External Auditory Canal Examination and Cerumen Management

I. Introduction

Speech-language pathology and audiology are dynamic and expanding fields with constantly developing technological and clinical advances. Before conducting procedures involving such advances, practitioners must have acquired the knowledge, skills, education, and experience necessary to perform them competently. This policy statement is one of seven documents ^[1] developed by the Ad Hoc Committee on Advances in Clinical Practice. Each statement expresses the position of the American Speech- Language-Hearing Association (ASHA) concerning specific clinical procedures within the scope of practice of speech-language pathology or audiology, most of which have developed only within the last few years. Each statement further provides guidelines for practitioners performing these procedures. The guidelines consider the knowledge and skills normally associated with the required competencies, the clinical settings recommended for the procedure, and the appropriate involvement of personnel from other disciplines.

Clinical certification by ASHA ensures that practitioners have met the education, knowledge, and experience requirements established by the Association for providing basic clinical services in the professions of speech-language pathology or audiology. Certification in the appropriate profession is necessary, but not sufficient to perform the specific clinical procedure(s) discussed in this statement. The procedure(s) addressed in this document requires the practitioner to obtain education and training beyond that necessary for ASHA certification. Practitioners are bound by the ASHA Code of Ethics to maintain high standards of professional competence. Therefore, practitioners should engage only in those aspects of the professions that are within the scope of their competence, considering their level of education, training, and experience.

In promulgating this policy statement, there is no intention to imply that the practitioner holding ASHA Certification is prepared to conduct the procedure(s); nor is it incumbent on any certified professional to provide the procedure(s) merely because the practitioner holds certification.

The following document is intended as guidelines for the practitioner to ensure the quality of care, welfare, safety, and comfort of those served by our professions.

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II. Background

Many areas within the practice of audiology, including but not limited to: caloric irrigations associated with vestibular assessment, impressions of the external auditory canal (EAC) and pinna, acoustic and electrophysiologic measurements from the EAC, require an appropriate inspection of the EAC and, in the case of calorics, verification of the integrity of the tympanic membrane (TM). These procedures may also require removal of matter from the EAC that, while perhaps not completely occluding the canal, may affect the ability to satisfactorily complete procedures such as those listed above. The most common matter to be removed is cerumen (a waxlike secretion found within the external auditory canal).

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III. Purpose

Although it is recognized that not all audiologists would be involved with pneumatic otoscopy and cerumen removal, the purpose of this position statement is to: (a) inform audiologists that performing external auditory canal examination and cerumen management is within the scope of practice of audiology: (b) define the collection of procedures related to external auditory canal examination and cerumen management; (c) advise audiologists of the education, training, circumstances, and precautions that should be considered prior to undertaking the procedures; (d) provide guidance for audiologists as to the knowledge and skills which are required to perform external auditory canal examination and cerumen management; and (e) ultimately, to educate health care professionals, consumers and members of the general public about the services offered by audiologists as qualified health care providers.

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IV. Scope of Practice

It is the position of the American Speech-Language-Hearing Association (ASHA) that otoscopic inspection of the external auditory canal and the tympanic membrane, as well as limited management of occluding cerumen, is within the scope of practice of audiologists. This area of practice requires that audiologists possess sufficient knowledge and skills in the use of pneumatic 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. Audiologists should have knowledge of the medical conditions of the pinna external canal and tympanic membrane, and of how these potentially could have an impact on the examination and the audiological procedures. Practical, supervised experience along with efficiency (skill) in the inspection of the pinna and external auditory canal, tympanic membrane integrity and cerumen management are required.

If practitioners elect to perform these procedures, indicators should be developed, as part of a continuous quality improvement process, to monitor and evaluate the appropriateness, efficacy, and safety of the procedure conducted.

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V. Education and Training

Education and training may vary for these procedures; however, a foundation for the knowledge required should be obtained through the audiologist's academic program. The training should take place through direct supervision by a qualified professional in a setting allowing the trainee adequate clinical experience. The training of the use of pneumatic otoscopy is needed since determination of integrity of the TM by the referring physician is typically limited to an otolaryngologist, yet referrals for the caloric irrigation procedures are received from a wide range of medical specialties. Tympanometry may be substituted as a means for determining TM integrity, however pneumatic otoscopy is a more direct and simpler method for this determination, and therefore is felt to be a needed skill. Each practitioner must determine whether he/she has obtained a sufficient degree and kind of education and training to be competent to perform external auditory canal examination and limited cerumen management.

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VI. Precautions

Each practitioner should consider the following precautions of circumstances prior to undertaking these procedures:

1. Inform institutional and/or regulatory bodies, such as state licensure boards, about these procedures as within the scope of practice;

2. Check with appropriate state licensure board(s) to determine whether or not there are any limitations on the scope of audiology practice that restrict the performance of these procedures;

3. Check professional liability insurance to ensure that there is no exclusion applicable to these procedures;

4. Check medical policy, institution insurance coverage and delineation of practice privileges for the specific institution to ensure that there are no restrictions applicable to an audiologist performing these procedures (most hospitals and medical centers provide avenues whereby audiologists may become formally privileged to provide a service of this nature);

5. To prevent the risk of disease from blood-borne pathogens, follow the Universal Precautions contained in the Centers for Disease Control Morbidity and Mortality Weekly Report (June 24, 1988, Perspectives in Disease Prevention and Health Promotion, 37 (24), 377–388); or ASHA's AIDS/HIV update ( Asha, 1990).

