Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
General Practitioner
Practice Nurse
A Report by the Health and Disability Commissioner
Parties involved
The Commissioner received the complaint from ACC on 23 August 1999 and contacted the consumer, Mr A, who indicated that he supported the complaint. An investigation was commenced on 8 February 2000. Information was obtained from:
Mr A Consumer
Dr B General Practitioner at the Medical Centre
Mrs C Provider/Practice Nurse at the Medical Centre
The Commissioner obtained and reviewed the ACC file and Dr B's medical records of Mr A. Expert advice was obtained from an independent practice nurse, and an independent otorhinolaryngologist.
Complaint
The Commissioner received a complaint from the Medical Misadventure Unit of the Accident Rehabilitation and Compensation Insurance Corporation (ACC) regarding the services Mr A received from Mrs C, a practice nurse at a medical centre. The complaint is that:
- On 3 August 1998 [Mrs C] syringed [Mr A's] right ear instead of referring him to the otorhinolaryngologist, although she knew he had a history of right ear perforation, and this resulted in a further ear perforation.
Information gathered during investigation
Previous medical history
When Mr A was five years old he perforated his right ear, which healed itself over time. Mr A subsequently developed hearing problems because he worked as a mechanic and in a soft drink factory during his working life, in noisy environments.
On 28 August 1986 Mr A underwent a right stapedectomy (removal of the stapes (a bone in the middle ear) and insertion of a graft and prosthetic bone to improve hearing). On 14 December 1990 Mr A was treated for tinnitus (buzzing or ringing in the ear) and a trial hearing aid was arranged. Mr A subsequently wore a hearing aid in his right ear on a permanent basis. In 1995 he experienced head noises, tinnitus and a loss of hearing in his left ear. He received treatment and the specialist suggested a hearing aid for his left ear.
Mr A stated that in mid-1998 he was financially able to apply for two hearing aids. He contacted the Audiology Department at a public hospital, and had a final check for the hearing aids on 31 July 1998. During this consultation the audiologist noted he had wax in both ears and suggested that it be removed before the hearing aids arrived in a few days' time. Accordingly, Mr A made an appointment for 3 August 1998 at the medical centre where his general practitioner, Dr B, worked.
Consultation on 3 August 1998
Mr A stated that on 3 August 1998 he saw Mrs C, Dr B's practice nurse, who advised that she performed the syringing (use of a syringe to wash out a cavity such as the outer ear) of Mr A's ears. Mrs C syringed his left ear first and he found the procedure painful. Before Mrs C syringed his right ear, Mr A told her to be careful, as he had suffered a perforation in this ear when he was a child. Mrs C proceeded to syringe his right ear. Mr A stated: "[I] nearly collapsed with pain as I felt the eardrum perforate." He told Mrs C, who examined the ear and referred him to Dr B. Mr A stated that he is certain that the perforation was caused by the syringing and that he was in "serious pain".
Mr A saw Dr B immediately and, after an examination of his ear, she stated, "I'm sorry we have perforated your eardrum." Dr B also thought that he had an inner ear infection, so she prescribed drops and antibiotics.
Mrs C stated that on examination prior to syringing she noticed that Mr A's right ear was "filled with soft yellow mucus". The mucus was also on Mr A's hearing aid, which was "stained and smelly". In a letter dated 24 June 1999 to ACC, Mr A stated that there was no yellow mucus in his right ear. His hearing aid did not smell, as he is very careful about cleaning it. Further, Mrs C did not see or examine his hearing aid as he removed it prior to the syringing. The records at the Audiology Department of the public hospital document the results of the hearing test, but there are no clinical notes relating to Mr A's ear or the condition of his hearing aid.
Mr A reiterated to me during this investigation that he had taken his hearing aid out prior to the consultation. I am unable to determine whether Mr A's hearing aid was examined, but I do not need to resolve this issue in order to form my opinion in this case. However, I do accept that Mrs C noted that there was yellow mucus in Mr A's ear prior to syringing. While Mr A denies that this was the case, he was obviously not in a position to observe the condition of his ear, while Mrs C was, and did.
