As an audiology licensee in the Commonwealth of Virginia for over thirty-six years, I commend the Board for its ongoing service to audiologists of Virginia and to the citizens of the Commonwealth that we jointly serve.  I have provided audiology services in a variety of locations across central Virginia, including academic medicine (VCU Hospitals), inpatient/outpatient rehabilitation (Sheltering Arms Hospital), ENT private practice, and most recently, my own audiology private practice.     Access to the ear canal (and professional management of all aspects of complications that interfere with that) is the cornerstone of literally everything an audiologist does professionally.  Many aspects of the Emergency Regulations for Cerumen Management, in their current form, fail to recognize and respect this reality.   Unlike the regulations promulgated by other state boards of Audiology and Speech Language Pathology across these United States, the Virginia Emergency Regulations for Cerumen Management are unusually and unnecessarily restrictive.  Specifically:

• According to the Emergency Regulations specifically in 18VAC30-20-214.D An audiologist performing cerumen management shall;  1. obtain informed written consent of the patient or legally responsible adult and maintain documentation of such consent and the procedure performed in the patient record.  I request that the requirement of written informed consent be removed as a requirement for audiologists to perform cerumen management. 
  • While we are licensed to place ear tips and other accessories into the external auditory canal without written consent, the Emergency regulations require Virginia audiologists to obtain written consent prior to remove any ear wax FROM THE SAME ANATOMICAL REAL ESTATE of the patients we serve and treat.  This is unnecessarily and illogically restrictive.
  • Prior to seeing a patient, providers obtain consent for evaluation and treatment.  Does the Board propose that audiologists must obtain written consent for each portion of a patient interaction?  Prior to performing otoscopic examination?  Prior to conduction air and bone pure tone audiometry?  Prior to performing tympanometry and acoustic reflex testing?  Prior to performing optoacoustic emissions?  Prior to removing cerumen from hearing aid receivers or ear canals?  Prior to administering electrocochleography or auditory brainstem response?  Prior to performing any procedure, this audiologist informs the patient describes the procedure and obtains verbal consent.  To require written consent to perform cerumen management is illogical and unnecessary. Are physicians (or their assistants with far less expertise concerning cerumen management) required to obtain written consent before removing ear wax?  They are not. 
• Section C of 18VAC30-20-241, stipulates 11 contraindications to audiologist performance of cerumen management, requiring audiologists to refer any patients with a contraindication to a general practitioner or otolaryngologist for cerumen removal.  I suggest many of these conditions are cautions for and are not rigid contraindications for cerumen management.  Imposition of such restrictive contraindications imposes undue hardship (treatment delays, additional copayments and increased medical costs) to patients and their care givers, requiring that ongoing audiologic treatment (including hearing remediation) must wait until the contraindicated patient visits their general practitioner.   I view the following contraindications as unusually restrictive and request that they be removed as a contraindication:
  • Hearing in only one ear—I submit that audiologists are most sensitive to the implications of unilateral hearing loss and are well qualified to recognize when it is safe to remove wax from the ears of such patients. 
  • Current tympanostomy tubes—I submit that this audiologist is qualified to determine when said ear wax in the lateral portions of the ear canal can be removed without compromising tubes located in the tympanic membrane, deep in the external auditory canal.
  • Actual or suspect foreign body in the ear (I assume the regulations are referring to the external auditory canal): The current Virginia audiology scope of practice recognizes that audiologists are sufficiently trained to place EAR inserts, canal electrodes, Immittance and optoacoustic emissions ear tips as well as otoblocks or cotton blocks in patient external ear canals, as well as prior to making earmold impressions of the external ear canal and to remove said ear canal impression from the patient ear.  Audiologists regularly remove receiver domes from errant receiver in the canal hearing aids, portions of cotton swab heads that patients inadvertently leave in their ears, or other objects that may be visualized in the cartilaginous portion of the external auditory canal).
  • It is in the scope of practice to create and remove earmold impressions, but an audiologist cannot remove ear wax if a foreign body is present.  The foreign body can be removed, but the audiologist may not remove scant amounts of ear wax in the presence of a foreign body?  This is illogical and undesirable.    
  • Cerumen impaction that occludes the ear canal:   In the event of impaction that occludes the ear canal, audiologists have access to and use tympanometry to confirm intact eardrums prior to initiating treatment or prior to referring patients to an ENT specialist.  The Emergency Regulations now direct audiologists to send such patients to general practitioners and their assistants who do not have such technology available.
  • Traditionally, audiologists have been employed in hospital or otolaryngology practices where immediate referral to ENT services is available.  Across the Commonwealth, there are increasing numbers of independent audiology private practices where audiologists regularly provide safe, comprehensive audiological services. As one of these private practitioners, I regularly refer patients to an otolaryngologist when otoscopic inspection reveals pathology or conditions that contraindicate my safe removal of cerumen.  It is unethical for me NOT to make such referrals.  Yet, to compel me to stop treatment (that I am trained and experienced to provide) due to visibility of the tympanic membrane and/or external ear canal is also illogical and imposes undue hardship on the very patient that we seek to assist.
  • Diabetes mellitus, HIV Infection, bleeding disorder, or other medical contraindications: There are different levels of acuity in patients diagnosed with diabetes mellitus.  Patients with easily controlled diabetes present with better skin and canal health than do patients with fragile or poorly controlled diabetes.  The efficacy of contraindication of all diabetic patients by diagnosis rather than fragility or intensity of symptomology is questionable.  Refusing treatment to a patient with HIV infection is tantamount to discrimination.
• During the past fourteen years of private practice, more and more general practitioners physicians refer their patients to audiologists for safe cerumen management. As a sidebar, many patients regularly report that their experience of cerumen management by audiologists is much more comfortable and more efficient than management provided by their general practitioner—or support staff in that office.  General practitioners who do ‘provide’ such services typically defer cerumen management to their support staffwho typically have neither proper tools nor training to perform cerumen management.  They certainly do not conform to the training stipulated through the Emergency Regulations.  In its present form, the Emergency Regulations would send ‘contraindicated patients’ to health care providers who are less equipped to provide cerumen management than Audiologist licensees.  As noted previously, to mandate referral to other healthcare professional for simple and common conditions is in no way efficient patient care, nor in anyone's best interest.

Increasing numbers of citizens are home bound and cannot be easily transported to outpatient ENT practices because of their debilitated health and limited mobility.  The Emergency Regulations infer that audiologists who travel to such communities may no longer provide careful cerumen management in the safety of their home communities.  These patients will have to wait weeks for physician appointments and waste hours of time waiting their turn for treatment at the physician office—or will never receive treatment. 18VAC30-20-241.c

The American Academy of Audiology, the Academy of Doctors of Audiology, the American Speech Hearing Language Association and the Speech Hearing Association of Virginia all affirm cerumen management to be a part of the Audiologist Scope of Practice.  Access to the ear canal (and professional management of all aspects of complications that interfere with that) is the cornerstone of literally everything we do professionally. I urge the Board of Audiology and Speech Language Pathology to immediately revise the Emergency Regulations to be less restrictive to audiologists performing safe cerumen management