6. Know whom to contact in the event that emergency medical assistance is needed; and

7. Obtain the informed consent of the patient (explanation to the patient and permission from the patient to proceed), and maintain complete and adequate documentation.

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VII. Knowledge and Skills

Each audiologist who intends to perform these procedures must ensure that he/she has acquired the knowledge and skills necessary to do each task related to the procedure. Outlined below are the objectives to be met, the necessary proficiencies, and the knowledge and skills necessary to accomplish each objective.

1. Objective: To inspect visually via hand-held otoscope or head light (mirror) and speculum the pinna, EAC and TM for presence of obstructing material, evidence of lesions or ongoing infectious process, evidence of anatomical anomalies that may affect the satisfactory completion of the desired procedure(s); and obtain a relevant history concerning conditions of the outer and middle ear, or past medical/surgical procedures of the outer and/or middle ear.

   Proficiency in: Visual inspection of the pinna, EAC and TM.

   Knowledge/Skills needed:

   1. Knowledge of anatomy, physiology, and pathophysiology of the pinna, EAC and TM.

   2. Knowledge of common medical or postsurgical conditions of the pinna, EAC, TM or middle ear that alter the appearance and/or function of the EAC and/or TM.

   3. Skill in the use of otoscopy and pneumatic otoscopy.

   4. Skill in the interpretation of visual inspection of the pinna, EAC, and TM.

2. Objective: To inspect the EAC and TM visually via hand-held pneumatic otoscope or head light (mirror) and Seigel scope for determining the mobility of the TM.

   Proficiency In: Determination of appropriateness of TM mobility.

   Knowledge/Skills needed:

   1. Knowledge of anatomy, physiology, and pathophysiology of the EAC and TM.

   2. Knowledge of common medical or postsurgical conditions of the EAC, TM, or middle ear that alter the appearance and/or function of the EAC and/or TM.

   3. Skill in the use of otoscopy and pneumatic otoscopy.

   4. Skill in the interpretation of visual inspection of the EAC and TM.

3. Objective: To inspect the EAC and TM visually prior to and following procedures involving insertion of instruments or other materials into the EAC for the purpose of documenting status of the EAC and TM.

   Proficiency in: Visual inspection of the EAC and TM.

   Knowledge/Skills needed:

   1. Knowledge of common medical or postsurgical conditions of the EAC, TM or middle ear that alter the appearance and/or function of the EAC and/or TM.

   2. Skill in the use of otoscopy and pneumatic otoscopy.

   3. Skill in the interpretation of visual inspection of the EAC and TM.

4. Objective: To determine if occluding material visualized in the EAC is cerumen and if it can be removed comfortably and safely without the use of an operating microscope.

   Proficiency in: Recognizing cerumen versus other occluding materials, and determining its need for removal and the most effective method for removal.

   Knowledge/Skills needed:

   1. Skill in the use of otoscopy and pneumatic otoscopy.

   2. Skill in the interpretation of visual inspection of the EAC and TM.

   3. Skill in cerumen removal by a variety of techniques and equipment.

5. Objective: To determine if the procedure to be performed should be deferred, based on pinna, EAC and TM inspection, and if referral to an otolaryngologist is indicated.

   Proficiency in: Determining the status of the pinna, EAC and TM relative to the needs of the procedure to be performed.

   Knowledge/Skills needed:

   1. Knowledge of anatomy, physiology, and pathophysiology of the pinna, EAC and TM.

   2. Knowledge of common medical or postsurgical conditions of the EAC, TM or middle ear that alter the appearance and/or function of the EAC and/or TM.

   3. Skill in the use of otoscopy and pneumatic otoscopy.

   4. Skill in the interpretation of visual inspection of the EAC and TM.

   5. Skill in cerumen removal by, for example, use of cerumen loop and hand-held otoscopic device; use of cerumen loop, head mirror and hand-held speculum; use of cerumen loop and binocular microscope; use of material for softening and gentle water irrigation; or a combination of these methods.

6. Objective: To establish appropriate protocol with medical personnel to handle EAC abrasion or laceration that could result from cerumen/desquamation material removal.

   Proficiency in: Determining need for other medical service involvement in the care of the EAC and TM.

   Knowledge/Skills needed:

   1. Knowledge of anatomy, physiology, and pathophysiology of the EAC and TM.

   2. Knowledge of common medical or postsurgical conditions of the EAC, TM or middle ear that alter the appearance and/or function of the EAC and/or TM.

7. Objective: To select appropriate method and remove occluding cerumen or refer to an otolaryngologist for removal once determining that: (a) contact with the TM is required or likely to occur; (b) the occluding material is not cerumen; (c) the comfort or safety of the patient may be compromised. (These represent suggested situations and are not intended to be an exhaustive list.)

   Proficiency in: Determining if occluding material is cerumen/desquamation material and, if it is cerumen/desquamation material, determining if it can be removed safely and comfortably without contact with the TM.

   Knowledge/Skills needed:

   1. Knowledge of anatomy, physiology, and pathophysiology of the EAC and TM.

   2. Skill in cerumen removal by a variety of techniques and equipment.

Notes