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Cerumen Management Using Otomicroscopy:  An Essential for Audiologists

By Gene McHugh, EdD CCC/A

Private Practice Audiologist, Colorado Springs, CO

 

Cerumen management using otomicroscopy (OM) and video display (OM/V) is more precise, more comfortable, more effective for patients; and now, more affordable for private practicing audiologists.  Upgrade your skills with better equipment!  

 

2017

 

INTRODUCTION

   

       Microscope enhanced cerumen management is an innovative technology that can immensely improve the audiologist's skill in removing cerumen from patient's ears.   Cerumen removal is within the audiologist's scope of practice (ASHA, 1992) and necessary when :

  • Excessive cerumen prevents adequate access to the ear canal for any audiological measurements

  • The presence of cerumen results in potentially misleading and/or inaccurate audiologic results; or

  • When cerumen interferes with the pre-selection, fitting, or operation of hearing instruments.  

     Research and personal experience suggests one out of every four patients in an audiology practice presents with some degree of cerumen problem that should be addressed with cerumen management.  Even though the advantages of microscope enhanced cerumen removal are well accepted (cf., Ballachanda, 1995; Courtois, 1999), audiologists as a rule have not incorporated microscopes into their practices.  Reasons often cited include the perceived high cost (Purdy, 2002) and lack of training (Ballachanda, 1995) and lack of space. 

Omni 10 Binocular Microscope from Prescott's

 

Microscope Enhanced Cerumen Management

 

      While microscope enhanced cerumen management may be new to the field of audiology, this audiologist has been using a microscope for over fifteen years.  Without question, the microscope provides superior illumination and magnification of the outer ear structures while giving me total freedom of both hands to manipulate the ears.  The purpose for writing this is to strongly encourage private practice audiologists, who often are faced with patients with cerumen blockages to consider the value of an otomicroscope with or without video display for their practices.  The improved ability to visualize patients' ears will enhance your skills as a clinician.  

         

SURVEY OF CURRENT CM METHODS BY AUDIOLOGISTS

 

       Using microscopy is somewhat atypical by private practicing audiologists.  Therefore, to determine what audiologists thought about microscopes, we conducted a small survey at the 2008 Academy of Audiology meeting in Charlotte.   In a survey of twenty-five audiologists, 68% of those interviewed stated they perform CM on a routine basis.  Of those performing CM, 58% stated they use a hand-held (HH) otoscope (usually of the Hotchkiss variety); 24% used a video-otoscope (VO) system with otoloop attachment (note: although most agreed VO is not very handy for cerumenectomies); 18% use a combination of HH and VO; 12% use a headlamp and only 1 of the 25 surveyed, i.e., 4% reported using an operating microscope

Hotchkiss Otoscope megaspot600002
Hotchkiss Otoscope     Video-Otoscope Small video-otoscope Head-light Otomicroscopy

TABLE OF CM SURVEY (McHugh, 2008):

 

Do you perform CM?

If you perform CM,  your preferred method?

Type of practice

YES

NO

HH

VO

VO+HH

HL

OM

PP

ENT

Other

68%

32%

58%

24%

18%

12%

4%

72%

11%

17%

KEY:  HH - Hand-Held otoscope; VO - Video-Otoscope; HL - Head Lamp; OM - Operating Microscope

PP - Private Practice; ENT - Ear Nose & Throat Clinic

 

     It is noteworthy that most of the audiologists (including students) surveyed believed an operating microscope would be the better and safer method to extract cerumen, but cited the following reasons for not using (or even considering) a microscope for their practice:

  • not trained with a microscope

  • not enough space

  • cost (some thought the cost of a microscope was between $20-30k)*

  • CM not reimbursed through insurance so anything more than an otoscope is too expensive

  • not sure if they could ever learn to use a microscope

 COMPARISON OF OTOSCOPIC & CM STRATEGIES

   Before purchasing otoscopic equipment, the practitioner must determine what he or she wants to achieve and how much room is needed to operate.  Are the goals outer ear screening only or both ear exams and CM?   The table below compares various otoscopy methods.  Price, illumination, magnification, ease of CM, approximate space needed to operate and ability document results are included.  