Mrs C stated that she asked Mr A if he had any problems or a recent ear infection and he advised that he did not. She also asked if he had had a recent perforation of the eardrum and Mr A replied that he had experienced a perforation in his ear as a child. Mrs C stated she then suggested that it would be better if the wax was suctioned out by an ear specialist.
However, Mr A insisted that the syringing needed to be performed as soon as possible and asked her to syringe the ear. In his letter of 24 June 1999 to ACC, Mr A stated that Mrs C did not ask him about previous ear infections or perforations, but that he told Mrs C he had had a perforation as a child. He advised that Mrs C did not mention the option of having his ear suctioned. Further, he asked to have, rather than insisted on having, the wax removed.
In a letter dated 9 March 2000 the New Zealand Nurses Organisation advised me that Mrs C accepts that she should have provided an explanation of the options available, including an assessment of the expected risks and benefits. Mrs C also acknowledges that she did not advise Mr A that a perforated eardrum is a common complication of syringing. Mrs C did not inform him of this because he was insistent on the procedure being performed. Nonetheless, she believed that she had the patient's consent.
In her response to my provisional opinion, Mrs C stated:
"I definitely informed him that a history of perforated eardrum was a contraindication to ear syringing and suggested he should have the wax suctioned by an ear specialist to prevent perforation of the eardrum. He enquired how this was done and I explained that the wax was removed with a suction tube and the specialist had the equipment to do this and we did not.
He then asked how he could access the services of a specialist on such short notice. I suggested that he made an appointment with [Dr B] and she would refer him. She did not have an appointment available on that day. He replied that this would take too long and would prefer that I syringed his ears. I agreed to do the procedure at this stage because I wanted to help him."
However, the letter from the New Zealand Nurses Organisation of 9 March 2000, submitted on behalf of Mrs C, stated:
"In relation to Right Six, [Mrs C] accepts that the patient was not fully informed. In particular, in relation to Right Six (b) she accepts that she should have given an explanation of the options available, including an assessment of the expected risks or side effects. Given this fact, [Mrs C] is prepared to write a letter of apology to the patient if the Commissioner believes it is appropriate .…
In relation to Right Seven, [Mrs C] did not specifically state to the patient that a perforated eardrum is a common complication with the procedure."
Based on the New Zealand Nurses Organisation letter, and the information given to me by Mr A, I accept that he was not given a proper explanation of options prior to syringing, and was not told that the syringing carried the attendant risk of an ear perforation.
Mrs C advised that she proceeded cautiously with the syringing. She placed the nozzle of the ear syringe slightly upwards at the entrance of the auditory canal so that the initial force of the water would be directed to the top surface of the auditory canal, and to allow the water to circulate in the ear. She stated that she stopped after one water flow application, and asked Mr A if he was all right and if the water temperature was acceptable. She advised that Mr A replied that it was acceptable and asked her to continue.
Mrs C advised that the wax was soft so it came out of the ear fairly easily. She checked Mr A's ear again to see if any wax was left in the ear. Some wax remained, so she proceeded with another water flow application. Shortly after this application Mr A informed her that he had heard a "whooshing sound" and asked her to stop, so she stopped and examined his ear canal. Mrs C noticed that the ear canal was inflamed and there was a film of white mucus. She referred Mr A to Dr B immediately as she thought that he had a fungal infection.
In his letter of 24 June 1999 to ACC, Mr A stated that he felt the perforation when it occurred and became "quite light headed and dizzy" so he asked Mrs C to stop. He advised she did not mention that there was a film of white mucus in his ear canal.
In a letter dated 16 June 1999 to the New Zealand Nurses Organisation, Dr B stated that she came out of the consultation room and saw Mr A and Mrs C standing in the hallway. Mrs C asked her to check Mr A's ear so she examined him immediately in her consultation room. She stated that on examination it appeared that Mr A had a purulent (containing pus) infective discharge from his right ear. She also noted that the tympanic membrane (eardrum) was perforated. Dr B stated that Mr A did not have the symptoms of someone who had just had an acute tympanic perforation (puncture or hole in the eardrum) as he was not in any pain, there was no blood in the external ear canal and he was not ataxic (impaired ability to co-ordinate movement characterised by shaky movements and an unsteady gait). Dr B advised that she prescribed eardrops for the ear infection.
