Module 10: Cerumen Management Flashcards
What is 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
What are the 3 layers of the TM?
-Outer epithelial layer
-Middle fibrous layer (tends not to re-build after large perforations)
-Inner mucosal layer
The pars tensa of the TM consists of the lower __ quarters
3
T/F: The pars flaccida of the TM consists of the upper quarter
True
What are we looking for in healthy tissue when performing otoscopy?
-Consistency/texture
-Colour
-Shape
-Overall health
-Abnormalities
What are the average lengths of ear canals for females, males, and paediatric patients?
28mm, 30mm, and 20-25mm, respectively
T/F: when removing cerumen, we should focus on the inferior/posterior portion of the ear canal because it is not sensitive like the superior/anterior portion
False: both portions are sensitive for their own reasons and extreme caution must be taken (though the inferior/posterior canal wall may be more sensitive due to bleeding sensitivity)
Between the cartilaginous and osseous portion of the ear canal lies the ___
Isthmus
Which 4 cranial nerves innervate the ear canal, making it sensitive to touch?
V, VII, IX, and X
What is the name of the reflex that can be particularly sensitive in some patients (causing a cough), and is a branch of the vagus nerve (X)?
Arnold’s Reflex
What letter represents the shape of a typical ear canal? How many bends are there?
S, 2
___ portion between the 1st and 2nd bend
Cartilaginous
___ portion past the 2nd bend
Bony
Main features of the cartilaginous portion of the ear canal
-Cerumen production area
-Cartilage is flexible and can shift with jaw movements
Main features of the bony portion of the ear canal
-More rigid
-More sensitive compared to cartilaginous portion
T/F: we can perform cerumen management on an ear with an untreated infection
False
T/F: we can perform cerumen management on someone who complains of ear pain
False
T/F: we can perform cerumen management on someone with a PE tube or perforation
True (but no irrigation as we don’t want anything going into the ME space)
T/F: we can perform cerumen management on someone with exostoses
True (depending on our comfort and prioritizing patient safety)
T/F: we can perform cerumen management on someone with visible cholesteatoma
False
T/F: we can perform cerumen management on someone with otitis externa
False
What aspects of case history should be considered when thinking about performing cerumen management?
-Immunocompromised/immunosuppressed (e.g., diabetes, HIV, hepatitis, patients on steroid meds, patients on chemotherapeutic meds)
-Heart conditions and heart meds
-Elevated bleeding risks and anti-coagulant meds
-Anti-platelet meds
-Hx of radiation
-Other health conditions that may elevate risk: head injuries, acute health conditions
What is cerumen? What is its purpose?
Cerumen (often called earwax) is a naturally occurring bi-product of the ear that exists to clean, protect, and lubricate the external auditory canal
T/F: cerumen is always harmless
False: it is MOSTLY harmless but can be problematic when it blocks the ear or affects the delivery of sound to the ear (i.e. through a hearing aid)
What is cerumen comprised of?
-Ceruminous Glands: modified apocrine sweat glands
-Sebaceous Glands: secrete sebum, which is made up of triglycerides
-Products of these glands combine with skin and debris (such as hair cells)
Cerumen is ___ to the first portion of our auditory system
protective
What are some protective properties of cerumen?
-Hydrophobic, waxy consistency helps provide physical protection and a microbial defence for the external auditory canal
-Antibacterial and anti fungal properties help to maintain a slightly acidic environment within the ear canal
Where is cerumen produced?
The outer two-thirds of the ear canal (cartilaginous portion)
T/F: cerumen naturally migrates out of the ear with assistance from jaw movement
True
What are the causes for accumulation of cerumen? (3)
- Overproduction: rate of cerumen being produced exceeds the rate of cerumen migrated out of the ear canal
- Obstruction: growth in the ear, narrow canals, difficult shapes of canals, soft tissue malformations, objects inserted into the ear canals (e.g., earplugs)
- Inadequate epithelial migration: slows down as we age
1 in ___ children, 1 in ___ adults, and 1 in ___ geriatric/developmentally delayed population have excessive or impacted cerumen
10, 20, 3
Why does cerumen tend to be drier as we age?
Cerumen glands reduce in number, resulting in drier cerumen (which is less easily carried out of the canal)
Colour of cerumen may be affected by other ___ or the process of ___
debris, oxidation
Hard consistency of cerumen can be due to ___
dryness
What are the two types of cerumen?
Wet and dry (wet is a dominant phenotype)
What kind of cerumen do those of Asian/Eastern descent have?