 

 

PRICE

ILLUMINATION

MAGNIFICATION

EASE OF CM  

SPACE

VIDEO DISPLAY

OM

AVE $6200

EXCELLENT

EXCELLENT

EXCELLENT

FAIR 4'

NO

OM/V

AVE $10000

EXCELLENT

EXCELLENT

EXCELLENT

FAIR 4'

YES

Small VO

APPROX $850

FAIR

FAIR

VERY POOR

GOOD 1'

POSSIBLE

Large VO

AVE $7500

EXCELLENT

EXCELLENT

POOR

FAIR 3'

YES

HH -Hotchkiss

APPROX $250

FAIR

FAIR

FAIR TO GOOD

GOOD 1'

NONE

HL

APPROX $250

FAIR

POOR

FAIR

GOOD 1'

NONE

HH - Hand-Held otoscope; VO - Video-Otoscope; HL - Head Light; OM - Operating Microscope OM - Operating Microscope with video display

 

* The price factor would appear to be a misperception, especially when compared to the cost of the larger video-otoscope systems.  Indeed, operating microscopes are about the same price ($5000 - $9000) and considerably more practical if one performs cerumen removal on a routine basistop

 

 

MARKETING TO AUDIOLOGISTS

      Companies that sell and service microscopes are recognizing private practice audiologists, while not a large group as compared with ENT or dentistry, represent an excellent opportunity for additional sales.  As marketing actively increases in our field, it is expected the use of simple otoscopes and video-otoscope systems will decline in favor of superior equipment.

*Disclosure:  Dr. McHugh is an unpaid consultant with Prescott's Microscopes   top

 

MAKING THE TRANSITION TO OTOMICROSCOPY AND LEARNING A NEW SYSTEM  

     Transitioning to the stereoscopic (or binocular) microscope takes a couple of weeks to get used to, but should be relatively easy for practitioners already skilled at CM.  Otoscopy and video-otoscopy offer only one dimension limiting depth perception, whereas loupes and microscopy provide three dimensional acuity.  Ocular loupes demand the clinician use convergent vision to overlap two images.  This is not as clear as microscopy and causes more eye strain as magnification increase.  In the operating microscope, the clinician adjusts the binocular lens and looks straight ahead with clearer magnification without eye strain.   Since most audiologists were not trained using the microscope, understandably, new users may be intimidated.  New users tend to over-correct their vision when first looking the the microscope rather than relax and look straight on.  With practice, depth perception improves in a short period of time.  Also at time, a few adjustments in the scope's lens are necessary by the manufacturer's representative.  Dr. McHugh along with Prescott's Microscopes has developed a training DVD regarding video otomicroscopy.  In the meantime, if you are interested in transitioning to a microscope in your audiology practice, feel free to contact me personally by phone (719)520-1155 or by e-mail at emchugh@coloradoaudiology.com

 

INCLUDING OTOMICROSCOPY IN TRAINING INSTITUTIONS

     Video-microscopes provide instructors and supervisors with a very effective method to instruct students. Instructors are able to easily demonstrate anatomy, physiology and cerumen removal technique. Moreover, this can allow instructors to watch and guide students for more effective training of ear examinations and CM methods.         

 

 

TESTIMONIAL

     Since 1993, this office has been using otomicroscopy for routine ear exams and cerumen removal.   Our first "used" wall-mounted microscope, purchased from Prescott's, Inc. was very affordable when compared to other audiologic equipment in our clinic and relatively easy to use.  It now seems inconceivable to use anything but a microscope for CM on our patients.