The records at the medical centre stated:
"ENT tympanum [middle ear or eardrum] perforation:
Ear syringed for wax build up. For fitting of hearing aid left ear this week. Discussed ? perforated eardrum left [error; was the right ear] ear prior to syringing ? Suggested suctioning instead. External aud canal [passage linking the pinna (part of the ear lying outside the head) of the outer ear to the eardrum] inflamed with white mucus. Referred to DR for RX Four drops, r/v 1/52 Rx. SOFRADEX EAR DROPS."
Consultations with [Dr B] and an otorhinolaryngologist
On 10 August 1998 Mr A consulted Dr B for a review of his ear. Dr B's notes stated that Mr A's ear was reviewed and no inflammation was found. Mr A was to return for a further review in a week's time.
Mr A saw Dr B again on 18 August 1998. Dr B's notes stated that the ear was draining again. On examination there was mucopurulent discharge (discharge containing mucus and pus) and the ear was slightly inflamed. Dr B advised Mr A to continue with the eardrops and to return for a review in two weeks.
On 1 September 1999 Mr A returned for a review and Dr B referred him to the otorhinolaryngologist whom Mr A had previously consulted.
Dr B's letter of referral dated 14 September 1998 to the otorhinolaryngologist stated:
"… As discussed [Mr A] relates that he had had a perforated eardrum as a child and that it had drained on and off for many years. He underwent a skin graft some years ago and maintains he has had no problems since. However, in early August he requested an ear syringe for wax build-up as he was quite keen to have his hearing aid fitted. At this time the eardrum had perforated.
This initially seemed to be improving but now appears very inflamed. I have taken a swab."
Mr A saw the otorhinolaryngologist on 17 September 1998. The otorhinolaryngologist's examination notes stated:
"… Audiogram:
As enclosed shows a mild to moderately severe hearing loss in the left ear, and a moderate to profound hearing loss in the right ear.
Opinion:
[Mr A] almost certainly has an Aspergillus infection [type of fungal infection] involving the right ear, and this is the likely cause of the perforation in the drum. This can sometimes cause an inner ear hearing loss, and he is best treated with an oral agent for the Aspergillus."
Mr A was reviewed by the otorhinolaryngologist on 24 September, 19 October, 14 December 1998, 1 February, 15 February and 29 March 1999. The otorhinolaryngologist's notes documented that Mr A had discharge from his right ear but this cleared. The perforation in his right ear remained and the hearing in his right ear deteriorated. On 15 February 1999 the otorhinolaryngologist stated that there was severe to profound hearing loss, so a right tympanoplasty (surgery to repair defects such as perforations to improve or restore hearing), and possibly a revision stapedectomy depending on the finding, would be worthwhile. Mr A was placed on the hospital's urgent waiting list.
[Mr A] also saw [Dr B] on 24 September, 6 October and 30 October 1998. The consultation notes for 24 September 1998 stated that [Dr B] "… noticed hearing aid looked stained and smelly on removal and wax in ear soft and yellow in colour". On 6 October 1998 [Dr B] noted that the ear was still perforated but would close with time, and on 30 October 1998 she recorded that [Mr A] was improving.
Letter to ACC
On 29 March 1999 the otorhinolaryngologist sent a letter to ACC regarding the syringing of Mr A's ears by Mrs C. The letter stated:
"The problem appears to be an aspergillus infection involving the right ear drum and middle ear in someone who has had a previous right stapedectomy. This has resulted in a significant deterioration in hearing. This was first noted about three weeks prior to when I first saw him following syringing of the ear prior to a hearing aid fitting.
