Outer Ear Examination Cerumen Management Disclaimer Presenter is receiving an honorarium and travel support from the Association Presenter has no relevant non-financial relationships to disclose. Bopanna B. Ballachanda, Ph.D. The purpose of this presentation is to inform and Albuquerque, New Mexico. educate the members, the presenter does not take any responsibility for the consequences by the use of this October 27, 2017 information by any individual. Michigan Audiology Coalition Meeting Lansing, MI 2 Cerumen Impaction and clinical AUDIOLOGY NOW INVOLVES A protocol for management CLEAR AND CLEAN EAR CANAL IMMITANCE (IMPEDANCE) AUDIOMETRY Introduction ELECTRONYSTAGMOGRAPHY Position Statements from Professional REAL EAR MEASUREMENTS organizations COCHLEAR EMISSIONS Cerumen impaction on health care burden ELECTROCOCHLEOGRAPHY A&P of cerumen glands EAR IMPRESSIONS Outer ear examination HEARING AIDS Primary and secondary interventions SOUND PLUGS OTHER SCOPE AND PRACTICE OF AUDIOLOGY HAS PROFESSIONAL STATUS OF 1940`S EXPANDED SO WE SPEND A LOT OF TIME IN THE EAR CANAL AUDIOLOGY WORKED FOR UNIVERSITIES AND CLINICS PEOPLE REFERRED TO AUDIOLOGIST BY MEDICAL STAFF • MALPRACTICE INSURANCE PEOPLE HAD BEEN SCREENED MEDICALLY IF WAX • PUBLIC EXPECTATION PRESENT IT HAD BEEN REMOVED REFERRED FOR AUDIOLOGICAL TESTING...TO LOCATE AIR • EAR HYGIENE IS OUR RESPONSIBILITY BONE GAP • SCOPE AND PRACTICE OF OUR PROFESSION THE ENT OFFICE WAS THE POINT OF ENTRY FOR HEARING HEALTH CARE 1
A NEW AND GROWING PROFESSION AUDIOLOGY NOW INVOLVES A CLEAR AND CLEAN EAR CANAL • AUDIOLOGY 1950`S IMMITANCE (IMPEDANCE) AUDIOMETRY • AUDIOLOGY 1960`S ELECTRONYSTAGMOGRAPHY • AUDIOLOGY 1970`S • AUDIOLOGY 1980`S REAL EAR MEASUREMENTS • AUDIOLOGY 1990`S COCHLEAR EMISSIONS • AUDIOLOGY 2000`S ELECTROCOCHLEOGRAPHY • AUDIOLOGY 2010`S EAR IMPRESSIONS HEARING AIDS SOUND PLUGS OTHER AMERICAN SPEECH-LANGUAGE HEARING ASSOC. SCOPE AND PRACTICE OF AUDIOLOGY HAS EXPANDED SO WE SPEND A LOT OF TIME IN THE It is the position of the American Speech-Language EAR CANAL Hearing Association that otoscopic inspection of the external auditory canal and tympanic membrane, as • MALPRACTICE INSURANCE...? EAR CANAL? well as limited management of occluding cerumen, is • PUBLIC EXPECTATION well within the scope of practice of audiologist. This • EAR HYGIENE IS OUR RESPONSIBILITY area of practice requires that audiologists possess • SCOPE AND PRACTICE OF OUR PROFESSION sufficient knowledge and skills in the use of pneumatic • PROFESSIONS DISAGREE otoscopy, recognition of the canal and tympanic membrane condition, and removal of cerumen when it can be performed comfortably and safely, not requiring direct contact with the TM. ASHA POSITION CONTINUED AMERICAN ACADEMY OF AUDIOLOGY Audiologist should have knowledge of the medical conditions of the pinna, external ear canal and … defined by the training and tympanic membrane, and of how these potentially knowledge base of licensed and could have an impact on the examination and the audiological procedures. Practical, supervised certified Audiologist. Areas of experience along with efficiency (skill) in the competency include assessment and inspection of the pinna and external auditory canal, rehabilitation of individuals with tympanic membrane integrity and cerumen auditory disorders. Audiologists management are required. (Nov 1991) conduct otoscopic examinations, clean ear canals, take ear impressions... 2
ACADEMY OF DISPENSING AUDIOLOGIST AMERICAN ACADEMY OF OTOLARYNGOLOGY Whereas: Cerumen removal requires mechanical ... cerumen management or chemical manipulation of the external auditory is considered within the canal, and Whereas: Such manipulation may result in scope of practice of the traumatic and/or inflammatory lesions to the external auditory canal, tympanic membrane, dispensing audiologist …. and/or middle ear conducting mechanism, be it therefore Resolved: Why audiologists don’t perform cerumen Knowledge and skills required to perform management cerumen management • Potential for patient injury • Knowledge of anatomy and physiology • Inadequacy of training • Knowledge of pathophysiology • Liability for injury • Skill in otoscopy • Exposure to and transmission of pathogens • Training • Transmission of pathogens • Supervised experience • State laws – Texas law Ques Questio ion Ques Questio ion What is health care burden due to cerumen impaction? Answer: What is health care burden due to 2 to 6 % of the general population suffer from cerumen impaction? cerumen impaction in the UK. Applying this to US population: 12 to 18 Million CMS report: Cost of disimpaction is around 46.9 Million – Yang et al. 2016 JAMA 3