     HISTORY:  It started in 1993.  I was cleaning the ears of a local opera celebrity being extra careful, in part because of his notoriety.  I was using my best eye to look through my handy Hotchkiss otoscope (dealing with the "fair" at best, illumination and magnification) while having to position the scope with my left hand so I could remove cerumen with my right. It was not easy and in my opinion, the reason was inferior equipment.  I finished the procedure without causing too much discomfort for my opera star, but decided I needed better illumination and magnification, along with a hands-free system to perform cerumen removal.  

 

 

 

 

 

 

 

 

 

 

 

Gene McHugh, EdD

      As most fellow audiologists remember, in 1993 video-otoscopy (VO) was being heavily marketed to audiologists and hearing aid specialists. There were exceptional articles on its benefits (Sullivan, 1993); and many colleagues had one, so I requested a demonstration.  I thought that video-otoscopy provided excellent illumination and magnification of the canal and TM, along with outputting a handy color picture (that helps with hearing aid sales), but in my opinion was nearly useless with respect to CM. I discussed my dilemma with local otologist David Barrs who recommended I get a microscope rather than a video-otoscope.  Once I was able to view an ear canal through a binocular microscope with its excellent - fiber optic- illumination and magnification, the decision on the most effective method for exams and CM was clear.  Most of all, both hands were free to work.  

      I have been using an operating microscope on my patients for over 20 years and believe it to be an excellent investment considering the potential liability associated with CM.  Patients are more comfortable, my visual accuracy significantly enhanced, and the hands free operation while cleaning ears indispensable.  Prior to every hearing test, my patients have completely clear ears.  In 2007, I did not have to refer out any patients to ENT because of earwax issues.     

 Upon Dr. Barrs' recommendations, I purchased a "used" Zeiss Opni-9 microscope from Prescott's Microscope located a few miles north of Colorado Springs, CO.  The cost was $4500.00 when I bought it.  Interestingly, at the same time, video-otoscopes were running between $8.000.00-10,000.00.  Ironically, the microscope was more affordable.  In 2008, I traded my 15 year old "used" microscope (that has needed little or no servicing) for a new Omni-10 with S-Video output to a 45" Flat Screen TV.  The cost was slightly more than $10,000.00.  The addition of the video has been an excellent source of patient and staff education.

    

For information on costs etc., click here for their audiology brochure.

 

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FINAL COMMENT

     I have often wondered why oto-microscopy is not incorporated into most audiologist's offices.  I have come to believe the reason is "marketing."  It is my opinion that once audiologists are given a "hands-on" demonstration with a microscope, learn of the relatively affordable price, and given a couple of pointers on using the microscope, the operating microscope will hopefully merge as a standard piece of equipment in the average audiology office. 

 

It's time to upgrade our services and our profession.

 

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References:

   Academy of Dispensing Audiology (1991).  Cerumen Management Seminar.  ADA Feedback, 2(4):7.

   American Speech-Language-Hearing Association (1992).  External auditory canal examination and cerumen management.  ASHA, 34. 22-24)

   Ballachanda, B. (1995).  The Human Ear Canal.  Singular Publishing Group, San Diego.

   Chaiken, R. (2000).  Issues in Cerumen Management.  Audiology Online.  

   Courtois, J. (1999) Earwax and foreign bodies in the ear canal.  Available through Widex.

   CASLPO, 2005.  Preferred Practice Guidelines for Cerumen Management, College of Audiologists and Speech-Language Pathologists of Ontario.

   Gleitman, R.M., Ballachanda, B.B. & Goldstein, D.P. (1992).  Prevalence of cerumen impaction in the general population.  The Hearing Journal, 45, 28-32.

   Purdy, J. (2002).  Managing CerumenAudiology Online.

   Sullivan, R (1993)  How video otoscopy benefits hearing health care practice.  Hearing Instruments, 44(4), 15-18.

   Sullivan, R. (1997).  Video Otoscopy in Audiologic Practice.  J. Am Academy of Audiology, 44(8), 447-467.

 

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