[Mr A] was seen today and I have gone further into the history of the syringing. It seems he had no symptoms at the time the ears were syringed and this was on the recommendation of the Audiology Department as he was having hearing aids fitted. The Nurse at the practice syringed his ears and he felt the left ear was syringed fairly forcefully. After the right ear had been syringed the nurse had a look and then asked [Dr B] to have a look as there appeared to be a perforation. She thought the syringing might have caused this and he was put on some drops. Subsequently discharge started from the right ear about a week later.
There are a number of possibilities as to the sequence of events. It is possible that the syringing caused a perforation that subsequently became infected with aspergillus or it is possible that he had a pre-existing aspergillus infection which had already caused a perforation of the eardrum and this was exacerbated by syringing.
The former is probably the most likely as he did not have a perforation at the time of the stapedectomy or following this in 1987 and he had been asymptomatic prior to the syringing.
An aural aspergillus infection not infrequently causes a perforated eardrum and can occasionally cause a significant sensory neural hearing loss. They occur relatively infrequently, but I would probably see one or two aspergillus otitis externas per year.
The hearing in the right ear is currently down compared with that in the left ear and at this stage he is only considering a left sided hearing aid although he may wish to try a right hearing aid. Today I have discussed a tympanoplasty with him and we have decided to proceed with this, with the advantages of a successful operation being that he would no longer need to keep water out of the ear and possibly it will give him sufficient hearing that he could wear a hearing aid on this side, although the likelihood of this is not high. At the same time it will be possible to check the prosthesis in the ear in case there is evidence of a perilymph fistula [the fluid between the bony and membranous labyrinths of the ear is discharging into other areas] or the prosthesis has come loose.
At present there is still a small amount of pus on the inferior portion of the drum [below the eardrum] and there is some minor crusting in the ear canal although the appearances are not of an invasive infection and hence I have opted to take an expectant approach to this. However, a recent swab did show that aspergillus was still present and further treatment remains a possibility."
Surgery and further consultations with the otorhinolaryngologist
On 24 May 1999 Mr A underwent a right tympanoplasty and an adjustment of the stapes replacement prosthesis.
Mr A saw the otorhinolaryngologist again on 3 June, 21 June, 4 October 1999, 3 April, 20 April, and 25 May 2000. The otorhinolaryngologist recorded that there were "no particular problems". On 21 June 1999 the otorhinolaryngologist documented that it appeared that Mr A would "get a good result" from the surgery so "an expectant approach is indicated". On 3 April 2000 the otorhinolaryngologist noted that Mr A would like to start swimming again so a fat plug myringoplasty (surgical repair of a perforation with a tissue graft) would be worthwhile. On 20 April and 25 May 2000 it was noted that this procedure appeared to be successful.
Other information
Dr B advised me:
"[Mrs C] is an experienced practice nurse and has successfully performed a great many ear syringes without complication. She is very diligent and at all times attempts to meet the needs of her patients. It is unfortunate that on this occasion, her best intentions resulted in a complication.
[Mrs C] continues to take a thorough history from patients and now provides all patients with information regarding the procedure of ear syringing and the possible complications. She also obtains written consent for the procedure. …
In conclusion, [Mrs C] is a diligent and experienced practice nurse. It is unfortunate that her diligence in helping her patients has resulted in a single, unforseen complication."
Independent advice to Commissioner
During the course of the investigation expert advice was obtained from an independent practice nurse, who advised:
"Issues
- Should [Mrs C] have taken a full medical history from Mr A in relation to his ears? If so, why should such a history be taken?
Yes. A full medical history in relation to a patient's ears should always be taken prior to syringing. I feel there has been enough coverage on this topic from the ACC and in professional journals for [Mrs C] to be aware of the risks of syringing ears. If she had taken a full ear history then the following contraindications would have been revealed:
• Stapedectomy
• Hearing deficit
• Perforated drum
• Ear infection
• No doctor input
- What, if any, information should [Mrs C] have provided to [Mr A] in relation to the risks or side effects of the syringing of ears?