Cerumen Exocrine Glands of the Ear Canal Gland Type Secretion • Physiology Sebaceous Holocrine Sebum • Pathophysiology Apocrine Mixed “Sweat” (Ceruminous) (Eccrine- • Prevalence of Cerumen Impaction Aprocrine- Holocrine) • Secrections of the Sebaceous and Apocrine glands together form cerumen 4
Qus Qustio ion Which glands are responsible for the production of Cerumen? Freshly formed Cerumen Ans nswer • Sebaceous • Apocrine Changes due to time Dry cerumen 5
Wet type of cerumen Chemical composition of Cerumen Cerumen Composition Protein Fyrosine Cerotic Acid Amino Acids: Lucine, Cholesterol Esoleucine, Valine, Alanine, Hexos Bases Theronine, Serive, Guitamin Neurostaric Acid a “Bitter Acid, Aspiratic Acid, Glycine, Substance” Amino Butyric Acid Acid C17H34NO2 Fatty Acids: L-Elestearic, Substances C8H14NO2 Arachidic, Behenic, Argimon Ligonoceric Stearic, Cerotic, Cystine Erucid, Myristic and Palmitic. Histindine Copper/Iron Lysine Functions of Cerumen CLEANSING FUNCTION • Lubricate • Cleanse • Protect* *antibacterial/antifungal action 6
Protective Function of Cerumen Innervation of External Ear Canal Perry (1955)- cerumen has no significant antibacterial or Nerve Area Supplied antifungal properties. Auriculotemporal Branch Anterior and Superior Chail and Chai (1980)- cerumen has a bactericide activity of Mandibular Division Walls against some stains of bacteria tested. Cerumen of Trigeminal (V) functions to kill certain foreign organisms that enter the earcanal. Posterior Auricular Branch Concha and Outer Portion of Facial (VII) of Canal Stone and Fulghum (1984)- bacteria were reduced 17-99% by treatment with a 3% suspension of human Auricular Branch Inferior and Posterior cerumen or the soft or “wet” type of Vagus (X) Walls Complications of Excessive/Impacted Unusual Complications of Cerumen Excessive/Impacted Cerumen • Tinnitus • Cardiac Depression (Prasad, 1984) • Vertigo • Itching • Chronic Cough (Ramen, 1986) • Earache • Pseudodementia (Myers & Pueschel, 1987) • Otitis Externa • Hearing Loss 7
Cerumen Impaction By Age Cerumen Fact Age Range Impaction (In Years) Percentage 26-44 5 45-54 15 The amount of cerumen found in 55-64 25 earcanals varies widely from individual to individual and among 65-75 34 different populations 75-84 22 75-84 Incidence of Excessive/Impacted Incidence of Excessive/Impacted Cerumen in Normal Populations Cerumen in Special Populations Children Mentally Retarded Adolescents Roche, et al (1978) 10% (n=224) Briscco (1985) 10% (n=349) Nudo (1965) 36% (n=494) Fulton & Griffen 28% (n=191) Adults (1967) Brister, et al (1986) 22% (n=88) Lebensohn (1943) 3% (n=794) Crandall & Roeser 28% (n=121) Perry (1957) 17% (n=111) (1993) Hopkinson (1981) 4% (n=500) Foltner (1984) 9% (n=100) Geriatric Population Mahoney (in Press) 34% (n=104) Cooper (1985) 5% (n=587) 8
Cerumen Fact Cerumen Fact • Certain drugs, increased emotional states, and mechanical “milking” • There are marked racial tendencies in the consistency and color of increase the production of cerumen cerumen Dry cerumen Wet type of cerumen Asteatosis Cerumen Facts • Cerumen topic of interest for anthropologists • Diminished or arrested action of the sebaceous glands • Cerumen topic of study for Breast cancer specialists • Etiological Factors • Eczema • Cerumen and Otitis externa • Cleaning • Old Age • Treatment • Skin lubricant (mineral oil) 9
Questi Qu tion Answ swer Higher propensity in: Cerumen impaction is more 1. Elderly common in what type of patient population? 2. Patients with cognitive impairment 3. Hearing aid users 4. All of the above Hearing Aids ??? Insert Hearing Protection ??? Outer Ear Examination Historical Overview Otoscopy Interest since 14th Century ➢ Rationale for examination Illumination 1. Identification of Pathologies Artificial Light 2. Cerumen management 3. Identify contraindications Candles-Shine through a Flask or Water Glass to 4. Precautions Concentrate Light 5. Impact on hearing aid fitting/habilitation Light Boxes a. Ear canal movement Water Glass b.Fit, Comfort, and Feedback Concentrate Light with Concave Mirror Mineral Oil Lamps in Late 19th Century 10
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