice if complications arise. 619

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12.2. Educating service users about ear wax management 620

There is limited advice and evidence available regarding how often ear wax should be removed and also 621

whether regular removal actually encourages the production and accumulation of ear wax, therefore 622

expert opinion varies on these matters. 623

Service users should be advised following an ear wax removal episode that a build-up of ear wax may 624

recur in the future and require further management. 625

Education regarding the prevention and reduction of ear wax levels should be encouraged. This may 626

include advising regular use of softening preparations and regular check-ups. Subjects with non-routine 627

ears should discuss with their pharmacist or GP regarding the use of over-the-counter devices or 628

treatments. 629

To reduce opportunities for service users to harm themselves, patients should be advised against the 630

use of cotton buds or any other devices to manually remove the wax themselves. Hopi candles do not 631

remove wax from ears and should also be discouraged, as discussed by Ernst (2006) cited by Bandy 632

(2017). 633

634

13. References 635

Bandy, Veronica T. 2017. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 19th 636 Edition. 637 638 Beatrice F, Bucolo S, Cavallo R. Earwax, clinical practice ACTA Otorhinolaryngologica Italica.2009;29 639 (Suppl 1):1–20 640 641 British Society of Audiology (2016) Procedure for processing documents for recommended procedures 642 and guidelines. Available at https://www.thebsa.org.uk/resources/ 643 644 British Society of Audiology (2016) Recommended Procedure: Ear Examination. Available at 645 http://www.thebsa.org.uk/resources/ 646 647 British Society of Audiology (2016) Minimum Training Guidelines for Aural Care. Available at 648

http://www.thebsa.org.uk/resources/ 649

Clegg A.J. et.al (2010) The safety and effectiveness of earwax removal: a systematic review and 650

economic evaluation. Health Technology Assessment (14) 28 651

652

653

https://www.thebsa.org.uk/resources/

http://www.thebsa.org.uk/resources/

http://www.thebsa.org.uk/resources/

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Ernst. E. (2006) Ear candles – a triumph of ignorance over science. Available at: 654 https://www.cambridge.org/core/journals/journal-of-laryngology-and-otology/article/ear-candles-a-655 triumph-of-ignorance-over-science/CECFD65315BB519D8F4AD491FC2CDDDA 656

Gholami-Parizad E et al. (2011) Cerumen as a potential risk for transmission of Hepatitis B virus. 657

Available at https://www.ncbi.nlm.nih.gov/pubmed/21715280 658

Guest. J.et al (2004) Impacted wax: composition, production, epidemiology and management QJM. 659

97:477-488 660

L. A. Fox (2015) Successful Removal and Complication rates for the Instrumented Wax Removal in the 661

Audiology Clinic. BAA Magazine Summer 2015. 26-27 662

MRHA (2008) Medicine and Medical Devices Regulation – what you need to know. Available at 663

http://www.mhra.gov.uk/home/groups/comms-ic/documents/websiteresources/con2031677.pdf 664

NICE Clinical Knowledge Summaries https://cks.nice.org.uk/earwax#!scenario:1 665

NICE (2018) Hearing loss in adults: assessment and management. Available at 666 https://www.nice.org.uk/guidance/ng98 667 668 Primary Ear Care Centre (2019) Available at: 669

http://www.earcarecentre.com/uploadedFiles/Pages/Health_Professionals/Protocols/Cleaning%20Guid670

elines%20for%20Electronic%20Irrigator.pdf 671

Schwartz SR, Mait AE, Rosenfield RM, et.al. (2017) Clinical practice guideline (update): Earwax (cerumen 672 impaction). Otolaryngol Head Neck Surg. 2017;156 (1):S1-S29 673 674 Snelling JD, Smithard A, Waddell A. (2009) Noise levels generated within the external auditory canal 675 during microsuction aural toilet and the effect on hearing: a prospective controlled series. Clinical 676 Otolaryngology 2009; 34:21-5 677 678 Wright T (2015) Ear wax. Systematic review 504.BMJ Clinical Evidence. Available at 679

