• Do not use ear irrigation to remove wax for people with:
• A history of any previous problem with irrigation (pain, perforation, severe vertigo).
• Current perforation of the tympanic membrane.
• A history of perforation of the tympanic membrane in the last 12 months. Not all experts would agree with this: some experts would advise that any history of a perforation at any time, even one that has been surgically repaired, is a contraindication to irrigation because a healed perforation may have a thin area which would be more prone to re-perforation.
• Grommets in place.
• A history of any ear surgery (except extruded grommets within the last 18 months, with subsequent discharge from an Ear Nose and Throat department).
• A mucus discharge from the ear (which may indicate an undiagnosed perforation) within the past 12 months.
• A history of a middle ear infection in the previous 6 weeks.
• Cleft palate, whether repaired or not.
• Acute otitis externa with an oedematous ear canal and painful pinna.
• Presence of a foreign body, including vegetable matter, in the ear.
• Hearing ear in only one ear if it is the ear to be treated, as there is a remote chance that irrigation could cause permanent deafness.
• Confusion or agitation, as they may be unable to sit still.
• Inability to cooperate e.g. young children and some people with learning disabilities.
• Use ear irrigation with caution in people with:
• Vertigo, as this may indicate the presence of middle ear disease with perforation of the tympanic membrane.
• Recurrent otitis media with or without documented tympanic membrane perforation, as thin scars on the tympanic membrane can easily be perforated.
• Warn people with a history of recurrent otitis externa or tinnitus that ear irrigation may aggravate their symptoms.

In depth

• Use an electronic ear irrigator. This should have a variable pressure control so that irrigation can begin at the minimum pressure.
• Prepare equipment as per local guidelines and manufacturer's instructions. This will include a fresh speculum and jet tip for each person. Protect the person's clothing with a towel or waterproof covering. Ask the person to hold the water receiver under their affected ear.
• Ensure that the person is sitting comfortably and that you are sitting at the same level. Use a good light source, preferably with a head lamp or head mirror, throughout the procedure.
• Ensure that the temperature of water used for irrigation is around body temperature.
• Pull the pinna upwards and outwards (downwards and backwards in children) to straighten the ear canal.
• Angle the jet tip so that the flow of the water is along the top of the posterior wall. Compare the perimeter of the canal to a clock face: for the left ear direct the fluid towards 1 o'clock, and for the right ear direct the fluid towards 11 o'clock.
• Inspect the ear canal periodically with the auriscope and monitor the solution running into the receiver to determine whether wax is coming out.
• If the person complains of dizziness or pain, stop the procedure.
• In general, use no more than 500 mL of water per ear in any one irrigating procedure.
• Following irrigation, examine the ear with an auriscope to check that the wax has been removed and the tympanic membrane is intact. Look for old healed perforations. Inspect the canal for otitis externa. Follow local protocols regarding dry mopping.
• Seek immediate advice from an Ear Nose and Throat specialist if severe pain, deafness, or vertigo occur during or after irrigation, or if a perforation is seen following the procedure.

In depth

• The following have been reported:
• Failure of wax removal
• Otitis externa
• Perforation of the tympanic membrane
• Damage to the external auditory meatus
• Pain
• Vertigo
• Otitis media due to water entering the middle ear when there is a previous perforation.
• Exacerbation of pre-existing tinnitus.
• Bleeding may also occur but is usually self limiting.
• Nausea, vomiting, and vertigo may result from temperature variations of the irrigating fluid.
• There is evidence that rarely (approximately 1 in every 1000 ears syringed) serious complications may occur.

In depth

• Advise anyone who has had earwax removed to return if they develop earache, or significant itching of the ear, discharge from the ear (otorrhoea), or swelling of the external auditory meatus, as this may indicate infection.