[Mr A] should have been informed of the risks associated with ear syringing i.e. the possibility of a perforation. I recommend our practice nurses to go through a checklist [see Appendix 1] with the patient that covers any ear history they may have. It is not always clearly evident from a patient's notes what may be relevant in their history as some problems such as a perforation may have been years before as was the case with [Mr A]. On completion of the checklist, informed consent is sought. This does not have to be written consent. Verbal is sufficient as long as it is documented well in the notes. I usually recommend having a written practice protocol that can be referred to in the patient notes.
- What, if any, information should [Mrs C] have given to [Mr A] in relation to why it would be preferable for his ears to be syringed by an ear specialist?
If a checklist had been gone through and the risks of the procedure explained to [Mr A] then it would have become quite apparent that syringing [Mr A's] ears was inappropriate. He should have been informed of the option of having his ears suctioned by an ear specialist with appropriate equipment that allows visual access to the ear during the procedure. This is significantly safer for everyone and is the only option that would have been safe for [Mr A].
Should [Mrs C] have proceeded to syringe [Mr A's] ears even if he did insist on his ears being syringed at this consultation, when he had had a perforation in his right ear as a child?
No, but this is a difficult area. [Mr A] presented for an ear syringe and according to Mrs C 'insisted' on this being carried out however [Mr A] denies the insistence. [Mrs C] says she recommended ear suctioning as Mr A had had a past perforation. [Mr A] says [Mrs C] did not mention this.
If a patient presents for a procedure and then insists, it becomes very difficult for the nurse to decline to perform the procedure. I can sympathise with her carrying out the procedure despite the fact that she may have had reservations about it. If she had declined to perform the procedure her practice would not now be in question but what would have happened if she had refused [Mr A]. He was insistent, as he wanted to get his hearing aid fitted.
That said, in the ideal world, [Mrs C] should not have syringed [Mr A's] ears, as she was aware that he had had a perforation in the past. It does not matter how long ago. The contraindication is 'ever had a perforated ear drum'.
- Should [Mrs C] have noticed that [Mr A] had a fungal infection in his right ear before she started to syringe the ears?
Yes. This is basic. An examination with an auroscope [apparatus for examining the eardrum and the internal passage leading to it] should be made of the ears prior to syringing. There is no mention of this taking place. If this had been performed, and there was infection present, (which was in doubt), then debris and inflammation should have been observed. If there was infection present then syringing should not be performed. Sometimes gentle syringing is performed to remove debris from otitis externa [inflammation or infection of the external canal or the part of the ear lying outside the head] but this is not recommended. [Mrs C] said she saw soft, yellow mucous (not wax). This should have raised her suspicion of infection, which would alert her to another contraindication to performing the syringing.
- Did [Mrs C] use the correct techniques when she syringed [Mr A's] ears?
Yes. From the description the technique was quite correct. (appendix 1). She proceeded carefully and checked patient comfort at intervals and stopped immediately [Mr A] felt discomfort and pain. On examination of the ear she noticed inflammation and referred [Mr A] to the doctor. All this is good practice.
- Are there any other issues arising from the supporting information?
The issue of whether or not [Mrs C's] syringing caused the perforation is not proven. [Mrs C] thought that the syringing had caused the perforation. [Mr A] states that [Dr B] said '… we have perforated your ear drum' and [the otorhinolaryngologist] contradicts himself over the issue but as there were no symptoms prior he felt that the syringing could have caused it but then he said the pre-existing infection may have caused it.
All this aside, [Mrs C] should not have syringed [Mr A's] ears based on what she knew. She should also have carried out a full ear history before syringing, explained the risks of the procedure and other options and sought [Mr A's] 'informed consent'. I note that she has made changes to her practice to prevent this happening again.
Questions raised.
• Did [Mrs C] examine the ears prior to syringing?
• What did the audiologist see in July?
• The problem occurred with [Mr A's] right ear but the medical notes refer (confusingly) to the left ear."
During the course of the investigation expert advice was also obtained from an independent otorhinolaryngologist, who advised:
"I have reviewed all the documents sent to me regarding this case. It is my opinion that [Mr A's] right tympanic membrane perforation occurred as a result of syringing. There are conflicting statements from the specialists seen at the time but certainly perforation is a recognised complication of syringing, particularly when there has been previous surgery.
