Issues in Cerumen Management

Periodically, the Academy of Dispensing Audiologists (ADA) conducts Cerumen Management Workshops. We invite local physicians to speak for approximately one hour regarding anomalies and conditions of the outer and middle ear which might contraindicate cerumen management by an audiologist. In addition, we ask the physician to address problems such as scratches, bleeding, etc. Additionally, we instruct them to bring slides of interesting outer ears they have treated.

Several months ago, I approached an otolaryngologist about participating in a workshop, taking place in his city. ''Speak for an hour?!'' he replied. ''Everything you need to know about cleaning wax from the ears can be said in 20 minutes!'' He proceeded to summarize the entire 3 hours of lectures I was about to give and then took questions. While he only touched on topics we hoped he would elaborate on, I looked at it as a fine introduction to the next 5 or 6 hours of lectures, demonstrations and hands-on experiences that our group of audiologists would have.

Importantly, please note, state laws vary greatly as to whether cerumen management falls within the audiologist's scope of practice and, if so, under what circumstances. Before engaging in cerumen management, be certain to familiarize yourself with your state laws relating to this topic.

Anyone who takes a cerumen management course knows there is a great deal of information and skill to be developed for proper management of cerumen. Every practicing audiologist should learn these techniques and develop expertise in this area to more efficiently, thoroughly, safely and ethically treat their patients. Impacted cerumen is a contraindication to the performance of many audiology procedures, ranging from basic audiological evaluations to OAE's. Additionally, cerumen and other debris in the ear canal can have tremendous impact for hearing aid users.

Cerumen lubricates the ear canal and protects the eardrum from dirt and foreign bodies. Our goal in performing cerumen management is to simply remove the earwax and debris that blocks the ear canal. It is not necessary or recommended to remove every trace of cerumen At the same time, we do not want to exacerbate pathologic conditions which should be evaluated and treated by physicians, nor do we wish to disrupt structural landmarks. Identifying such conditions, as well as treating actual cerumen and foreign bodies, requires a detailed case history. The interview should include factors such as: history of outer or middle ear infections, surgery, and treatment; medications (particularly blood thinners), infectious diseases, etc. Depending on the information from the case history, additional precautions should be taken, medical referral should be made, or cerumen management should be postponed.

A critical piece of equipment used in cerumen management is the light source. Many of us interchange our light sources depending on the clinical presentation. Common light sources include video-otoscopes, traditional hand-held otoscopes and Hotchkiss otoscopes. Video otoscopes give us the advantage of an ear canal image the size of the video monitor and the ability to simultaneously allow the patient to view the ear canal. Additionally, audiologists often use disposable attachments at the end of the camera to remove cerumen. Hotchkiss otoscopes have been popular for many years because their light source better illuminates the area of concern and the glare of traditional speculum reflection is eliminated. Other advantages of the Hotchkiss otoscope include: the ''work'' area is separate from the ''viewing'' area and the apparatus is smaller, lighter and easier to handle than traditional otoscopes.

Great improvements have also been made to headband-mounted lights for use during cerumen removal procedures. Newer designs are lighter and brighter and are now portable. There are even eyeglass-mounted lights, which give the double benefit of wide binocular magnified viewing and bright lighting.

Instruments and equipment for performing earwax removal have also changed. Audiologists who prefer using irrigation as their primary method of cerumen management are no longer limited to using dental irrigators and irrigating syringes. Bionix has introduced the ''Otoclear'', a portable hand held rechargeable irrigator. Its specula-shaped attachments are available for use with syringes and dental irrigators. In addition, another new product used for irrigation is the ''Earigator''. An otolaryngologist in New York developed the Earigator. This unit addresses many of the concerns audiologists have regarding irrigation, such as water temperature and water flow pressure. Although it is a large and somewhat expensive piece of equipment, it has many useful features. For more information about the Earigator go to www.surya.net.

Suction has gained popularity over the years as a method of removing cerumen. I use this method frequently because I find it faster and safer than other methods. Some audiologists and physicians argue that the loud sound level of suction noise in the ear can be harmful or uncomfortable to the patient. Frankly, I have had no complaints about the sounds and due to the efficient use of this device I find that I am actually in the ear canal a very short time. JedMed, Gomco and others produce sturdy and reliable equipment. They offer new cabinetry and portable rack designs to accommodate different office needs. However, a great improvement would be the redesign of the suction tubes, to allow easier manipulation as well as the ability for audiologists with smaller hands to simultaneously brace the patient's head.

The most popular method of cerumen management for audiologists is still instrumentation: stainless steel and disposable curettes, wax spoons and forceps. These are available in a wide range of sizes and features. Disposable units are more flexible than their metal counterparts and arguably safer. In addition, since they are disposed of, rather than re-used, sterilization is not required. Disposables are particularly convienient for use outside the office (such as in nursing homes). However, loops on some of the disposable units are thicker and more bulky than metal curettes, which can decrease the visualization of the target area.

Anyone who routinely performs cerumen management will eventually cause some problem such as abrading or irritating the canal wall. It is important the audiologists not be over aggressive when removing cerumen. An excellent clinical protocol is to ALWAYS tell the patient when a procedure has caused a scratch that may bleed. It is far better to prepare a patient that there may be bloody residue on their earmold or pillow at night, than to have them surprised and concerned. Although I have heard many physicians recommend using remedies such as covering the lesion with cornstarch or applying a vaso-constrictor such as Affrin to the effected area, these products are not FDA approved for this purpose and therefore I cannot recommend them.


The Academy of Dispensing Audiologists will conduct two day-long Cerumen Management Workshops this fall. . One will be at the Florida AAA convention in Coral Springs, Florida, on September 14, 2000. The second workshop will be in conjunction with the annual ADA convention in San Diego, California, Oct. 25, 2000. Participants in the workshops receive certificates of course completion to use as documentation of training in this area.

For more information contact the ADA office at 1-800-445-8629. For online information: Please visit the world -wide-websites of medrx-usa.com, bionixusa.com, jedmed.com, audiologistschoice.com, surya.net and rcsullivan.com.