https://www.bmj.com/content/351/bmj.h3601.full 680

681 682

683

684

685

686

https://www.cambridge.org/core/journals/journal-of-laryngology-and-otology/article/ear-candles-a-triumph-of-ignorance-over-science/CECFD65315BB519D8F4AD491FC2CDDDA

https://www.cambridge.org/core/journals/journal-of-laryngology-and-otology/article/ear-candles-a-triumph-of-ignorance-over-science/CECFD65315BB519D8F4AD491FC2CDDDA

https://www.ncbi.nlm.nih.gov/pubmed/21715280

http://www.mhra.gov.uk/home/groups/comms-ic/documents/websiteresources/con2031677.pdf

https://www.nice.org.uk/guidance/ng98

http://www.earcarecentre.com/uploadedFiles/Pages/Health_Professionals/Protocols/Cleaning%20Guidelines%20for%20Electronic%20Irrigator.pdf

http://www.earcarecentre.com/uploadedFiles/Pages/Health_Professionals/Protocols/Cleaning%20Guidelines%20for%20Electronic%20Irrigator.pdf

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Appendices 687

Appendix A 688

689

CONSENT FORM FOR EAR WAX REMOVAL 690

Your Aural Care Professional has discussed with you the need to remove wax from your ears. 691 In order to check that it is safe to proceed you will be asked some questions about the health of your 692 ears and general health. It is also necessary to carry out a detailed visual inspection of your ear/s and 693 the wax present. If safe to do so, wax will be removed from your ear/s using the safest and most 694 appropriate method for the quantity and consistency of the wax discovered. 695 696

Three methods of wax removal may be used, and these are sometimes used in combination: 697

Removal of wax deposits using manual instruments 698

Fine instruments are inserted carefully into your ear and used to gently extract the wax from the ear 699

canal 700

701

Wax removal using suction 702

A fine suction tube is carefully inserted into the ear canal while being viewed closely through a 703

microscope or endoscope or under magnification from a head loupe. Wax is removed from the ear by 704

suction from the tube. This procedure can be quite noisy. 705

706

Wax removal using irrigation 707

A fine jet of water is gently circulated around the ear canal to loosen and remove the wax deposit. This 708

procedure can also be noisy. 709

710 Your Aural Care Professional has undertaken training in wax removal and will use best-practice 711 procedures to minimise any risk of harm. However, even when performed with the utmost care, there 712 are risks involved in wax removal. These risks include: 713 714

damage to skin of the ear canal or the ear-drum during the procedure 715

infection of the ear canal or other ear structures following the procedure 716

temporary reduction in hearing 717

temporary dizziness and (rarely) possible sickness or fainting 718

triggering of new tinnitus or temporary aggravation of existing tinnitus 719

temporary irritation to the throat, especially if already dry, tickly or sensitive 720

http://www.actaitalica.it/issues/2009/Argomenti/supplementi.pdfAppendices

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If the wax cannot be removed 721

Sometimes, depending on the amount and consistency of the wax and your own comfort, it may not be 722

possible to remove all of the wax in one visit. If this situation occurs the Ear Care Professional will stop 723

the procedure and you will be advised to continue to use a wax softener for a few days and return to 724

have the remainder removed. 725

726

If a complication arises 727

Sometimes it may be necessary to refer you to a medical professional for further management following 728

this procedure. Most commonly this is because: 729

evidence of a recent or previous infection has been discovered 730

evidence of recent or previous damage or disruption to the ear has been discovered 731

the wax removal procedure has made you feel unwell 732

the wax is too difficult to remove without discomfort 733

a foreign object has been discovered in the ear 734

735

Please tick the box to confirm: 736

I have read the information above and understand there are risks involved. I give my 737

consent to allow the Aural Care Professional to remove wax from my ear using the 738

safest and most appropriate method for the amount and consistency of wax discovered. 739

