10 - Cerumen Management Flashcards
Define cerumen management
“Cerumen management refers to the strategies, procedures, and tools used for the purposes of removing cerumen from the external auditory canal and/or the management of patients with impacted cerumen”
Do patients typically require cerumen management just once?
No, patients that require cerumen management often require it on a scheduled basis
Tympanic membrane comprised of ____ distinctive layers
3
What are the layers of the TM?
1) Outer epithelial layer (we see this layer during otoscopy, this part comes off and starts to migrate down the EAC)
2) Fibrous middle layer (very strong drum, but won’t be as strong if its compromised through a tube or perf)
3) Inner Mucosal layer (faces the ME space)
What are the 2 different parts of the TM?
1) Pars tensa
2) Pars flaccida
Explain the pars tensa
- Lower 3 quarters
- Fibrous layer
Explain the pars flaccida
- Upper quarter
- Sparse fibrous layer
- Weak point (often where a cholesteatoma will be)
If there is no cerumen in the EAC, what are the 4 landmarks you should see during otoscopy?
1) Membrane tissue
2) Cone of light/light reflex
3) Long and short process of the malleus
4) Annulus
What 5 things are we looking at in a healthy EAC?
1) Consistency/texture
2) Color
3) Shape
4) Overall health
5) Abnormalities
What is the average length of the EAC in a female, male, and child?
Average Length: approximately 28mm for female, 30mm for male, and 20-25mm in pediatric patients
What part of the EAC is longer?
The inferior side of the canal is longer than the superior side (more length on the bottom part of the ear canal)
What part of the EAC is most sensitive?
The inferior/posterior canal wall may be more sensitive than the superior/ anterior canal wall* (if you touch the inferior/posterior canal, it is more likely to bleed)
Where is the isthmus?
Between the cartilaginous and osseous portion of the ear canal lies the isthmus (an extremely sensitive portion of the EAC; stay out of the isthmus)
What gland creates saliva?
Parotid gland
What happens if you touch the superior/anterior EAC?
Patient reaction
What happens if you touch the inferior/posterior EAC?
Bleed
There is CN innervation to the EAC from CNs ____, ____, ____, and ____.
Nerve innervation from cranial nerves V, VII, IX, X
What reflex causes a cough in patients?
Arnold’s reflex (CN X)
What part of the EAC trigger Arnold’s reflex?
Inferior/posterior area
Why is the EAC sensitive to bleeding?
Connection to the jugular vein through the superficial temporal and posterior auricular vein
Why is bleeding a risk to our patients?
Bleeding poses a risk to patients as a way to potentially introduce infection to the ear. We need to be exceptionally cautious in our approach, our tools, and our vigilance in infection control.
The EAC is an ____ shape
“S” (2 bends)
What are the two portions of the EAC?
1) cartilaginous portion
2) bony portion
Explain the cartilaginous portion
- Cartilaginous portion between 1st & 2nd bend
- Cerumen production area
- Cartilage is flexible and can shift with jaw movements (helps cerumen move out of the ear)
Explain the bony portion
- Bony portion past the 2nd bend
- More rigid
- More sensitive compared to cartilaginous portion
- Cerumen can get into this portion
We want to go as ____ as possible to get wax out effectively
Shallow
What is happening here?
Perforated TM (trauma or medical intervetion)
- entry point to the ME space
- immediate refer
- if the perf has been seen by an ENT, you can proceed with CM
- with any hole, no irrigation (do not want water in the ME space)
What is happening here?
Acute otitis media (AOM) and otitis media with effusion (OME)
- infections in the ME space
- needs to be cleared before attempting CM
What is happening here?
Exostoses
- these are in the bony portion close to the TM
- we can do CM, but need to be extremely cautious
- if you think you may touch the exostoses, refer
What is happening here?
Cholesteatoma
- congenital or acquired
- refer to ENT ASAP
- typically seen in the pars flaccida (point of less resistance)
What is happening here?
Bollous Myringitis
- most likely a significant amount of pain
- refer to ENT
What is happening here?
Otitis Externa
- very inflamed and painful
- refer (needs treatment from a physician)
- same for fungus or fungal spores
What is happening here?
