Cerumen Management- Diagnostics
case history (3) -____ ______ -chronic _______ -other _____ _______
-heart disease -chronic bleeding -other systemic disorders (diabetes, HIV, hepatitis)
Contraindications of cerumen management (3) -recent/current ______ -external ______ -post ____ ______
-recent/current chronic OME -external otitis -post otic surgery
lucae hook-
90 degree angle
hold tip at
90 degree angle cross cheek point tip superiorly
functions of cerumen: EAC skin of EAC is very ______ at ____ section, ____ in _____ portion ____ cartilaginous _____ bony lateral 1/3= middle 1/3= medial 1/3=
skin of EAC is very thin at bony section, thicker in outer portion 2/3 cartilaginous 1/3 bony lateral 1/3= cartilage and ceremonious glands middle 1/3= cartilage and no glands (sensitive) medial 1/3= bone
cerumen extraction
snag, loop, pull loop, scoop grab
Cerumenologist: Cerumenology: Cerumenosis: Cerumenectomy: Cerumenolytic:
someone who studies earwax/deals with removing earwax study of cerumen increased formation of cerumen someone who removes cerumen something that dissolves cerumen
Causes of Cerumen Buildup
stenosis aging q tips ear canal hair hearing aids HPDs
infection control (4)
sterilization disinfection protective barriers waste management
curette-
straight extraction tool
irrigation is the opposite of
suction -Least popular but easiest Have patient hold basin under ear Water pik -pulsation rocks wax out -aim toward ear canal -not directly striking tm Use speculum to help keep canal straight and protect ear -true for all procedures Shoot/aim water to roof of canal -not tm water temp. should be body temp. Don't irrigate with patients who have dizziness, diabetes, cardiac problems
suctioning instruments
suction unit suction tip noisy
aim tip
superiorly and flush in posterior and anterior direction -flows out of canal
what are ceruminous glands? (3) -______ glands (_____) -enclosed in -secrete
sweat glands (apocrine) enclosed in muscle tissue secrete milky white substance
cerumen is a combination of (5)
sweat, sebum, and desquamated epithelial cells, dead hair, dust
irrigation instruments
syringe water PIK-oral irrigator special tip illumination
the smaller the extraction tool,
the more you can see around it
mechanical removal protocol -start at -roll -enter canal with -do not remove wax that is -do not touch
Start at superior or weakest aspect Roll impaction out Enter canal with closed forceps Do not removed wax attached to skin Do not touch canal wall -Can cause abrasion -Can place a drop of lubricant on curette and put on the skin to move wax out of the way
Precautions for cerumen management
State licensing Limitations on scope of practice Liability insurance Specific institutional prohibitions Observe universal precautions Emergency procedures Obtain informed consent
post extraction evaluation
ear canal examination documentation medical referral
Cerumen classifications: sullivan scale
four point scale from 0 to +3 0= cerumen entirely absent (no removal) +1- non occlusive minor amount of cerumen (removal optional) +2- non occlusive moderate amount of cerumen (removal advised) +3- occlusive major amount of cerumen (removal essential)
exocrine glands of the ear canal combination of ______ and ______ makes ceruminous glands ceruminous gland type:
gland: sebaceous type: holocrine secretion: sebum gland: apocrine type: mixed secretion: sweat gland: ceruminous type: exocrine-aprocrine-holocrine sebacious and aprocrine
ear canal examination instruments
head mirror head lamp otoscopes microscopes video otoscopes
incidence of impacted cerumen in children: in adults: in people w/ intellectual disabilities: in geriatric population:
in children 3-10% In adults 3-17% In people with intellectual disabilities 22-36% In geriatric population 34%
Preliminary considerations: risks (4) -______ to the EC -_____ of the TM -exacberation of -damage to
injury to the ear canal Perforation of the tm Exacerbation of chronic middle ear disease Possible damage to ossicular chain
complications of impaction (5) Hearing loss slight HF loss from 25-30 dB HL loss with 30-35 dB HL loss with 30-40 dB LF loss and 40-60dB HF loss with ____ configuration
tinnitus, vertigo, itching, earache, otitis externa hearing loss Slight HF loss from 80% impaction 25-30 dB HF loss with 90% impaction 30-35 dB HF loss with 95% impaction 30-40 dB LF loss and 40-60 dB HF loss with 100% impaction Flat configuration
use fist as
practice to judge depth
innervation of EAC (3) can get cough reflex if ______ stimulated if cough occurs,
trigeminal - anterior/superior wall facial - concha and outer portion vagus - innervates larynx and heart can get couch reflex if vagus is stimulated if cough occurs, head moves, instruments can move
Precautions when you're about to remove cerumen use... may cause...