I understand that the removal may take more than one visit and that it may be 740

necessary to refer me to a medical professional if any complications arise. 741

742

Name (please print): ……………………………………………………… 743

744

Signed: …………………………………………………………………………… 745

746

Date signed: …………………………………………………………………… 747

748

749

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Appendix B 750

EAR WAX REMOVAL BY MANUAL INSTRUMENTS, SUCTION OR WATER IRRIGATION 751

Checklist to ensure ears are routine 752

Condition None reported: ok to proceed

Condition reported: do not proceed

History of any previous complications from wax removal procedures (e.g. vertigo, pain, tinnitus or other)

Presence of a foreign object

Ear pain (current or within last 90 days)

Middle ear infection (current or within last 90 days)

Outer ear infection (current or recurrent)

Current active eczema or psoriasis (e.g. currently causing pain, swelling, irritation or discharge)

Abrasions or inflammation of the ear-canal (current or within the last 90 days)

Perforations or recently healed perforations (current or within the last 90 days)

Ear surgery (unless isolated to the pinna and in which case must not be within last 90 days)

Troublesome vertigo (current or recurrent history)

Cleft palate even if repaired (applies to irrigation only)

Troublesome tinnitus affected by noise exposure

Grommet (currently in situ or within last 90 days)

Communicable blood or skin condition such as Hepatitis B, MRSA etc.

For the following conditions, a further risk assessment is required:

Poor head and neck control (unable to hold head in a stable position when sat or lying down)

Current neck pain

Dry, tickly or irritable throat

Diabetes

Anticoagulant or blood thinning medication

High or low blood pressure

753

For those conditions indicated where a further risk assessment is required, it may be possible to proceed 754

based on the clinical judgement of the aural care professional. The risk in proceeding in their own 755

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environment with their own equipment, training, competence, and experience should be assessed. Any 756

additional risk will be discussed with the patient/client in order to obtain further consent to proceed. 757

Practitioners shall not proceed with aural care if they are in any way unsure about the procedure being 758

safe for the individual that they are considering it for. 759

760

761

762

763

764

765

766

767

768

769

770

771

772

773

774

775

776

777

778

779

780

781

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Appendix C 782

783 CLEANING GUIDELINES FOR AN ELECTRONIC IRRIGATOR* 784 785 The Electronic Irrigator must be disinfected using a solution of Sodium Dichloroisocyanurate 0.1% 786 (NaDCC) 787 788 Each day before use, the electronic irrigator must be disinfected using a solution of Sodium 789 Dichloroisocyanurate 0.1% (NaDCC). Suggest use Chlor-Clean tablets, or similar, according to 790 manufacturer’s instructions, to make a solution which provides 1000 parts (NaDCC) per million (0.1%). 791 792

Fill the water tank with NaDCC solution 793 794

Run the irrigator for a few seconds to allow the solution to fill the pump and flexible tubing 795 796

Leave to stand for 10 minutes. Empty the water tank, then rinse the system through with well-797 run cold tap water before use 798

799 Explanation: 800 Sodium Hypochlorite 0.1% has only 1 Chlorine molecule and will release ALL this Chlorine if in contact 801 with any vegetative matter. Sodium Dichloroisocyanurate (NaDCC) 0.1% has 2 Chlorine molecules which 802 are slowly released, maintaining at all times 50% of its own weight. This is available in the form of 803 cleaning tablets containing Sodium Dichloroisocyanurate (NaDCC) 0.1% chlorine plus a detergent agent. 804 A covered litre container can be used to mix and store the solution for up to 8 hours. 805 Disposable tips should be used with the electronic irrigator. 806

807

With thanks to The Primary Care Centre, Rotherham 808

*Copyright: The Primary Ear Care Centre, Rotherham 809

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