Modified canal: mastoidectomy
- space has been modified, so structure has been changes (which can change sensitivity and nerve innervation patterning)
- refer to ENT
What are 7 important questions to find out about in case history before proceeding with CM?
1) Immunocompromised/Immunosuppressed (Diabetes, HIV, Hepatitis, steroid medications, chemotherapeutic medications, prednisone)
2) Heart conditions and heart medications
3) Elevated bleeding risks and anti-coagulant medication (warfarin)?
4) Anti-platelet medication (clopidogrel)?
5) Past radiation?
6) Any other health conditions that may elevate risk?
7) Head Injuries? Acute health conditions?
These are patients where you would proceed with extreme caution or refer out
If patients are immunocompromised they have a greater risk for ____ and ____
infection, bleeding
History of TM perforation or perforation
a) potential concern
b) resolution
a) weakened TM and/or exposure of ME cavity
b) irrigation and/or mechanical/suction
History of ME surgery
a) potential concern
b) resolution
a) weakened TM, change in anatomy, susceptible to potential infection
b) irrigation, mechanical/suction, ENT
History of otitis media
a) potential concern
b) resolution
a) weakened TM or persistent perf
b) irrigation and/or mechanical/suction
Otalgia
a) potential concern
b) resolution
a) active OE or ME disease
b) ENT
Unilateral HL
a) potential concern
b) resolution
a) cerumen removal complications in good ear
b) proceed with caution
PE tubes
a) potential concern
b) resolution
a) concern for TM and/or ME cavity
b) mechanical/suction
Chronic ear drainage
a) potential concern
b) resolution
a) active ear disease
b) refer to ENT
Irritation and/or inflammation
a) potential concern
b) resolution
a) active ear disease
b) refer to ENT
Cholesteatoma
a) potential concern
b) resolution
a) active ear disease
b) refer to ENT
Exostoses, osteoma
a) potential concern
b) resolution
a) exacerbation of symptoms
b) proceed if growth is not affected by wax or refer to ENT
Deep canal wax
a) potential concern
b) resolution
a) no binocular vision, can’t judge depth
b) GP for irrigation, refer to ENT
What does it mean if a person is using anti-coagulant or anti-platelet medication?
a) potential concern
b) resolution
a) increased bleeding
b) mechanical/suction
What happens if there is a history of systemic disease (diabetes, AIDS)
a) potential concern
b) resolution
a) increased risk of infection
b) irrigation or mechanical/suction
What happens if the person is using medications such as steroid or chemotherapy
a) potential concern
b) resolution
a) increased risk of infection
b) irrigation or mechanical/suction
What happens if there is a history of dizziness
a) potential concern
b) resolution
a) exacerbation of dizziness
b) irrigation or mechanical/suction
What happens if there is a heart condition
a) potential concern
b) resolution
a) sensitivity to vagal reflex
b) proceed with caution
What happens if there is a history of radiation
a) potential concern
b) resolution
a) increased sensitivity of ear canal, increased risk of infection
b) mechanical/suction
What happens if there is a cleft palate
a) potential concern
b) resolution
a) altered EAC anatomy
b) irrigation, mechanical/suction
What is cerumen and why do we have it?
- Cerumen (also commonly referred to as “earwax”) is a naturally occurring bi-product of the ear which exists to clean, protect, and lubricate the external auditory canal
- Most often, cerumen is harmless (a little bit of cerumen is good for the ear)
What three things can happen if there is too much cerumen?
When cerumen blocks the ear, or effects the delivery of sound to the ear (i.e. through the use of a hearing aid) it can be problematic
- Prevent thorough examination/interfere with diagnostics
- Cause itching, irritation, otalgia, sensation of fullness
- Can be odorous/can block the ear from proper ventilation
Cerumen is made in the ____ portion and can get pushed into the ____ portion
Cartilaginous, bony
If the cerumen if shiny it is usually ____
The less shiny the cerumen is, the ____ it is
Softer, dryer
How is cerumen made?