use gloves, eye protection, mask may cause laceration or bleeding universal precautions/infection control
insert superiorly past
wax, pull it out against floor of EAC if impacted, create opening superiorly, scoop away, and watch for TM
FDA regulations for fitting HAs (3) -HA eval and fitting should take place
prior to 2017, required medical exam, waiver if over 18 yrs -still required for children, no longer required for adults -incumbent on audiologist to recommend medical eval if concerns are present -HA eval and fitting should take place within 6 months
not enough wax can be caused by (4) can result in:
self cleaning swimming chronic ottorhea radiation can result in otitis externa cant wear HAs foreign bodies
sebum and sweat are formed below the -sebacious glands look _____
skin and travel through a duct along the ciliar structure into the EAC -sebacious glands look "intestinal"
cerumen extraction procedures - mechanical removal (3)
brace wear gloves instruments- forceps, loops, currettes, other
What is cerumen?
A substance formed in the earcanal to lubricate, cleanse, and protect the ear canal
causes of impaction
Abnormal EAC anatomy (curved/narrow) Excessive ear hair Occlusion by HA mold Overproduction of cerumen Either too much is made or not enough is removed Osteoma Use of Q-Tips; hair pins Misguided attempts at removal
When NOT to remove cerumen using irrigation
Previous ear surgery (tubes, mastoid cavity) Perforation Chronic OME Drainage, discharge, rash Only hearing ear Under 12 -need cooperation
functions of cerumen: protection cerumen has an _____ function and an _____ function -it is high in ____ which prevents growth of ____ (ideal place for ____-warm, dark moist) insecticidal function- _____ in taste and _____
Cerumen has an antibacterial function and an antifungal function It is high in acid which prevents growth of fungus Ideal place for fungus -warm, dark, moist Insecticidal function -bitter in taste and odor
infection control
Cerumen is an infectious agent when contaminated by blood/mucous/organisms Can't always know if contaminated, so always consider cerumen as infectious Disinfection -Do with items that don't touch blood -Kills germs Sterilization -Kills 100% -Do with anything that contains blood/infection Autoclave -Hot sterilization
Procedures for cerumen management -____ step procedure... -sit at
Cerumen removal is a two-step procedure -Softening agent -Ear canal irrigation Sit at eye/ear level
other functions of cerumen -coats surface of -____ repellant -entraps ____, ______, ______ -_____ barrier preventing ____, ______, ______ healthy ___ _____ decreases _____ growths
Coats surface of EAC Water repellant Entraps dust, hair follicles, insects Oily barrier preventing germs, fungus, bacteria Healthy ph-acidic Decreases fungus growth
Documentation
Considered a treatment procedure Document -What ear looked like beforehand -Where wax is -What you did -What ear looks like afterward -Take a picture (if available)
Informed Consent
Describe procedure -What they will be doing -How it may feel Describe possible side effects Ask if there are questions Sign form
asteatosis _____ or _____ action of _____ glands _____ damages skin and interferes w/ causes ____ ____ _____
Diminished or arrested action of sebaceous glands Cleaning damages skin and interferes with production of cerumen Causes dry ear canals
irrigation protocol
Document integrity of TM Instruct that patient may feel fullness and pressure Steady stream of water Dry ear
suctioning protocol -gently
Start at superior or weakest aspect Gently rock impaction to change position There may be screeching sounds Do not remove attached skin or touch ear canal wall
if pinna manipulation causes pain,
could be wax against tm or an ear infection -medical referral
Steps in cerumen management (6)
Ear Canal Examination Case History Contraindications Precautions Techniques to Extract Cerumen Post Extraction Evaluation
contraindications for irrigation
Hx of dizziness TM perforation Can't see TM Diabetes Cleft palate PE tubes Systemic diseases
Consent form content
I have been given information about my condition and consent is hereby voluntarily given for cerumen removal -The procedures, alternatives, potential gains and risks have been explained to my satisfaction -Cerumen removal risks are rare and may include: abrasion, discomfort, soreness, bleeding, infection and pain
