I am beginning to perform cerumen removal for my patients on a more regular basis. What are some common mistakes that are made, and what precautions should I take to prevent or minimize those risks?
This is a good question, considering that approximately 150,000 ears are cleaned of wax each week in the United States! Universal precautions, such as hand washing and proper sterilization of removal tools, are obviously of utmost importance. Some patients present with conditions where we, as audiologists, should take care or refer out. If there is an effusion in the ear or canal, visible hematoma or surgical modification of the ear canal, or a foreign body that is not supposed to be there we should refer to a physician. Other contraindications for removal would be if the patient has diabetes, a suppressed immune system, bleeding disorders, or if the patient has a lack of muscular control where you would otherwise need to constrain them to remove the wax.
There are other behind-the-scenes considerations you might make, also. If the patient has a history of or any pending legal proceedings, you may make a judgment call to defer or refer the patient to a physician. In some states, audiologists or hearing aid dispensers assume that they can remove cerumen, but it is not always included in their particular scope of practice. As a cautionary measure, you might want to do some investigating at the licensure level. If it is not within your scope, your malpractice insurance may not provide coverage if an error occurs, and then, unfortunately, the patient has a stronger stance in seeking compensatory damages.
In our clinics, we use a cerumen removal consent form. It asks the patient to not only to sign and give consent to remove the wax, but it also asks them specifically about any conditions already identified that would be a contraindication for removal. This can serve as a way to gain more information about the patient as well as a safety measure for us.
Additionally, we routinely perform a pre- and post-removal tympanogram to identify that the tympanic membrane is intact. There was one instance where a pre-removal Type A tympanogram was obtained, and post-incident there was a 7.0 ml ear canal volume with a slight amount of blood.
The case history, consent or decline to treat, tympanogram, and outcome of the procedure must all be documented in the patient's medical record. It will save time and inconvenience in the future, especially if the file is audited by your regulatory agency or maybe a health plan. The extent and the quality of documentation plays such an important role in assessing what type of a job we're doing and how effective we are in the delivery of care. If it isn't written down, it didn't happen. Keeping all these things in mind when removing cerumen will help minimize risks and prevent medical errors, while performing an often-needed service. Thanks for your question!
Editor's Note: This Ask the Expert was taken from the eSeminar Preventing Medical Errors for Audiologists - 2011 Update published on 6/23/2011. To access the recorded course, please visit the AudiologyOnline library.
Dr. Cindy Beyer has a master's degree from West Virginia University and an Au.D. from PCO School of Audiology. She has over 20 years of experience working as a clinical audiologist, supervisor and manager. She is currently the Senior Vice President of Professional Services at HearUSA.