I do not think that an infection is likely to have caused the perforation as there were no symptoms of infection prior to syringing. There is some conflict in the notes between what [Mr A] recalls was said to him and what the general practitioner recalls, although I note that in her letter of 14 September 1998 she implies that the ear drum had perforated following syringing.
Regarding the loss of hearing following the syringing of ears, I cannot give a precise percentage hearing loss as the copy of the audiogram I have received is difficult to read accurately, although [Mr A] has certainly gone from a moderate hearing loss in the right ear to a profound hearing loss in the right ear, and this does not seem to have improved.
[Mr A] developed a perforation following syringing which required a right tympanoplasty and then a subsequent revision fat patch myringoplasty. It is my opinion that if he had not had the syringing he would have not needed those two procedures.
There is further conflict between statements made by [Mr A] and [the practice nurse, Mrs C]. This relates to the history taken by the nurse prior to syringing [Mr A's] ears and to whether he asked or insisted that his ears were syringed. This means it is very difficult to form an opinion as to whether [Mr A] was provided with services that complied with professional and other relevant standards. If the situation is as he stated, that he was not advised about an option other than syringing the ear and was not asked about any previous surgery or perforation, then I do not think that [Mr A] was provided with services to an appropriate standard. If, however, as [the practice nurse] stated, she did question him about such things and advised him to have his ears suctioned but he did not take that advice, then the situation is different, and I therefore cannot form an opinion when I am faced with these conflicting statements. I do, however, note that syringing should not be performed when there has been a history of previous ear surgery and that question does not appear to have been raised."
Code of Health and Disability Services Consumers' Rights
The following Rights in the Code of Health and Disability Services Consumers' Rights are applicable to this complaint:
RIGHT 4
Right to Services of an Appropriate Standard
1) Every consumer has the right to have services provided with reasonable care and skill.
RIGHT 6
Right to be Fully Informed
1) Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive, including -
…
b) An explanation of the options available, including an assessment of the expected risks, side effects, benefits, and costs of each option ….
Opinion: Practice Nurse, Mrs C - Breach
Right 4(1)
Syringing ears in face of contraindications
In my opinion Mrs C breached Right 4(1) of the Code of Health and Disability Services Consumers' Rights by syringing Mr A's ears.
There is some dispute as to whether the syringing actually caused the perforation, or whether the perforation had been caused by the infection in Mr A's ear, observed by Dr B immediately following the syringing. However, I do not need to determine that issue in order to determine whether Mrs C's actions were appropriate in the circumstances. It is apparent that, irrespective of whether the syringing caused the perforation, there were two matters, known to Mrs C, that should have led her not to undertake the procedure.
My advisor stated that there has been enough coverage of the syringing of ears for Mrs C to be aware of the risks and contraindications associated with syringing. One of these contraindications is a previous perforation of the eardrum. There is no dispute that Mr A informed Mrs C of a previous perforation.
My advisor stated that a further contraindication to syringing is the presence of a fungal infection. Dr B noted this infection when she saw Mr A immediately after the syringing. My advisor stated that an examination with an auroscope should be conducted prior to syringing. Debris and inflammation should be evident if an infection is present, and syringing should not proceed in these circumstances. Mrs C does not mention that she examined Mr A with an auroscope. However, Mrs C advised that she saw soft yellow mucus which should have raised the suspicion of infection and restrained her from syringing.
Accordingly, in my opinion Mrs C failed to exercise reasonable care and skill by continuing with the syringing in the face of two contraindications: first, the previous perforation, and second, the presence of the soft yellow mucus, indicative of infection.
Mrs C clearly felt pressured by Mr A into performing the procedure. Mr A disputed this and advised that he only asked for syringing. I am unable to resolve this dispute as to whether, or to what degree, Mr A pressured Mrs C. However, even if Mr A did pressure Mrs C to perform the procedure, this would make no difference to Mrs C's failure to observe professional standards. A provider has no obligation to provide a service when it is not clinically indicated. In Mr A's case there were two obvious contraindications that indicated a serious risk of harm if syringing occurred.