- Mixture of secretions from ceruminous and sebaceous glands
- Products of the ceruminous and sebaceous glands combine with skin and debris (such as hair cells)
Explain the ceruminous glands
Ceruminous Glands
- Modified apocrine sweat glands
- Secrete milky white substance that turns to brown when exposed to air (oxidation)
Explain the sebaceous glands
Sebaceous Glands
- Secrete sebum which is made up of triglycerides
Why do we produce cerumen?
- Cerumen is protective to the first portion of our auditory system
- Hydrophobic, waxy, provides physical protection, and a microbial defence for the external auditory canal
- Antibacterial and antifungal properties helps to maintain a slightly acidic environment within the ear canal
What happens the more you clear your ears?
he more wax will be produced
Where is cerumen produced? How does it exit the EAC?
- Cerumen in produced in the outer two-thirds of the ear canal (cartilaginous portion) and is
normally eliminated through a self-cleaning system within the external auditory canal - Skin tissue (epithelial tissue) naturally migrates out of the ear and with assistance from jaw movement, carries cerumen and sloughed skin cells with it
- Accumulation of cerumen can occur when this mechanism is not working effectively, or another factor may be interfering with this process.
Skin/epithelial migration ____mm – ____mm per day
0.05, 0.07
What else could effect the migration of cerumen out of the ear?
Health, age, HA use, sleep plugs, ear plugs, air pods
Who may have issues with cerumen?
Patients seeking assistance for cerumen accumulation is one of the most common reasons patients look to have assistance with their ears
Excessive or impacted cerumen effects….
- 1 in 10 children
- 1 in 20 adults
- More than one third of the geriatric and developmentally delayed population
When does cerumen accumulation occur?
- Accumulation of cerumen can occur when the self-cleaning mechanism is not working effectively, or another factor may be interfering with this process.
- May be symptomatic or asymptomatic
What are the 3 causes for cerumen accumulation?
1) Overproduction: Rate of cerumen being produced exceeds the rate of cerumen migrated out of the ear canal
2) Obstruction: Growth in the ear, narrow canals, difficult shapes of canals, soft tissue malformations Objects inserted into the ear canals can influence the migration of debris out of the canals
3) Inadequate Epithelial Migration: Changes over time
What happens as we age?
- As we age, cerumen glands change in functioning, and become less numerous.
- This can result in drier cerumen, and is less easily carried out of the canal with the migration of skin cells.
- Coarser hair in the canal as part of the aging process can continue to impact the ability for debris to move out of the ear canal
What is cerumen impaction? What does it prevent?
- Impaction suggests that debris is lodged, wedged, or firmly packed in the ear canal.
- Prevents an assessment of the ear canal, tympanic membrane (and possibly beyond).
What is cerumen with complete obstruction?
Can be associated with a complete blockage of the ear canal, and present with other symptoms reported by the patient
Explain the colour and consistency of cerumen
- Color may be effected by other debris or the process of oxidation (and time in canal)
- Consistency in hardness can be due to dryness (another indication of time in ear canal)
What are the 2 types of cerumen?
Wet and Dry cerumen (wet is a dominant phenotype)
Asian/Eastern Descent cerumen is ____
Dry/Flakey
African Descent cerumen is ____
Soft, “honey-like” consistency
European Descent cerumen is ____
Soft, sticky consistency
What is this?
Dry epithelial tissue
- When you see this, think of it as a hang nail (when you pull it off you will see redness)
- May be attached to epithelial tissue that isn’t ready to come off
What 5 reasons would we consider removing cerumen?
1) Prevents thorough audiological examination/interfere with diagnostics
2) Prevents the ability to perform REMs
3) Prevents the ability for hearing aids to be effective (sound delivery)
4) Will cause impaction in future
5) When requested by patient
What are 4 technical aspects of cerumen?
1) Visualization, light sources, and instruments
2) Approaches to cerumen management
3) Removal techniques and aids
4) Cerumen and foreign bodies
What are the 3 main categories for CM removal?
1) Mechanical Removal
2) Irrigation (flushing)
3) Suction
What are 5 tools for mechanical CM removal? Which one should you work with?
