What is the proper procedure for placing an ear wick in a patient with otitis externa?

Ear Wick Placement Procedure for Otitis Externa

Place a compressed cellulose wick in the ear canal when edema prevents topical medication entry or when the tympanic membrane cannot be visualized, then prime it with 6 drops of the prescribed antibiotic solution before starting the regular dosing regimen. 1, 2

Indications for Wick Placement

• Severe ear canal edema that prevents topical drops from reaching the medial canal 1
• Inability to visualize most of the tympanic membrane due to canal narrowing or swelling 1
• When anatomic factors make delivery of topical medication problematic 1

Pre-Procedure Preparation

Aural Toilet (Essential First Step)

• Clear the ear canal of inflammatory debris, obstructing cerumen, or foreign objects before wick placement 1, 3
• Use gentle lavage with body-temperature water, saline, or hydrogen peroxide for most patients 1
• For diabetic or immunocompromised patients: avoid irrigation entirely and use atraumatic aural suctioning under microscopic guidance instead 1, 3
• Alternative cleaning methods include suction or dry mopping with cotton-tipped applicators 1

Wick Material Selection

• Preferred material: compressed cellulose because it expands when exposed to moisture, facilitating drug delivery and reducing ear canal edema 1
• Alternative: ribbon gauze if compressed cellulose is unavailable 1
• Never use simple cotton balls as the cotton can fragment and be retained in the ear canal 1

Placement Technique

Step-by-Step Procedure

1. Insert the dry wick into the edematous ear canal 1
2. Prime the wick with 6 drops of the prescribed antibiotic solution to ensure penetration through to the deep canal 2
   • Research demonstrates that it takes 6 drops before medication penetrates through an otowick 2
   • This priming ensures the initial therapeutic dose is fully absorbed 2
3. Moisten with aqueous solution (water, saline, or aluminum acetate) before first application if using an otic suspension or nonaqueous viscous medication 1
   • Note: aqueous antibiotic solutions can be applied directly to expand a dry wick without pre-moistening 1

Post-Placement Instructions

Patient Education

• Position: Have patient lie with affected ear upward for 3-5 minutes after applying drops 4, 3
• Apply gentle to-and-fro movement of the pinna or press the tragus with in/out movement to aid drop penetration 4, 3
• Continue drops for at least 7 days even if symptoms improve, applying drops directly to the wick 3
• Keep ear dry during treatment and avoid inserting anything into the ear canal 3

Wick Removal Timing

• Remove when ear canal edema subsides, which typically occurs within 24 hours to a few days of topical therapy 1
• The wick may fall out spontaneously 1
• Patient may remove it if instructed by the clinician 1
• Clinician may remove it at a scheduled follow-up visit 1

Critical Safety Considerations

Tympanic Membrane Status

• If tympanic membrane perforation is known or suspected (including tympanostomy tubes), prescribe only non-ototoxic topical preparations such as quinolone drops 1, 3
• Avoid ototoxic aminoglycosides when membrane integrity is compromised 3

High-Risk Patients

• Diabetic or immunocompromised patients require special precautions 4, 3
• Avoid ear canal irrigation in these populations due to risk of malignant (necrotizing) otitis externa 1, 3
• Monitor carefully for signs of infection extension beyond the ear canal 3

Bacterial Contamination Prevention

• Continuous application of antibacterial drops prevents bacteria from penetrating through the otowick 2
• Research shows that when antibiotic drops are applied to bacterially contaminated wicks, penetrating drops show no bacterial growth 2

When Wick Placement Is Not Feasible

• Consider systemic antibiotics if severe external auditory canal edema prevents adequate aural toilet or wick placement 1
• Systemic antibiotics are also indicated for infection extension beyond the ear canal, diabetes, immunosuppression, or failed topical therapy 3, 5

Documentation Requirements

• Document pre-procedure ear canal examination findings and tympanic membrane visibility 4
• Record the type of wick material used (compressed cellulose or ribbon gauze) 4
• Note patient positioning and priming technique 4
• Document instructions given regarding wick care and expected duration of placement 4
• Record instructions not to remove the wick unless directed 4