Right 6(1)
Right to be fully informed
In my opinion Mrs C breached right 6(1) of the Code of Health and Disability Consumers' Rights in not informing Mr A of the risk of a perforated eardrum when syringing his ears, and in not explaining to him the available options.
Mr A was entitled to receive all information that a reasonable consumer, in his circumstances, would expect to receive. Mrs C did not provide this information. She acknowledged that she explained neither the available options nor the risks or potential side effects of syringing to Mr A.
There was a clear risk to Mr A that in syringing his ears, his eardrums might perforate. This was especially so given that he had previously suffered a perforated eardrum, and he was suffering from an ear infection. Mr A was not told of that risk. It is unacceptable that he was not informed of such a serious potential outcome.
Mrs C has said that the reason she did not fully inform Mr A was because he was insistent on having the procedure performed. This is no excuse. Although Mr A may have been insistent, his attitude is likely to have changed once he received all the appropriate information. Accordingly, in my opinion Mrs C breached Right 6(1)(b) of the Code.
General Practitioner, Dr B - No Breach
In my view, Mrs C's syringing of Mr A's ears was an isolated case of clinical mismanagement by a practice nurse. Accordingly, in my opinion it is not necessary to consider whether Dr B should be vicariously liable for Mrs C's actions.
Actions - Recommendations
I recommend that Mrs C provide a written apology to Mr A: first, for her failure to inform Mr A that perforation was a recognised potential complication of syringing (I note that Mrs C has already indicated that she is happy to apologise in relation to this issue); secondly, for proceeding with syringing in the face of two contraindications.
The apology is to be sent to my Office and will be forwarded to Mr A.
I note that, since this incident, Mrs C has changed her practice regarding the syringing of ears. All patients are seen by the doctor before and after having such procedures performed and the nurse advises them that the most common risk is a perforation of the eardrum.
However, I also recommend that Mrs C carefully review the guidelines appended to this opinion in relation to syringing ears. A copy of these guidelines is appended to this report as Appendix 1. The guidelines are comprehensive and a valuable source of reference for all practitioners who undertake this procedure. I would therefore recommend that Mrs C review them and, if necessary, further amend her practice.
I am grateful to both the author of the guidelines and PrimeHealth for allowing me to append these guidelines to this report for educational purposes.
Further actions
- A copy of this opinion will be forwarded to the Nursing Council of New Zealand and ACC.
- A copy of this opinion, with identifying features removed, will be sent to the Royal College of General Practitioners, for educational purposes.
Appendix 1
Ear Syringing
[Guidelines written by Ms Diane Newland, for PrimeHealth]
Ear syringing is a time-honoured method of dealing with ear wax impaction and if a few precautions are taken it should "very rarely" end with an iatrogenic injury. However:
• Ears don't like anything in them particularly water
• You can't see what you are doing
• You can slough off the skin from the ear canal which may lead to infection
• You can perforate the drum
• It can cause tinnitus
• Patients don't really like it.
Mishaps from syringing
Pressure from syringing will not usually perforate a healthy eardrum. However, complications occur in about 1:1000 ears syringed. You may be liable for mistakes so ensure that you are properly trained.
A 16-month study by ACC Medical Misadventure Unit revealed a quarter of ENT claims related to ear syringing and half of these were due to medical mishap or error. Perforation was the commonest outcome with otitis externa accounting for many of the remaining causes. Practice Nurses had performed syringing of ears in two thirds of accepted claims.
As at 26 May 1998, the ACC Medical Misadventure Unit had accepted 26 claims related to ear syringing by a Practice Nurse. 77% of these people have a noticeable hearing loss due to the perforation of the eardrum. Just under quarter of these people went on to have myringoplasty. The reasons the claimants experienced such injuries were related to the following:
1. Pain & bleeding during procedure but the practitioner continued with syringing
2. Past history of ear complications such as stapedectomy or myringoplasty
3. Prior infection which predisposed the eardrum to perforation
Symptoms of otitis externa:
Pain, deafness and discharge may develop within 2 days of syringing the ear. Acute severe earache plus vertigo & faintness indicate a perforation has occurred. A bloody discharge, deafness & tinnitus are also possible. Secondary infection may develop.