Curettes
1) Buck
2) Billeau
3) Shapleigh
4) Lucae
5) Day
- Work with the smallest curette that will allow you to take the wax out effectively (less of a chance of touching the EAC)
- These are reusable with sterilization
Is there a single use option for mechanical removal that does not require sterilization?
- Yes
- These have a bend to them that the metal ones don’t have (more comfortable if you accidently touch the EAC)
What are 3 other options for mechanical removal?
1) light source (with magnifier)
2) cork screw type thing
3) alligator forceps (to grab)
When to use mechanical removal methods
Generally, mechanical removal methods can used to clear partially or completely occluded canals
The choice of mechanical removal will depend on what 3 things?
1) Shape/size of curette and ear canal
2) Degree of impaction
3) Consistency of cerumen
What are 8 guidelines for mechanical CM?
1) Stay in the cerumen, stay off the skin
2) No leveraging, scraping, peeling, sweeping!
3) Identify the point of least resistance to take the most cerumen out with as little irritation as possible
4) Attempt to removal cerumen from a more medial point when safe to do so
5) Attempt to place the tip of the tool slightly behind the cerumen
6) SLOWLY move instrument down and out of canal
7) Clean tool in-between passes
8) Speculum may be used for enhanced visualization
When would you use a Buck and/or Billeau?
scooping out or moving through cerumen impaction
When would you use a Lucae and/or Day?
Getting behind debris, and pulling to dislodge
When would you use forceps?
Grabbing dry wax that is not plugged or removing other foreign objects (such as domes, ends of cotton swabs, etc.)
What should you do if a problem arises during CM?
Pause, reassess, and stop procedure if safety is compromised
- Need to be aware of proximity to the TM
- If the tissue of the canal is being damaged, procedure should be stopped
- If the blockage cannot be removed safely, the procedure should be stopped
- Reassess method, consider additional tools, or refer out
How does irrigation remove cerumen?
Irrigation removal of cerumen involves flushing the ear with water, that dislodges the cerumen, ideally in fragments, and forces it out of the ear canal
When to use irrigation for CM?
- These tools move water through the EAC
- To do this, we have to know the integrity of the TM (100% need to know if there is a perf)
- A tympanogram is needed before doing this
What 3 things do you need for irrigation?
1) Draping
2) Basin
3) Water temperature
What is the correct water temperature for irrigation?
- Cold water = painful and makes you dizzy
- Hot water = can be too hot and painful
- Anywhere between 37-40 degrees (or lukewarm)
4 guidlines for CM through irrigation
1) The integrity of the TM MUST BE KNOWN for this method. An intact TM is CRUCIAL. TM perforations are absolutely contraindicated.
2) The stream of water should not be directed directly towards the TM
3) The lowest effective amount of pressure should be used (high pressure has more potential risks)
4) Identify if the cerumen is soft enough to remove with water irrigation (a softer wax will do better with irrigation)
How does suction CM work?
- More suction when you cover up the hole
- No suction when the hole is open
Should you use suction on patients with tinnitus?
Do not use suction for patients that have tinnitus (do not want to increase the tinnitus by putting another loud sound in the ear)
When should you use a suction approach?
When the wax is more viscous (wet/runny) suctioning may be a good option for removal
What are the 6 steps of using suction for CM?
1) Place the tip of the suction at the top of the impaction
2) Place your finger over the small hole in the suction tip
3) Orient the tip slightly down and pull out of the ear canal
4) Stay on the cerumen
5) Stay off the ear
6) Patients need to be counselled that this can be very loud
Infection control for CM must include what 3 things?
1) Use of barriers (gloves minimally) consider donning and face shields
2) Use of clean tools
3) Used on clean surfaces
Treat any cerumen as it is ____
Infectious
When is cerumen considered infectious?
Cerumen is considered infectious if it contains blood, ear discharge or mucous, but this is not always clear through otoscopy
What happens if you come in contact with infectious cerumen?
1) CLEANING: Soap in sink
2) Disinfecting: Ultrasonic Cleaner or disinfectant wipe
3) Sterilization: 100% germs are destroyed (cold or hot)
What requires sterilization for the suction pump?