Dry/flakey
What kind of cerumen do those of African descent have?
Soft, “honey-like” consistency
What kind of cerumen do those of European descent have?
Soft, sticky consistency
Normal earwax colours
Off-white, yellow, orange, brown, pale orange
Abnormal earwax colours
Black, gray, wax with streaks of blood, green, yellow-green
When should we consider removing cerumen?
-Prevents thorough audiological examination/interferes with diagnostics
-Prevents the ability to perform REMs
-Prevents the ability for hearing aids to be effective (sound delivery)
-Will cause impaction in the future
-When requested by patient***
What are the 3 main categories for cerumen removal techniques?
-Mechanical removal
-Irrigation (water-based, flushing)
-Suction
The choice of tool to use for mechanical removal of cerumen will depend on:
-Shape/size of curette and ear canal
-Degree of impaction
-Consistency of cerumen
Guidelines for mechanical removal of cerumen
-Stay in the cerumen, stay off the skin
-No leveraging, scraping, peeling, sweeping
-Identify the point of least resistance to take the most cerumen out with as little irritation as possible
-Attempt to remove cerumen from a more medial point when safe to do so
-Attempt to place the tip of the tool slightly behind the cerumen
-SLOWLY move instrument down and out of canal
-Clean tool in-between passes
-Speculum may be used for enhanced visualization
Pause, reassess, and ___ procedure if safety is compromised
stop
Guidelines for irrigation removal of cerumen
-The integrity of the TM must be known for this method. An intact TM is crucial
-The stream of water should not be directed directly towards the TM
-The lowest effective amount of pressure should be used (high pressure has more potential risks)
-Identify if the cerumen is soft enough to remove with water irrigation
Guidelines for suction removal of cerumen
-Place the tip of the suction at the top of the impaction
-Place your finger over the small hole in the situation tip
-Orient the tip slightly down and pull out of the ear canal
-Stay on the cerumen
-Stay off the ear
-Patients need to be counselled that this can be very loud
When the wax is more ___ suctioning may be a good option for removal
viscous (wet/runny)
We shouldn’t use suction for patients with ___
tinnitus
Infection control during cerumen management include:
-Use of barriers (gloves minimally), consider donning and face shields
-Use of clean tools & on clean surfaces
Sterilization process for cerumen management tools
- Cleaning: soap in sink
- Disinfecting: ultrasonic cleaner or disinfectant wipe
- Sterilization: 100% of germs are destroyed (cold or hot)
Why should cerumen be treated as potentially infectious?
Cerumen is considered infectious if it contains blood, ear discharge, or mucous, but this is not always clear through otoscopy
What sterilant should be used?
-2% or more glutaraldehyde or 7.5% hydrogen peroxide or UV machine
-Autoclaving
What are cerumenolytics?
Compounds used to break down impacted cerumen to lessen the need for irrigation or manual removal
What are the different kinds of cerumenolytics?
Oil-based, water-based, and peroxide-based
What kinds of patients are cerumenolytics limited to?
Patients with intact TMs and without active dermatitis or infection of the ear canal
True informed consent regarding cerumen management outlines the need to inform patients of:
-Nature of treatment
-Expected benefits
-Potential, probable or serious risks
-Side effects
-Alternative courses of action
-Consequences of inaction
Pre-counselling for cerumen management
-Explaining the procedure to patient
-Explaining the tools to be used
-Explaining both your, and their role in their procedure (i.e. the importance of them being still and communicating their comfort)
-Explaining the right to withdraw from the procedure (patient or audiologist)
Post-cerumen management 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
When to reach out to GP or ENT post-cerumen management
-Inadvertent damage to the ear canal/tympanic membrane (including perforation)
-Active bleeding that has not resolved (*nasal decongestant on hand)
-Pain after procedure is completed
-Dizziness/new tinnitus/threshold shift at the time of patient discharge
-Any other post-treatment symptoms the audiologist feels is necessary
Guidelines for performing cerumen management
-Step 1: Otoscopic examination, familiarizing yourself with individual characteristics of shape–being extra cautious of irregularities. Do you know the status of the TM? Tymp obtained
-Step 2: Reviewing case history (both related to aural heath and to systemic health). Discussing options, risks, and benefit with patient and obtaining informed consent
-Step 3: Hand washing/infection control, gathering 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. Tymp
-Step 6: When finished, discharging information should be provided. Clear direction of what to do and what not to do