precautions
Information to the Patient Use Clean Instruments Personal Protective Barriers No Forced Removal Documentation Medical Assistance Follow up Guidelines
mechanical removal procedure
Instruction to the Patient Seat the Patient Comfortably Adequate Lighting Insert the instrument gently Dislodge the cerumen Gently Retract Using the Instrument
3 ways to remove cerumen
Mechanical Removal (sticky wax) Aural Suctioning (wet wax) Aural Irrigation (dry/deep wax)
cerumenolytics (4)
Mineral oil Olive oil Softening agents (Glycerine) -Debrox -Murine Ear -Audiologist's Choice -Colace -Docusate Sodium -Cerumenex -Triethanolamine(prescription) -Sodium bicarbonate Carbonide Peroxide-Breaks up wax
ear candling
No evidence to support medical benefits Doesn't create enough suction to extract ear wax Can leave candle wax behind Can also burn the ear canal, perforate the eardrum, and cause infection Fire hazard
irrigation contraindicated if the following are present
Oticdischarge PE tubes TM perforation Dried/cracked skin Open wound Foreign bodies Inability to visualize TM
Preliminary steps (5)
Otoscopic examination of ear canal Careful case history Review audiometric and immittance data Consider contraindications Need for Cerumen Management
disorders to watch for (6)
basal cell/squamous cell carcinoma melanoma exostoses osteoma otomycosis keratosis obturans
Use of softening agents -use a -wait -test the -if it is ______ have patient use
Use a syringe with tubing at the end Place lubricant in ear Wait 5-10 minutes Test the wax If wax is chronic, have patient use drops 2-3 days before appointment
which cranial nerves sensitive?
V trigeminal, VII facial IX glossopharyngeal X vagus
medical referral
Visible congenital or traumatic deformities of the ear History of active drainage for the ear within the previous 90 days Pain or discomfort in the ear Acute or chronic dizziness Visible evidence of significant cerumen accumulation or foreign body in the ear canal History of sudden or rapidly progressive hearing loss or recent onset with the previous 90 days Unilateral hearing loss of sudden or recent onset within the previous 90 days Audiometric air-bone gap equal to or great than 15 dB
irrigation
Water should be body temperature If using water pik -Place at 90 degrees -Face water superiorly Don't occlude ear -Need flow to come out Constant flow of water is what brings wax out
suctioning -you should always be it will be _____ -narrower lumen are _____, but have less ______ can exacerbate ______
You should always be in front of the impaction It will be loud -Narrower lumen are quieter -But you have less suction Can exacerbate tinnitus Cover the hole when you are ready to suction -Do not cover hole until you make contact with the wax in the ear -Minimizes suction until you need it
advantages/limitations of irrigation
advantages easy to remove cerumen requires minimal practice complete removal without complications limitations uncontrolled pressure or pulse water temperature TM perforation/ear canal infections dizziness, diabetes, cardiac problems
suctioning advantages (3) and limitations (1)
advantages easy to suction suction can reduce damage simple and easy limitations may damage the TM
mechanical removal advantages (2) and limitations (3)
advantages injury is extremely low direct control of the situation limitations requires skills patience, practice, time cooperative patient
external ear canal longer in the less sensitive? more discomfort? narrow portion? hard or easy to remove cerumen?
anterior-inferior portion, superior anterior portion less sensitive, inferior and posterior walls more discomfort -isthmus is narrow portion, difficult to remove cerumen
keep tip in
lateral portion of canal
loops good for removing
liquid wax
Functions of Cerumen lubricate: cleanse: skin migration of tm is ____ skin flakes off and then assisted by _____ _____
lubricate: sebum is a fatty/oily material cleanse: process of building and extracting wax skin migration of tm is radial (goes into EAC, once hits EAC migrates laterally. slow migration- several months) skin flakes off and then extrudes from canal assisted by jaw movement
post cerumen management
otoscopy if bleeding occurs, use water pressure, saline soaked cotton ball or afrin may need medical referral