- Glass Collection Jar – does not require sterilization
- Plastic tubing – does not require sterilization
- Metal suction tip – cold sterilant
- Glass jar for water – cold sterilant
What requires sterilization with curettes?
- Plastic – disposable
- Metal – cold sterilant
What requires sterilization with a specula?
Plastic – cold sterilant
How do we soften cerumen in the EAC?
- Cerumenolytic agents are compounds used to break down impacted cerumen to lessen the need for irrigation or manual removal
- Cerumenolytics can also be used in combination with other cerumen management strategies
- No one cerumenolytic has been proven to be more effective another agents
- Oil-based, peroxide-based, water-based
Who are cerumenolytics limited to?
patients with intact tympanic membranes, without active dermatitis, or infection of the ear canal
When do you need to counsel for the use of cerumenolytics?
1) Counselling for at home use
2) Counselling in clinic
3) Counselling with use of hearing aid (time of day matters; do it at night when you aren’t wearing a HA. We don’t want the HA to be sitting in the wet, cerumenolytic)
Explain ear candling
- can get burns from the hot wax dripping into the EAC
- more soot and debris is going into the ear rather than the cerumen being pulled out
Why do we need informed consent for CM?
Patients must be fully informed of the risks, reasons, and potential benefits of cerumen management (not just the “what”, but the “why”)
True informed consent outlines the need to inform patients of what 6 things?
1) Nature of treatment
2) Expected benefits
3) Potential, probable or serious risks
4) Side effects
5) Alternative courses of action
6) Consequences of inaction
Explain the 4 steps of pre-counselling for CM
1) Explaining the procedure to patient
2) Explaining the tools to be used
3) Explaining both your, and their role in the procedure (i.e. the importance of them being still and communicating their comfort)
4) Explaining the right to withdraw from the procedure (patient or audiologist)
Explain post-cerumen management
- Documentation must be provided and stored, when cerumen management has been attempted or completed.
- Documentation should include:
- What action was taken, what tools were used, what was completed (or not completed), if any irritation/pain/discomfort was noted, tympanogram information (if collected), what direction was provided to the patient post- management, and what the follow-up plan is following discharge
Example of post-cerumen management
- Example of post-cerumen management discharge documentation:
- “Patient was seen for cerumen management due to cerumen blocking visualization of the tympanic membrane, which prohibited further audiologic assessment. Cerumen removal was successfully completed using curette, suction and irrigation methods. Patient was counselled risks and agreed to proceed. Informed consent was obtained and signed. Post-otoscopic examination was unremarkable. Post procedure tympanogram revealed normal ear canal volume with normal static admittance. Patient was instructed to ______. Patient is to contact us if there are any issues or concerns.”
prompt medical attention; what 5 reasons to reach out to GP or ENT after CM
Prompt medical attention should be initiated for any of the following complications:
1) Inadvertent damage to the ear canal/tympanic membrane (including perforation)
2) Active bleeding that has not resolved (nasal decongestant on hand)
3) Pain after procedure is completed
4) Dizziness/new tinnitus/threshold shift at the time of patient discharge
5) Any other post-treatment symptoms the audiologist feels is necessary
Explain the 6 steps for CM
Step 1: Otoscopic examination, familiarizing yourself with individual characteristics of shape— being additionally cautious of irregularities. Do you know the status of the TM? Tympanogram obtained
Step 2: Reviewing case history (both related to aural health and to systemic health). Discussing options, risks, and benefit with patient and obtaining informed consent
Step 3: Hand washing/infection control, gathering of materials (tools, light sources, etc.). Ensure materials are placed on clean surface. Gloves are required. Explain the procedure to the patient. Ensure patient is seated comfortably, make sure you are seated comfortably
Step 4: Begin procedure. Slow and steady. Constantly checking in with patient
Step 5: Second otoscopic examination, evaluating and reevaluating. Determine when cerumen has been managed effectively. Tympanogram
Step 6: When finished, discharging information should be provided. Clear direction of what to do and what not to do
What 3 ways can you continue education for CM?
1) Provincial Colleges
2) Conference workshops
3) Mentorship