Referral
If damage results from syringing the ear, explain what has probably happened to the patient and refer to an ENT surgeon ASAP especially if the damage is overt, symptoms are worsening, there has been no improvement or there is any doubt about the cause of the damage.
Process (if you are going to syringe)
• Take careful detailed history taking into account any contraindications
• Check patient notes for evidence of ear disease
• Sit patient comfortably & explain procedure
• Gently pull pinna up and back (adults), pull pinna horizontally & back (child), this then straightens the canal
• Use an auroscope and the largest size speculum that will fit comfortably
• Examine ear for signs of surgery, middle or external ear infection or eardrum damage
• Assemble equipment - this is usually a syringe but a WaterPik is an alternative (delivers a consistent pulsating pressure) warm water, receptacle for syringed water, auroscope, towels and easy access to a sink
• Use water that is the same as body temperature or about 38 - too hot or too cold causes giddiness
• Ask patient to hold receptacle under ear
• Introduce nozzle gently about 3mm along posterior-superior canal wall
• NB: In European patients the nozzle should point slightly up & back so water flows along roof of canal, over the drum from above down exiting along the floor taking wax & debris with it. Maori & Polynesian patients have a straighter ear canal so more up & backwards angulation is needed
• Should only take 10-12 squirts to remove wax
• Syringe tips should be sterilised after use and stored surgically clean
• If there is any pain, stop immediately
• Dry the ear carefully
• Alcohol drops may aid drying but can also cause excessive drying & itching - take care in the elderly
• Document carefully what you have done
Appendix 2
Pre-syringing check list
x Previous ear surgery
x Perforated ear drum
x Severe otitis externa
x Previous discharging ear
x Prior or current middle ear infection
x Exostoses
x Choleastoma
x Keratosis obturans
x Previous radiation therapy to ear, skull base or mastoid
x Known inner ear disturbance
x Severe hearing loss
x Only hearing ear
x Previous injury from syringing
x Aversion to syringing
x Uncooperative patient
x Very narrow ear canals
x Children < 12 years
x Some foreign bodies especially sharp objects & vegetable matter
x Casual patient without doctor input
If yes to any of these questions, do not syringe ears.
Appendix 3
Ear syringing - Patient advice
Your doctor has recommended you have an ear syringe.
An ear syringe is performed to remove wax, debris or foreign material from the ear.
There is the remote possibility of a perforated eardrum.
Warm water is syringed into the ear canal. This will not be aimed directly at the drum.
If at any time during the procedure you feel pain, the water is too hot or too cold or you feel dizzy or sick please advise immediately.
After syringing, residual water may remain for a short while inside your ear. This can produce a popping or slightly deaf feeling. This will disappear in an hour or so.
Please phone if you have any concerns such as pain, deafness, discharge, dizziness, ringing in the ears.
If you are prone to wax build-up it would be wise to use softening drops like mineral oil or debrox 3-4 times daily for 3 days prior to coming to have your ears syringed.
Do not put small objects such as cotton buds in your ears as this can push the wax back against the eardrum.
Resources and References
1. Allen, P. Understanding ear infections. Smith Kline Beecham 1999.
2. Blake, P. Matthews, R. and Hornibrook, J. When not to syringe an ear. NZMJ Nov 1998; 422-424.
3. Docherty, B. Nursing in general practice: A New Zealand perspective. EBOS 1996; 165-167.
4. Greig, M. Otoscopy for the GP. New Ethicals Journal. March 1999; 19-27.
5. Matthews, R. and Sharp, R. Nursing claims in general practice. May 1998 Medical Misadventure Unit ACC.
6. Murtagh, J. Earwax and syringing. Practice Tips, 1992. Sydney McGraw Hill; 140-1.
7. Webber-Jones, J. Doomed to deafness? AJN Nov 1992; 37-39.